Non-invasive mechanical ventilation with average volume-assured pressure support. Results according to the aetiology of acute respiratory failure.

INTRODUCTION: Until now, the ventilatory strategy with BiPAP S/T plus average volume-assured pressure support (AVAPS) has not been evaluated for its use in the different types of acute respiratory failure (ARF). Consequently we report the results of the use of this ventilatory strategy in these clinical scenarios. MATERIAL AND METHODS: This is a single-centre prospective study. The subjects were categorised according to the type of ARF: (1) hypercapnic ARF: chronic obstructive pulmonary disease and bronchial asthma; and (2) hypoxaemic ARF: pneumonia, acute respiratory distress syndrome, congestive heart failure, and interstitial lung disease. Multiple logistic regression was used to determine predictors of non-invasive mechanical ventilation (NIV) failure (intubation). Further, in a subgroup of patients with de novo hypoxaemic ARF, analysis of variances with repeated measures was used to determine factors associated with NIV outcome. RESULTS: Sixty-eight subjects were included in this study. The NIV success rate was 69.1% and the mortality rate was 20.6%. A multivariate analysis showed that the number of affected lung quadrants on chest X-ray (OR: 4.23, 95% CI: 4.17-4.31; P < 0.001) and ARF precipitating disease (OR: 4.46, 95% CI: 4.43-4.51; P < 0.001) were determinants of NIV failure. In the hypoxaemic ARF subgroup (n = 58), significant differences in several parameters were found between patients with positive and negative outcomes. CONCLUSIONS: The use of BiPAP S/T - AVAPS in subjects with hypercapnic ARF is associated with a better outcome than in those with de novo hypoxaemic ARF.

The immediate effects of cervical spine manipulation on pain and biochemical markers in females with acute non-specific mechanical neck pain: a randomized clinical trial.

Study Design: Randomized clinical trial with pre-test, post-test control group design. Objectives: To examine the immediate effects of cervical spinal manipulation (CSM) on serum concentration of biochemical markers (oxytocin, neurotensin, orexin A, and cortisol). Background: Several studies have found an association between spinal manipulation (SM) and pain perception. However, the mechanism by which SM modulates pain remains undefined. Methods: Twenty-eight female subjects with non-specific mechanical neck pain were randomly assigned to one of two interventions (CSM versus sham CSM). Blood samples were drawn before and immediately after the respective interventions. Oxytocin, neurotensin, orexin A, and cortisol were measured from the blood and serum using the Milliplex Map Magnetic Bead Panel Immunoassay on the Luminex 200 Platform. Results: In the CSM group, there were significant increases in pre- versus post-manipulation mean oxytocin (154.5 ± 60.1 vs. 185.1 ± 75.6, p = .012); neurotensin (116.0 ± 26.5 vs.136.4 ± 34.1, p < . 001); orexin A (52.2 ± 31.1 vs. 73.8 ± 38.8, p < .01) serum concentration; but no significant differences in mean cortisol (p = .052) serum concentration. In the sham group, there were no significant differences in any of the biomarkers (p > .05). Conclusion: The results of the current study suggest that the mechanical stimuli provided through a CSM may modify neuropeptide expression by immediately increasing the serum concentration of nociception-related biomarkers (oxytocin, neurotensin, orexin A, but not cortisol) in the blood of female subjects with non-specific mechanical neck pain.

¿Conoce cuál es su riesgo de tener diabetes? / Do you know your risk of having diabetes?

La diabetes mellitus tipo 2 (DM2) es una enfermedad silenciosa que afecta hasta el 20% de nuestra población y de ella, hasta el 50% desconoce que la padece. Esta enfermedad se asocia a una alta prevalencia sobre factores de riesgo como el sobrepeso, la obesidad y la inactividad física. Con frecuencia, la DM2 se diagnostica en forma tardía y a veces genera diversas complicaciones asociadas que podrían evitarse

Etiología y perfil de resistencia antimicrobiana en infecciones del pie diabético / Etiology and antimicrobial resistance profile in diabetic foot infections

El pie diabético infectado (PDI) es aquel que presenta infección de piel y partes blandas u óseas por debajo del maléolo; constituye la complicación más frecuente de diabetes que causa hospitalización y amputación. En nuestro hospital los pacientes con pie diabético son asistidos en un consultorio multidisciplinario; el 40% presenta infección leve moderada o grave

Direct measurement of toxicants inhaled by water pipe users in the natural environment using a real-time in situ sampling technique.

While narghile water pipe smoking has become a global phenomenon, knowledge regarding its toxicant content and delivery, addictive properties, and health consequences is sorely lagging. One challenge in measuring toxicant content of the smoke in the laboratory is the large number of simplifying assumptions that must be made to model a "typical" smoking session using a smoking machine, resulting in uncertainty over the obtained toxicant yields. In this study, we develop an alternative approach in which smoke generated by a human water pipe user is sampled directly during the smoking session. The method, dubbed real-time in situ sampling (RINS), required developing a self-powered portable instrument capable of automatically sampling a fixed fraction of the smoke generated by the user. Instrument performance was validated in the laboratory, and the instrument was deployed in a field study involving 43 ad libitum water pipe use sessions in Beirut area cafés in which we measured inhaled nicotine, carbon monoxide (CO), and water pipe ma'ssel-derived "tar." We found that users drew a mean of 119 L of smoke containing 150 mg of CO, 4 mg of nicotine, and 602 mg of ma'ssel-derived "tar" during a single use session (mean duration = 61 min). These first direct measurements of toxicant delivery demonstrate that ordinary water pipe use involves inhaling large quantities of CO, nicotine, and dry particulate matter. Results are compared with those obtained using the Beirut method smoking machine protocol.

Principales factores que producen fragilidad cromosómica transitoria en los pacientes referidos para estudio citogenético / Main factors that produce transitory chromosomic fragility in the patients referred for cytogenetic study

The fragile sites are specific loci that show fractures during karyotyping perform under specific laboratory conditions. Are present in normal individuals and are classified by their population frequency. These sites have been associated with an increase in chromosome fragility, fractures and other chromosomal abnormalities. In recent years, the fragile sites have taken great importance because they represent regions in the genome that are particularly sensitive to replicative stress and are frequently rearrenged in tumor cells. Multiple risk factors endogenous and exogenous have been involved in the increase in chromosome fragility, including microorganisms, drugs, illegal drugs and toxins. The fragile sites have provided insight into understanding of the effects of replicative stress on DNA damage and genomic instability in cancer cells. In this work we aim to summarize the limited information available about the topic, and the clinical significance of fragile sites in vivo in the laboratory.

A risk assessment scoring system predicts survival following the Norwood procedure.

No one set of characteristics has been consistently predictive of perioperative mortality and morbidity associated with the Norwood procedure. The purpose of the current study is to further validate a scoring system shown to be predictive of mortality following the Norwood procedure. We performed a retrospective review of all infants with the diagnosis of hypoplastic left heart syndrome (HLHS) who underwent the Norwood procedure at St. Louis Children's Hospital from July 1, 1994, to December 31, 2002. A weighted score for each of six factors comprised the scoring system. The factors included ventricular function, tricuspid regurgitation, ascending aortic diameter, atrial septal defect blood flow characteristics, blood type, and age. A score of > or = 7 points indicated lower reconstructive mortality risk, and a total score of < 7 points indicated a higher mortality risk. A total of 57 patients were analyzed. Twenty-five infants (44%) had a low risk score. These infants had a significantly greater survival at 48 hours compared to infants with a score of < 7 (92 vs 75%, p < 0.05). Infants with a high risk score had a significantly greater relative risk of mortality at 48 hours [OR = 2.04; confidence interval (CI) 1.04-4.00; p = 0.036]. The area under the receiver operating characteristic (ROC) curve is 0.8534 (95% CI, 0.78-0.922). This suggests that the scoring system has a very good degree of discriminatory power in selecting children who did not survive. Based on the results of the ROC, a cutoff score of >7 gives the best sensitivity and specificity for survival. When applied retrospectively, the survival outcomes predicted by our scoring system significantly correlated with actual outcomes. This supports the conclusion that a specific population of HLHS patients may have a higher mortality risk independent of surgical technique and postoperative care based on factors that can be assessed preoperatively.

[Prepubic TVT: a prospective study of 164 female patients treated for stress urinary incontinence]. / TVT prépubien. Etude prospective longitudinale dans le traitement de l'incontinence urinaire d'effort de la femme: à propos de 164 cas.

OBJECTIVE: A prospective open study was conducted to evaluate the prepubic (TPP) route of TVT. PATIENTS AND METHODS: 164 patients suffering from stress or mixed urinary incontinence were operated by prepubic route mainly under spinal anaesthesia. The incision is more proximal and para-uretral dissection directed more lateral to reach ischiopubic bone. The tape is introduced while keeping the needle tip close to bone to perforate between bone and ischiocavernous muscle. Then the needle is brought forwards to get its tip in vertical position and pushed under vulva to supra pubic area. A cough test is done with more pulling than in TVT since in TPP the pulling forces will act more frontally and laterally. Evaluation included detailed clinical examination with stress test, pads, endoscopic and urodynamic assessments and questionnaires in order to detect prognostic factors and to have a global treatment policy for associated low urinary tract symptoms and prolapse. RESULTS: Mean follow-up time was 20 months (14-30). No significant intraoperative complications occurred. All patients urinated the first day. The mean postvoid residual urine was 45 ml. Objective cure rate was achieved in 135 (82.3%) patients and 7 (4.3%) patients were improved while failure was observed in 22 (13,4%) patients. From patients'point of view success and satisfaction rates were 85.4% and 86%. No significant modification of sexual activity occurred. DISCUSSION AND CONCLUSION: TPP is a simple technique with very low risks and the preliminary results are consonant with those of other published techniques.

Pre-pubic TVT: an alternative to classic TVT in selected patients with urinary stress incontinence.

OBJECTIVES: To evaluate in a prospective open study a pre-pubic route of TVT for surgical treatment of female stress incontinence. STUDY DESIGN: Consecutively, 74 patients were operated using a pre-pubic TVT tape application. All women were suffering subjectively and objectively from female stress urinary incontinence. The mean post-operative follow-up time was 5 months (range 2-10 months). The pre- and post-operative evaluations were performed according to a standard protocol. RESULTS: According to the protocol, 60 patients (81%) were cured of their stress incontinence symptoms. Another 10 patients (13%) were improved. Four patients (6%) were considered failures. There were no significant intra- or post-operative complications. CONCLUSION: The short-term results of pre-pubic TVT are consonant with those of classic TVT. The risks of intra-operative complications should be reduced by the pre-pubic route. If the long-term results of pre-pubic TVT are the same as those after classic TVT, then this surgical approach may be a tentative alternative in selected high-risk patients.

Anomalías cromosómicas y citometría de flujo en adenocarcinoma de vesícula biliar / Chromosome rearrangements and flow cytometry in gallbladder carcinoma

Background: Gallbladder carcinoma is the first cause of cancer deaths among chilean women. The few cytogenetic studies performed in these tumors have not found specific or primary chromosome abnormalities. Also, no relationships with specific oncogenes have been found. Aim: To perform cytogenetic studies in gallbladder carcinoma. Material and Methods: A chromosomal study and measurement of dna content, was performed in 38 samples of advanced gallbladder carcinoma and in 40 samples of gallbladders without malignant changes. Results: Hyperploidies were found in the karyotype of 15 carcinomas (near triploidies and near teraploidies). These findings were confirmed in the cytometric study. Multiple structural chromosome abnormalities were found in 11 and 15 samples, such as translocations, deletions, inversions, isochromosomes, rings and markers. Some chromosome alterations such as interstitial deletion of chromosome 4, deletion of distal region of chromosome 12, deletion of distal segment of the short arm of chromosome 17 with a fracture point in p12 and rearrangement of chromosome 6 were repeated in 2 or more cases. Conclusions: Hyperploidies in gallbladder carcinoma are an alteration that appears in advanced stages of the tumor. Chromosomal abnormalities may be a primary or specific alteration of this tumor, whose prognostic or diagnostic role should be explored. There are ongogenes related to some mentioned chromosomal fracture points, that should be explored with molecular techniques

Varicella pneumonitis: clinical presentation and experience with acyclovir treatment in immunocompetent adults.

OBJECTIVE: Cases of varicella pneumonitis were reviewed to examine the effects of acyclovir therapy on outcome. METHODS: A retrospective chart review was done of all admissions of adults to two hospitals, between 1985 and 1995, because of complications of chickenpox. RESULTS: Fifteen patients were hospitalized for varicella pneumonitis during this period. No patient had a history of chickenpox as a child; all had a recent history (within 2-4 weeks prior to admission) of exposure to chickenpox in their family or neighborhood and developed respiratory symptoms 1 to 4 days after the appearance of the rash. Twelve patients (80%) had a history of cigarette smoking, and seven patients had a platelet count below the normal range. All patients were treated with intravenous acyclovir within 24 hours of admission, and all but one survived and were discharged from the hospital without comorbid conditions. The one mortality was attributed to bacterial superinfection. CONCLUSIONS: Acyclovir treatment may be of benefit for varicella pneumonitis, but no controlled trial has been performed to definitively answer this question.

Antifungal susceptibility of Candida isolates at the American University of Beirut Medical Center.

For the first time from Lebanon, the antifungal susceptibility patterns of 70 consecutive clinical candida isolates (each from one patient) representing 48 C. albicans, 12 C. tropicalis, 6 C. parapsilosis, 2 C. kruseii, and 2 C. (Torulopsis) glabrata were studied against amphotericin B (AP), 5-fluorocytosine (FC), ketoconazole (KE), fluconazole (FL), and itraconazole (IT) using the Epsilometer test (E-test; AB Biodisk, Solna, Sweden). The MIC90 (and MIC range, mg/l) determined, at 24 h incubation, for each antifungal agent against C. albicans were: AP 0.032 (< or = 0.002-0.064), FC 0.75 (0.023-2), KE 0.064 (0.002- > 32), FL 2 (0.064- > 256), and IT 0.19 (0.012-2), against C. tropicalis were: AP 0.016 (< 0.002-0.047), FC 0.125 (0.023-0.19), KE 0.094 (0.012-0.19), FL 2 (0.5-2), and IT 0.5 (0.047-1) and against C. parapsilosis were: AP < 0.002 (< 0.002-0.002), FC 0.047 (0.003-0.5), KE 0.004 (0.002-0.004), FL 0.125 (0.032-0.19), and IT 0.004 (< 0.002-0.004). Based on the NCCLS established MICs breakpoints, resistance was found among C. albicans to FL (MIC > or = 6 mg/l) and IT (MIC > or = 1 mg/l) in 6 and 4%, respectively, and among C. tropicalis to IT in 17% of the isolates. The susceptibility dependent upon dose (S-DD) was noted only to IT (MIC 0.25-0.5 mg/l) among C. albicans (8%) and C. tropicalis (58%). MICs determination at 48 h incubation were higher, showed more resistance rates and more endpoint trailing particularly with the azoles drugs. The small numbers of C. kruseii and C. glabrata preclude providing meaningful results. Thus, this study indicates that the antifungal susceptibility by E-test can be conveniently incorporated and performed in a hospital-based clinical laboratory. Despite the uniform susceptibility to AP and FC, resistance to azoles drugs is encountered in a range of 4-17% among candida isolates in this country.

Estudio citogenético de 663 parejas con problemas reproductivos / Cytogenetic study of 663 partners with reproductive problems

Las alteraciones cromosómicas son invocadas invariablemente como una de las causas que es necesario estudiar en primera instancia, cuando se desea establecer el diagnóstico etiológico de una pareja con problemas reproductivos. En este trabajo presentamos los resultados de 1326 exámenes citogenéticos correspondientes a 663 parejas con este tipo de problemas en un período de 17 años, en el cual se obtuvo un rendimiento del 9.2 por ciento, similar a otros reportes de la literatura. Las alteraciones estructurales más frecuentes fueron las translocaciones recíprocas, seguidas de las translocaciones robertsonianas, las inversiones y los mosaicos estructurales

Trisomía 8: reporte de cuatro casos / Chromosome 8 trisomy: report of 4 cases

La trisomía 8 es una anomalía cromosómica que en la mayoría de los casos descritos corresponde a un mosaico. Sus características clínicas varían desde dismorfias discretas hasta malformaciones severas que, por lo general, incluyen retardo mental -leve a grave-, dismorfias faciales típicas, alteraciones esqueléticas,pliegues palmares y plantares profundos,anomalías renales y otras. Con el propósto de ilustrar la variedad de las características fenotípicas de estas anomalías se describen los casos clínicos de cuatro pacientes cuyo diagnóstico se confirmó citogenéticamente, tres con trisomía en mosaico y uno con trisomía 8 completa. La solicitud del estudio citogenético tuvo su origen en la dismorfia, retrasa del desarrollo psicomotor o del lenguaje o hipotonía muscular esquelética. Es importante tener en cuenta la variedad de las caractrerísticas fenotípicas de esta trisomía, para sospechar correctamente el diagnóstico y solicitar oportunamente el estudio citogenético

Diagnóstico citogenético antenatal: indicaciones y experiencia del servicio de genética del hospital clínico Universidad de Chile / Prenatal cytogenetic diagnosis: indications and experience of the genetical service in clinical hospital of Universidad de Chile

El diagnóstico cromosómico antenatal por amniocentesis y cordocentesis se realiza desde hace 7 años en el Laboratorio de Citogenética del Hospital Clínico de la Universidad de Chile. Su principal utilidad reside en la complementación diagnóstica cuando se detecta un embarazo patológico y en la tranquilidad que le da un resultado normal a una mujer con temor de una cromosomopatía por edad materna avanzada. El hallazgo de una alteración cromosómica en líquido amniótico ha ocurrido en el 16,2 por ciento de los casos referidos por anomalías detectadas ecográficamente y sólo en el 5,0 por ciento de aquellos con edades mayores en la madre. Las cromosomopatías encontradas en sangre de cordón corresponden a un 18,2 por ciento. Es importante destacar que un resultado normal es igualmente relevante para las decisiones en el manejo pre y postnatal

Estudio cromosómico y citometría de flujo en cáncer de vesícula biliar / Chromosomic study and cytometric flow in gallbladder cancer

A través de un proyecto Fondecyt, realizamos el estudio cromosómico y del contenido de DNA (o ploidía) en citómetro de flujo, en 23 muestras de adenocarcinoma de vesícula biliar, provenientes de pacientes operados en estados clínicos avanzados, con el fin de determinar la presencia de aberraciones cromosómicas que sena específicas de este cáncer, que puedan tener algún valor en el pronóstico o diagnóstico de la enfermedad, o bien que puedan ayudar en la búsqueda de un gen responsable de su desarrollo. También buscamos alteraciones del contenido de DNA (ploidía) en las mismas muestras, para determinar su validez en el pronóstico o diagnóstico clínico como seha establecido para otros tumores malignos. Todos los casos mostraron dos poblaciones celulares y otra con múltiples aberraciones cromosómicas, tales como deleciones, traslocaciones e inversiones

Estudio citogenético en abortos espontáneos / Cytogenetic study in spontaneous abortions

La reproducción humana es un proceso relativamente poco eficiente con una tasa de abortos espontáneosde alrededor de 15 por ciento en los embarazos clínicamente reconocidos. Las causa son múltiples, encontrándose una anomalía cromosómica en aproximadamente un 50 por ciento de los casos. Reportamos los resultados del estudio citogenético de 207 muestras de trofoblasto provenientes de abortos espontáneos que nos fueron enviadas durante el período comprendido entre noviembre de 1989 y abril de 1996. El cultivo fue exitoso en 134 casos; de estos, 60 fueron anormales (44,8 por ciento). Las anomalías más frecuentes fueron las trisomías autosómicas, seguidas por las poliploidías y las alteraciones estructurales. Consideramos que este tipo de estudio es altamente valioso en el diagnóstico etiológico del aborto espontáneo, permitiendo un adecuado asesoramiento de las parejas respecto a su futuro reproductivo

Antecedentes perinatales en trisomía 18 / Perinatal antecedents in trisomy 18

La T:18 tiene una incidencia de uno en 3000 a uno en 8000 RN vivos. Muchos se pierden como AE o MN. Los RN afectados tienen una pobre sobrevida. Se revisan los antecedentes clínicos de 32 RN vivos con T:18, nacidos entre los años 1980 y 1994, enviados a nuestro Laboratorio para estudio cromosómico. El objetivo es describir algunas características de la gestación, parto y período de RN y lactante. El promedio de edad materna fue significativamente mas alto que el de la población general. De los RN vivos la mayoría fueron de sexo femenino. Los antecedentes prenatales más comunes fueron: PHA, RCIU, onfalocele; síntomas de aborto o parto prematuro. Más del 50 por ciento nacieron por cesárea. Tenían presentación podálica cuatro de seis. El Apgar al minuto fue bajo tres en más del 50 por ciento de los RN vivos. Trece de 21 fueron prematuros y 50 por ciento fueron (PEG). Las malformaciones más frecuentes fueron las cardíacas, las gastrointestinales y las genitourinarias. La sobrevida promedio fue de 52 días. Damos énfasis en la importancia del diagnóstico temprano de la T:18 para que de este modo los padres y neonatólogos tomen las decisiones adecuadas en relación al manejo