[Implementation of a clinical prediction tool in renal transplant recipients]. / Aplicación de una herramienta de predicción pronóstica en receptores de trasplante renal.

BACKGROUND: Kasiske developed a tool for predicting the risk of 5-year graft loss. We analyzed our results using this model. METHODS: 109 deceased donor kidney transplants were included. 5-year probability of graft survival was calculated during transplantation, seven days after transplantation and 1-year after transplantation. Z-test and ROC curves were used for proportion differences and discrimination ability. RESULTS: Mean age of donor and recipient was 33.7 and 33.9 years, respectively. 59.6% died due to trauma. Mean of years on dialysis was 3.7. 22.9% of patients had delayed graft function (DGF). Calculated 5-year probability of graft survival during transplantation time was 74.1%; 7 days after transplantation, 74.9%; and one year after transplantation, 76.4%. 5-year death censored graft survival was 64.9%. There were no differences between death-censored graft survival and calculated probabilities (Z-test), with a C-statistic value of 0.54 ± 0.6 (95%CI 0.42-0.65, p = 0.5) and 0.51 ± 0.6 (0.39-0.63, 95% CI, p = 0. 7) for transplant time and seven days after. C-statistic value 1-year after transplantation was 0.68 ± 0.8 (95%CI 0.52-0.84, p = 0.02). CONCLUSION: Only calculated 5-year graft survival one year after transplantation had modest prediction ability.

Introducción: Kasiske desarrolló una herramienta para predecir el riesgo de pérdida del injerto a cinco años. Se analizaron los resultados utilizando este modelo. Métodos: se incluyeron 109 pacientes trasplantados de donantes fallecidos. La probabilidad de sobrevida del injerto a cinco años fue calculada al momento del trasplante, a los siete días y al año. La prueba Z y las curvas ROC fueron utilizadas para diferencias de proporción y capacidad de discriminación. Resultados: la media de edad del donador y del receptor fue 33.7 y 33.9 años, respectivamente. El 59.6% falleció de trauma. La media de años en diálisis fue de 3.7. El 22.9% tuvo retraso en la función del injerto. La probabilidad de sobrevida a cinco años del injerto en el momento del trasplante fue de 74.1%; siete días después fue de 74.9% y al año 76.4%. La sobrevida actuarial a cinco años del injerto fue 64.9%. No hubo diferencias entre la sobrevida del injerto y las probabilidades calculadas (prueba Z) con valor estadístico C de 0.54 ± 0.6 (intervalo de confianza al 95% [IC 95%] 0.42-0.65, p = 0.5) y 0.51 ± 0.6 (IC 95% 0.39-0.63, p = 0.7) para el tiempo de trasplante y al séptimo día. El valor estadístico C después del trasplante a un año fue de 0.68 ± 0.8 (IC 95% 0.52-0.84, p = 0.02). Conclusión: existió una predicción modesta al calcular la sobrevida del injerto a cinco años a un año posterior al trasplante.

[Diet and polymer standard vs. standard in the nutritional status of elderly patients with fragility]. / Dieta estándar y polimérica frente a estándar en el estado nutricio del paciente geriátrico con fragilidad.

BACKGROUND: The elderly patients with fragility show different physiological changes, so they are given polymeric diets to maintain and/or alter their nutritional status. The aim of this paper is to demonstrate the effect of changing a standard polymeric diet and a standard diet on nutritional status in elderly patients with fragility. METHODS: Clinical randomized controlled trial in 23 elderly patients, 70 years of age or older, with fragility, hospitalized in a Internal Medicine Unity in a period from July to December 2014. Nutritional status was determined through Minimum Nutritional Consulting (MNA) and body mass index (BMI). Descriptive statistics, Chi square, Student t test and McNemar. RESULTS: In the G1: 12 patients were in the G2 and 11, a positive change was observed in the nutritional status G1 initially being 14.00 (malnutrition) and end 22.75 (risk of malnutrition). According to BMI (kg/m2) was evident at the beginning 25 % of patients (3) with mild malnutrition, but the final results show figures with a zero percentage of malnourished patients. CONCLUSIONS: The use of standard polymeric diet increases body weight, BMI and nutritional status in elderly patients with fragility.

Introducción: los pacientes geriátricos con fragilidad evidencian diferentes cambios fisiológicos, por lo que les son indicadas dietas poliméricas para mantener y/o modificar su estado nutricio. El objetivo de este artículo es demostrar el efecto al cambiar de una dieta estándar y polimérica a una dieta estándar en el estado nutricio en el paciente geriátrico con fragilidad. Métodos: ensayo clínico controlado aleatorizado en 23 pacientes geriátricos, de 70 años de edad o más, con fragilidad, en un periodo comprendido de julio a diciembre de 2014. Se determinó estado nutricional mediante la Mini Nutritional Asssessment y el índice de masa corporal. Análisis estadístico descriptivo, Chi cuadrada, t de Student y McNemar. Resultados: en el G1: fueron 12 pacientes y en el G2 11, se constató un cambio positivo en el G1 en el estado nutricional, siendo inicialmente de 14.00 (malnutrición) y al final de 22.75 (riesgo de desnutrición). De acuerdo al IMC (kg/m2) se evidenció al inicio, al 25 % de pacientes con desnutrición leve, pero los resultados finales arrojan cifras con un porcentaje nulo de pacientes desnutridos. Conclusiones: el consumo de dieta estándar y polimérica incrementa el peso corporal, IMC y el estado nutricio en pacientes geriátricos con fragilidad.

[Lactate levels as a predictor of mortality in patients with septic shock]. / Niveles de lactato como predictor de mortalidad en pacientes con choque séptico.

BACKGROUND: The objective was to determine the association between serum lactate levels and mortality in patients with septic shock in the Emergency Room of the Instituto Mexicano del Seguro Social's Centro Médico Nacional Adolfo Ruiz Cortines. METHODS: We included the patients admitted to the Emergency Room with diagnosis of septic shock who had measure of serum lactate at admission during the period 01-12/2013; it was a case-control study. The cut-off value of serum lactate associated with mortality was performed using the ROC (receiver operating characteristic) curves. RESULTS: Sixty-seven patients were studied, out of which 56 survived (cases) and 11 died (controls). There was no association with gender, age and comorbidities. The cut-off value for mortality of serum lactate was 4.9 mmol/L. Ten patients out of 40 with lactate levels > 4.9 mmol/L, and only one out of 27 with lactate < 4.9 mmol/L died (p = 0.04); odds ratio was of 8.7. The mortality in patients with septic shock and lactate > 4.9 mmol/ is high and had a sensitivity of 90.9 % and specificity of 46.4 %. CONCLUSIONS: The levels of serum lactate greater than four are associated to an increased risk of mortality in patients with septic shock.

Introducción: el objetivo fue determinar la asociación que existe entre los niveles de lactato sérico y la mortalidad de los pacientes con choque séptico en el Servicio de Urgencias del Centro Médico Nacional "Adolfo Ruiz Cortines" del Instituto Mexicano del Seguro Social. Métodos: se estudiaron los pacientes que ingresaron al Servicio de Urgencias con diagnóstico de choque séptico y a quienes se les determinó lactato sérico al ingreso durante el periodo que abarca de enero a diciembre de 2013; se trató de un estudio de casos y controles. El valor de corte del lactato sérico asociado a mortalidad se realizó con las curvas ROC (del inglés receiver operating characteristic: característica operativa del receptor). Resultados: se estudiaron 67 pacientes del mes de enero al mes de diciembre del 2013. Sobrevivieron 56 (casos) y murieron 11 (controles). No hubo asociación con el género, la edad y las comorbilidades. El valor de corte para mortalidad del lactato sérico fue de 4.9 mmol/L. Fallecieron 10 de 40 pacientes con niveles de lactato > 4.9 mmol/L en comparación con solo uno de 27, con < 4.9 mmol/L, (p = 0.04) y razón de momios de 8.7. La mortalidad con valores de lactato > 4.9 mmol/L tuvo una sensibilidad de 90.9 % y una especificidad de 46.4 %. Conclusiones: los niveles de lactato sérico mayores a 4 mmol/L están asociados a un mayor riesgo de mortalidad en pacientes con choque séptico.

Resultados a 5 años de trasplante renal de donante vivo sin inhibidores de calcineurina / Results 5 years after living donor renal transplantation without calcineurin inhibitors

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Factores asociados con el cambio temprano de catéter de diálisis peritoneal en Veracruz, México / Factors associated with early peritoneal dialysis catheter replacement in Veracruz, Mexico

Antecedentes: Las complicaciones asociadas con el catéter en diálisis peritoneal causan disminución en su eficacia e interrupción de ésta, conversión a hemodiálisis, hospitalizaciones y necesidad de cirugía para cambiar el catéter. Objetivos: Determinar factores de riesgo para la disfunción temprana del catéter que hace necesario su cambio. Métodos: Se incluyeron 235 catéteres colocados con técnica quirúrgica abierta en línea media infraumbilical. Dentro de los posibles factores de riesgo se incluyó: edad, género, índice de masa corporal, área de superficie corporal, diabetes, enfermedad poliquística renal, cirugía previa, tiempo quirúrgico, omentectomía, omentopexia, infección de la herida y hernia posincisional. Resultados: El cambio del catéter por disfuncionalidad ocurrió en 47 pacientes (20%) durante el primer año. La complicación más frecuente fue: migración del catéter y peritonitis (4,3% en ambos casos), además de obstrucción por el omento (3,7%). En el análisis univariado, los pacientes que presentaron disfunción del catéter/cambio eran jóvenes con índice de masa corporal y área de superficie corporal bajos (p < 0,05). La infección de la herida y la hernia posincisional estaban asociados significativamente con el cambio de catéter. La omentectomía fue asociada a baja incidencia de disfunción de catéter/cambio en el análisis univariado y regresión logística (razón de momios: 0,275, intervalo de confianza: 95%, 0,101-0,751, p < 0,012). Conclusiones: Nuestra técnica de inserción de catéter ofrece bajas tasas de complicaciones y buenos resultados el primer año posquirúrgico. Además de la omentectomía, en nuestro estudio no se encontró un factor de riesgo para cambio de catéter en nuestra población. La omentectomía tuvo un efecto protector en términos de cambio de catéter (AU)

Introduction: Catheter-related complications in patients on peritoneal dialysis lead to decreased effectiveness and discontinuation of the technique, conversion to haemodialysis, hospitalisation, and surgical interventions to replace the catheter. Objectives: Determine risk factors for early catheter dysfunction that result in the need for replacement. Methods: We analysed 235 catheters placed by open surgery using an infra-umbilical midline incision. Possible risk factors included the following: age, sex, body mass index, body surface area, diabetes, polycystic kidney disease, previous surgery, time of surgical procedure, omentectomy, omentopexy, wound infection and postoperative incisional hernia. Results: During the first year, 47 patients (20%) required a catheter replacement due to poor function. The most common complications were catheter migration and peritonitis (4.3% in both cases), followed by obstruction from omental wrapping (3.7%). Univariate analysis showed that patients with catheter dysfunction or requiring catheter replacement were younger, with a lower body mass index and body surface area (P<.05). There was a significant association of wound infection and post-operative incisional hernia with catheter replacement. Omentectomy was associated with a low incidence rate of catheter dysfunction/replacement in the univariate and logistical regression analyses (odds ratio: 0.275; 95% confidence interval: 0.101-0.751; P<.012). Conclusions: Our catheter placement technique offers a low complication rate and good results in the first year after surgery. Except for omentectomy, we did not discover any risk factors for catheter replacement in our study population. Omentectomy had a protective effect in terms of catheter replacement (AU)

Factors associated with early peritoneal dialysis catheter replacement in Veracruz, Mexico.

INTRODUCTION: Catheter-related complications in patients on peritoneal dialysis lead to decreased effectiveness and discontinuation of the technique, conversion to haemodialysis, hospitalisation, and surgical interventions to replace the catheter. OBJECTIVES: Determine risk factors for early catheter dysfunction that result in the need for replacement. METHODS: We analysed 235 catheters placed by open surgery using an infra-umbilical midline incision. Possible risk factors included the following: age, sex, body mass index, body surface area, diabetes, polycystic kidney disease, previous surgery, time of surgical procedure, omentectomy, omentopexy, wound infection and postoperative incisional hernia. RESULTS: During the first year, 47 patients (20%) required a catheter replacement due to poor function. The most common complications were catheter migration and peritonitis (4.3% in both cases), followed by obstruction from omental wrapping (3.7%). Univariate analysis showed that patients with catheter dysfunction or requiring catheter replacement were younger, with a lower body mass index and body surface area (P<.05). There was a significant association of wound infection and post-operative incisional hernia with catheter replacement. Omentectomy was associated with a low incidence rate of catheter dysfunction/replacement in the univariate and logistical regression analyses (odds ratio: 0.275; 95% confidence interval: 0.101-0.751; P<.012). CONCLUSIONS: Our catheter placement technique offers a low complication rate and good results in the first year after surgery. Except for omentectomy, we did not discover any risk factors for catheter replacement in our study population. Omentectomy had a protective effect in terms of catheter replacement.

Evaluation of previous abdominal pain episodes in women with biliary pancreatitis: possible higher incidence of recurrent attacks.

BACKGROUND AND AIM: Recurrent biliary pancreatitis is described as episodes of new abdominal pain after diagnosis of pancreatitis. Few studies have analyzed the abdominal pain before the diagnosis of acute pancreatitis. Our study aimed to analyze factors associated with previous abdominal pain episodes in patients with biliary pancreatitis, and elucidate its possible pancreatic origin. METHODS: Data from direct interrogation and medical records was analyzed from 48 hospitalized female patients with diagnosis of acute biliary pancreatitis. RESULTS: Mean age of our patients was 31.6 years (SD +/- 13.9). Forty one (85.4%) patients gave history of at least one previous abdominal pain episode. During the episode 37 (90.2%) patients received H2 receptor antagonist or proton pump inhibitors as treatment; 26 (63.4%) had epigastric pain; 23(56.1%) gave association with cholecystokinetic food; 21 (51.2%) complained of nausea and/or vomiting; 23 (56.1%) had jaundice, acholia and/or dark urine; and 20 (48.9%) patients had microlithiasis and/or biliary sludge. CONCLUSIONS: Previous abdominal pain episodes had similar characteristics to a pancreatic episode in a high percentage of our patients. These characteristics suggest that these episodes are often undiagnosed pancreatic attacks.

Morbilidad y mortalidad después de la cirugía de pacientes en diálisis: Estudio de casos y controles / Morbidity and mortality after surgery in patients undergoing dialysis: cases and controls study

Objetivo: Describir nuestra experiencia quirúrgica en pacientes en diálisis, centrándose en la identificación de factores de riesgo perioperatorios (30 días) para morbilidad y mortalidad. Sede: CMN Adolfo Ruiz Cortines, Unidad Médica de Alta Especialidad 189, del Instituto Mexicano del Seguro Social, Veracruz, México. Diseño: Observacional, descriptivo, retrospectivo, transversal. Análisis estadístico: Desviación estándar y rango, método de la Chi-cuadrada (χ²) y el test de Mantel-Haenszel, análisis multivariado de regresión logística lineal. Material y métodos: Estudio retrospectivo de 6 años de revisión de casos y controles de 108 pacientes en diálisis sometidos a cirugía. El grupo de casos incluyó pacientes que sufrían una complicación o muerte. Los factores de riesgo evaluados: edad, género, índice de masa corporal, diabetes, tipo de diálisis, cirugía de emergencia, hemoglobina, urea, creatinina, albúmina y estancia hospitalaria. Resultados: La cirugía más común fue plastía de hernias de pared abdominal (n = 64), cirugía gastrointestinal (n = 18) y colecistectomía laparoscópica (n = 8). La tasa de morbilidad y mortalidad fue 25 y 9.3%, respectivamente. Los factores de riesgo identificados en análisis univariado (p < 0.05) fueron cirugía de emergencia, nivel bajo de hemoglobina, albúmina baja y estancia hospitalaria. El análisis multivariado confirmó la albúmina baja y estancia hospitalaria (p < 0.02) como factores de riesgo de morbilidad y mortalidad. Conclusiones: Los pacientes en diálisis tienen alta tasa de complicaciones y mortalidad después de la cirugía, que se relaciona con factores que dan pobres resultados, los cuales podrían ser corregidos con el fin de mejorar la morbilidad y la mortalidad.

Objective: To describe our surgical experience with patients undergoing dialysis, addressing the identification of perioperative (30 days) risk factors for morbidity and mortality. Setting: CMN Adolfo Ruiz Cortines, Unidad Médica de Alta Especialidad 189, of the Instituto Mexicano del Seguro Social [High Speciality Medical Unit of the Mexican Institute of Social Welfare], in Veracruz, Mexico. Design: Observational, descriptive, retrospective, cross-sectional study. Statistical analysis: Standard deviation and range, Chi square (χ²) and Mantel-Haenszel test. Linear logistic regression multivariate analysis. Material and methods: A six-year retrospective study of cases and controls reviewing 108 patients undergoing dialysis and subjected to surgery. The group of cases included patients with complications or who died. Assessed risk factors were: age, gender, body mass index, diabetes, type of dialysis, emergency surgery, hemoglobin, urea, creatinine, albumin, and in-hospital stay. Results: The most common surgeries were abdominal wall hernia repair (n = 64), gastrointestinal surgery (n = 18), and laparoscopic cholecystectomy (n = 8). Rates of morbidity and mortality were 25 and 9.3%, respectively. The identified risk factors through the multivariate analysis (p < 0.05) were emergency surgery, low hemoglobin level, low albumin, and in-hospital stay. Multivariate analysis confirmed low albumin and in-hospital stay as risk factors (p < 0.02) for morbidity and mortality. Conclusions: Patients undergoing dialysis have a high rate of complications and mortality after surgery related to factors that yield poor results, which could be corrected to improve the morbidity and mortality rates.

Prevalence and risk factors of hepatitis C virus, hepatitis B virus, and human immunodeficiency virus in multiply transfused recipients in Mexico.

BACKGROUND: Transfusion-transmitted viral infection (TTI) is a major problem in patients receiving blood products. Monitoring high-risk patients is essential for assessing the epidemiology of blood-borne infections. STUDY DESIGN AND METHODS: A 1-year, cross-sectional seroprevalence study in patients with a history of multiple transfusions was conducted. Peripheral blood samples were titered to detect serologic markers of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). The presence of these viruses and demographic, behavioral, and medical traits were assessed. RESULTS: A total of 300 male and female multiply transfused patients with a mean age of 30.7 (+/-17.5) years were studied. The prevalence was 13.7% for HCV, 7% for HBV, and 1.7% for HIV. Patients with hemophilia had the highest prevalence for HCV and HIV infections, and hemodialyzed patients, for HBV infection. The risk factors related to acquired HCV were hemophilia (odds ratio [OR], 5.6; 95% confidence interval [CI], 2.5-12.6), more than five hospitalizations (OR, 3.8; 95% CI, 1.6-8.9), and having received a transfusion before mandatory screening in 1993 (OR, 8.4; 95% CI, 2.0-34.6), and for HIV, having received a transfusion before 1987 (OR, 19.0; 95% CI, 2.0-177.7). The main risk factors for HBV were having end-stage renal disease and being treated with hemodialysis (OR, 3.7; 95% CI, 1.4-9.9) and transplantation (OR, 4.2; 95% CI, 1.4-12.1). CONCLUSIONS: This study showed that HCV infection was more frequently identified than HBV and HIV infections in multiply transfused Mexican patients. Additionally, several risk factors are associated with TTI such as mandatory screenings before 1987 and 1993, which were the most important for HIV and HCV infections but not for HBV.

[Tomography-electroencephalography agreement in pediatric patients with epilepsy]. / Concordancia electroencefalográfica-tomográfica en pacientes pediátricos con epilepsia.

OBJECTIVE: to evaluate the tomography-electroencephalography agreement in pediatric patients attended with epilepsy diagnosis at service neuropediatric in the Medical Unit of High Specialization "Adolfo Ruiz Cortines," during the period from January to October of year 2006. METHODS: retrospective, cross-sectional, descriptive, correlational, observational. One hundred eighty files of pediatric patients were reviewed with clinical diagnosis of epilepsy with electroencephalography of date next to their study of tomography; the agreement was realized with the test of kappa, comparing the results of each diagnosis method, in each patient. RESULTS: of 69 patients, 10 patients were catalogued as normal by both methods and 23 showed cerebral alterations in the same site of epilepsy focus; the observed agreement was 47.8 % with an index of kappa of 0.095 CONCLUSION: the agreement between the electroencephalography and the computed tomography is very low, in the findings of cerebral structural injuries related to the location of the epilepsy focus in pediatric patients with epilepsy diagnosis.

[The burnout syndrome in medical residents working long periods]. / Síndrome de burnout en residentes con jornadas laborales prolongadas.

OBJECTIVE: to evaluate the burnout syndrome in medical residents with working periods longer than 80 hours per week. METHODOLOGY: an analytical cross-sectional study was conducted with medical residents working at Instituto Mexicano del Seguro Social hospital in Veracruz, México. The residents were classified in two groups. One group working for > or = 80 h per week (study group, SG) and another group working < 80 h per week (comparison group, CG) were studied. Participants were selected by simple random sampling. The clinical evaluation instrument was the scale of Maslach burnout inventory. RESULTS: 143 medical residents were included in the sample (SG n = 72, CG n = 71); the average age was 29.6 +/- 2.5 years, 65 % were males and 51 % were unmarried. Their length of service was 2.2 +/- 0.7 years. The mean working time was 100.5 +/- 7.2 hours per week for the SG and 64.4 +/- 9.3 hours for the CG. Burnout syndrome was present in 46 (63.8 %) medical residents with long workdays (p = 0.002); it was observed more frequently in those residents that were on call 3 times per week (p = 0.002) and among surgery residents (p = 0.035). CONCLUSION: working periods longer than 80 h per week are related to the appearance of burnout syndrome.

Pediatric renal transplantation with mycophenolate mofetil immunosuppression in a single center from Mexico.

An MMF-based immunosuppression has reduced the acute rejection rate in adults and in children in the early post-transplantation period. In the present study, pediatric renal transplantation patients on a CyA, MMF, and steroids regimen were prospectively evaluated. Patients with CyA, MMF, and steroid therapy without antibody induction were evaluated for surgical aspects, renal function, rejection, and survival, growth after transplantation, adverse events and medication discontinuation. Between February 2003 and May 2005, 21 kidney transplantation patients under 18 yr old were followed for at least 12 months. Within one year after transplantation, three patients developed four episodes of acute rejection (19%). Graft loss because of rejection occurred in one patient. One-year mean serum creatinine was 1.19 +/- 0.3 mg/dL. Mean calculated CrCl by Schwartz formula was 82.3 +/- 19.7 mL/min*1.73 m(2). Major adverse events included infections of the urinary tract and diarrhea, abdominal pain, and GI symptoms. No patients have discontinued the use of MMF. Good results in pediatric kidney transplantation can be achieved by using CyA/MMF/steroids. MMF is effective and relatively safe in reducing the incidence of acute rejection even without induction therapy 12 months after transplantation.

Cardiovascular risk stratification by means of the SCORE system in health care workers in Veracruz, Mexico.

BACKGROUND: To assess cardiovascular disease risk by means of the SCORE system (Systematic Coronary Risk Evaluation) in health care workers (HCW) from Veracruz, Mexico. METHODS: A cross-sectional study was undertaken at the Mexican Institute of Social Security from Veracruz. Seventy six HCW without physical limitations (NYHA Functional Class I) were included. All HCW answered a standardised medical history questionnaire and were evaluated by physical examination and lab tests. The cardiovascular risk was assessed through the SCORE system. RESULTS: The median age of participants was 47 years (90% range 42-57 years), female HCW had higher prevalence of obesity and lower prevalence of overweight compared to male HCW (52% vs 23% for obesity and 26% vs 63% for overweight; p=0.014). The prevalence of hypertension was 22%, type 2 diabetes 8%, hypercholesterolemia 70%, hypertriglyceridemia 47% and mixed hyperlipidemia 26%. Cardiovascular risk assessed by the SCORE system showed that 14% of all patients had a cardiovascular risk higher than 2% and 51% had a risk lower than 1%. CONCLUSIONS: In this first study of cardiovascular risk assessment by means of the SCORE system in HCW in Mexico, we found that 14% of them have a cardiac risk higher than 2% and that it is double than expected for their age but it is lower than reported in a European population. Also, we found a higher prevalence of hypercholesterolemia and mixed hyperlipidemia showing poor education and treatment for cardiovascular prevention.