Towards the personalization of septic shock resuscitation: the fundamentals of ANDROMEDA-SHOCK-2 trial.

Septic shock is a highly lethal and prevalent disease. Progressive circulatory dysfunction leads to tissue hypoperfusion and hypoxia, eventually evolving to multiorgan dysfunction and death. Prompt resuscitation may revert these pathogenic mechanisms, restoring oxygen delivery and organ function. High heterogeneity exists among the determinants of circulatory dysfunction in septic shock, and current algorithms provide a stepwise and standardized approach to conduct resuscitation. This review provides the pathophysiological and clinical rationale behind ANDROMEDA-SHOCK-2, an ongoing multicenter randomized controlled trial that aims to compare a personalized resuscitation strategy based on clinical phenotyping and peripheral perfusion assessment, versus standard of care, in early septic shock resuscitation.

Disfunción miccional en el adulto. Un artículo docente / Voiding dysfunction in the adult. A teaching article

Voiding dysfunction is defined as an abnormally slow and/or incomplete micturition, and can be divided in bladder outlet obstruction (BOO) and detrusor underactivity (or hypocontractility). BOO is characterized by reduced urine flow rate and increased detrusor pressure, and can be of anatomical or functional origin. Detrusor underactivity encompasses a reduced urine flow rate associated to low pressure and/or poorly sustained detrusor contraction, and its etiology is multifactorial. Lower urinary tract symptoms are classified as storage, voiding and post micturition symptoms, may be objectively quantified with specific questionnaires, and don't correlate properly with voiding dysfunction. Patients' evaluation requires a directed physical examination of the abdomen, pelvis and genitals focused to detect anatomical and neurological abnormalities. Voiding dysfunction can be demonstrated non-invasively using uroflowmetry and pelvic ultrasound. Uroflowmetry allows determining urinary flow characteristics and their most important parameters are voided volume, maximum flow rate and shape of the curve. Pelvic ultrasound permits to estimate prostatic size and post void residual, suspect detrusor hypertrophy (due to BOO) and detect bladder stones. Invasive test must be reserved for special cases of confirmed voiding dysfunction: cystoscopy when there is concomitant hematuria, urethrocystography to study urethral stenosis and urodynamics to differentiate BOO from detrusor underactivity. (AU)

Physical properties of new ordered bimetallic phases M0.25Cd0.75PS3 (M = ZnII, NiII, CoII, MnII).

Four bimetallic phases of the thiophosphate family have been synthesized by the cationic exchange reaction using a freshly prepared K0.5Cd0.75PS3 precursor phase and methanolic solutions of nitrates of the divalent cations ZnII, NiII, CoII, and MnII. All the materials were characterized by FTIR, PXRD, SEM-EDXS and (in the case of the diamagnetic compounds) by solid state NMR. For the K0.5Cd0.75PS3 precursor, the X-ray powder diffraction data suggest a modification of the structure, while solid state NMR results confirm that this phase possesses an ordered arrangement of Cd vacancies. The cationic exchange reaction achieves a complete removal of potassium ions (no potassium detected by SEM-EDXS) and re-occupation of the vacancies by divalent cations. Therefore, the obtained compounds have an average composition of M0.25Cd0.75PS3 (M = ZnII, NiII, CoII, MnII) and possess an ordered distribution of the substituent cations. Even with the paramagnetic substitution level of 25%, antiferromagnetic behaviour is present in the phases with MnII, CoII and NiII, as evidenced by dc susceptibility and in the case of the MnII substituted phase by EPR. The cooperative magnetic interactions confirm the conclusion that the paramagnetic ions adopt an ordered arrangement. The analysis by broad band impedance spectroscopy allows to attribute the conductivity in these materials to charge movements in the layers due to the difference in electronegativity of the metal ions. Zn0.25Cd0.75PS3 is the phase that shows the highest conductivity values. Finally, the band gap energies of the bimetallic phases tend to be lower than those of the single-metal phases, probably due to an overlap of the band structures.

Heterometallic CuII/LnIII polymers active in the catalytic aerobic oxidation of cycloalkenes under solvent-free conditions.

Heterometallic 3d-4f inorganic polymers were prepared using 3,5 pyridinedicarboxylic acid (H2PDC), {[CuLn2(PDC)2(SO4)2(H2O)6]·H2O}n (Ln: SmIII, CuSmPDC, EuIII, CuEuPDC, GdIII, and CuGdPDC). These catalysts are active in the aerobic oxidation of cycloalkenes under solvent-free conditions, with a conversion for the oxidation of cyclohexene of 71% after one hour of the reaction, and a TOF value of 1438 h-1 for CuSmPDC. On the other hand, the oxidation of cycloheptene and cyclooctene exhibited slightly lower conversions of 52% and 47%, and TOF values of 1053 and 159 h-1 after 1 and 6 hours of the reaction, respectively. The radical mechanism for the oxidation reaction of cyclohexene was assessed by Raman and EPR spectroscopy. The first evidenced the formation of Cu-O2 adducts and the second permitted is to observe the presence of the oxygen centered radical species, which act as initiators of the reaction chain to generate the products. An increase in the temperature of the reaction correlates with the adduct formation, and with the enhancement of the oxidation reaction.

Fístulas vesicovaginales / Vesicovaginal fistulas

Objetivo: mostrar nuestra experiencia en el manejo de las fístulas vesicovaginales (FVV), analizando etiología, diagnóstico, tratamiento quirúrgico y complicaciones postoperatorias. Material y método: estudio descriptivo retrospectivo de pacientes hospitalizados con diagnóstico de FVV entre enero de 1987 y diciembre de 2000. Serie constituida por 35 pacientes, edad promedio 47 años, 22,8 por ciento de cirugía reparadora previa en otro centro. Resultado: el diagnóstico fue hecho por pérdida de orina vaginal y prueba de azul de metileno vesical positiva. La cistoscopia fue concluyente en el 94,3 por ciento requiriendo uretrocistografía los casos restantes. No hubo asociación con fístulas ureterovaginales. fueron secundarias a cirugía ginecobstétrica (82,9 por ciento) y radioterapia por cáncer cervicouterino (17,1 por ciento). Se intervinieron 34 pacientes, dividiéndose en: a) FVV secundarias a cirugía ginecobstétrica: 28 reparaciones transvesicales, con 4 recidivas y 1 reparación supravesical que no recidivó. b) FVV secundaria a radioterapia por cáncer cervicouterino: 3 derivaciones urinarias (2 neovejigas continentes y 1 conducto iliar) y 2 reparaciones supravesicales, las cuales recidivaron. No hubo mortalidad operatoria en la serie. Conclusiones: todas las FVV fueron secundarias a procedimientos ginecobstétricos. Preferimos la técnica supravesical con éxito superior al 85 por ciento. La mayor dificultad está dada por las FVV secundarias a radioterapia

Migración intratorácica de cálculos biliales post colecistectomia laparoscópica: complicación poco habitual / Intrathoracic migration of gallstones after laparoscopic cholecystectomy: unusual complication

El hecho de haber operado un caso de cálculos biliares intratorácicos, subpleurales en una paciente colecistectomizada vía laparoscópica hace dos años, nos motivó a la siguiente revisión. En la literatuta mundial se reportan 49 casos de complicaciones por cálculos abandonados en el peritoneo durante colecistectomías laparoscópicas. Seguramente la frecuencia es mayor, sin embargo, gran número de ellos no han sido reportados

[Erythropoietin and transfusions in patients with anemia of chronic renal failure origin : an update view]. / Eritropoietina y transfusiones en la anemia del insuficiente renal crónico: visión actualizada.

Aiming to know the factors that influenced the use of erythropoietin (EPO) in chronic hemodialysis patients, we retrospectively studied 82 patients (41 male), of whom 15 received EPO. No differences, between patients receiving or not receiving EPO, were found in age (46.9 +/- 25 and 57 +/- 13 years respectively), male/female ratio (9/6 and 32/35 respectively), time on dialysis (36.4 +/- 25.6 and 36.8 +/- 31.8 months respectively), dialysis hours (3.19 +/- 0.6 and 3.33 +/- 0.39 h respectively) and proportion of diabetics (6.6 and 20.8% respectively). Prior to EPO use and compared to untreated patients, treated patients were transfused with a higher frequency (60 vs 22%) and with more units/patients/years (0.12 vs 0.08). Hemoglobin levels at the start of the treatment was similar in treated and untreated patients (8.4 +/- 1.46 vs 8.78 +/- 1.97 g/dl). EPO was indicated in 11 patients due to general symptomatology associated to anemia and in 4 due to cardiac failure or angina. We conclude that EPO treatment is indicated in approximately 18% of patients in dialysis. An adequate dialytic treatment may achieve optimal hemoglobin levels with minimal transfusion requirements and without need of EPO, thus reducing costs.

[Chronic intermittent peritoneal dialysis: a 12-year experience]. / Peritoneo diálisis crónica intermitente: 12 años de experiencia.

Since 1981, we have treated 46 adults aged 56 +/- 21 years, of whom 17 were diabetic, with intermittent peritoneal dialysis. Their mean time on dialysis has been 21 months with an accumulated experience of 493 months/patient. The program included 2 dialyses per week, 25 exchanges of 21 per session and 30 min of dwell time. Arterial pressure control has been satisfactory. Diabetic patients had lower levels of serum calcium, alkaline phosphatases and m-PTH. The incidence of peritonitis has been 1 episode/14 months/patient and the causative agent has been Staphylococcus aureus in 47% of episodes. Mean catheter duration has been 15 months and 1 episode/34 months/patient of exit site infection has been recorded and Staphylococcus aureus has been the causative agent in 83% of episodes. The risk of acquiring the first peritonitis was 12% at 3 months, 23% at 6 months and higher for non diabetic patients. Actuarial survival of treated patients at 12 and 24 months was 89 and 67% respectively. No differences in survival were recorded between diabetic and non diabetic patients. Fifty two percent of patients that dropped out continued on hemodialysis, 23% died, 11% abandoned treatment, 8% continued on chronic ambulatory peritoneal dialysis and 6% received a kidney allograft. We conclude that intermittent peritoneal dialysis is a good alternative treatment of chronic renal failure, even in diabetic patients.

[Chronic dialysis in advanced age patients: a reasonable therapeutic alternative?]. / Dialisis cronica en pacientes de edad avanzada: una alternativa terapeutica razonable?

Thirty two elderly patients (mean age 68.8 +/- 6.95 years) were treated by maintenance hemodialysis or intermittent peritoneal dialysis. 28.1% were diabetics and no survivors in this group were observed after 24 months. Median survival for non diabetic patients was 72.4 months vs 9.03 months in diabetics (p < 0.01). The main cause of death was discontinuation of dialysis (33%) or cardiovascular disease. Thus, chronic dialysis is a reasonable treatment for elderly patients with end stage renal disease. However, diabetes is associated to a poor prognosis.

[The discontinuation of chronic dialysis treatment]. / Suspensión del tratamiento de diálisis crónica.

Chronic dialysis was discontinued in 11 patients with end-stage renal disease. Most patients were diabetics of old age and all had presented a variety of acute medical complications. The patient initiated the decision in 2 cases, the medical team in 4 and the medical team and family in 5. Five patients were mentally incompetent when the decision was made.

[Intermittent peritoneal chronic dialysis in diabetic patients: effect of the technique on blood glucose and protein loss during the procedure]. / Peritoneo diálisis crónica intermitente en el paciente diabético. Repercusión de la técnica en las glicemias y en la pérdida de proteínas durante el procedimiento.

We performed a prospective study in 4 diabetic (one insulin dependent) patients with end stage chronic renal disease, in whom intermittent peritoneal dialysis was performed with and without addition of insulin to the dialysate. Plasma levels of glucose and insulin were compared to those obtained in 5 non-diabetic controls. With no insulin added, absolute changes in glucose and insulin from predialysis levels were similar in diabetics and non-diabetics. The addition of insulin to the dialysate did not modify nitrogen losses through the peritoneal membrane. The absorption of glucose from the dialysate fluid in the presence of insulin was greater in diabetics than in non-diabetic patients (p less than 0.01).

[Intermittent peritoneal dialysis: a 6 years' experience]. / Peritoneo diálisis crónica intermitente: seis años de experiencia.

We show our experience, results and complications with Intermittent Peritoneal Dialysis (IPD). We treated with this technique 28 patients with end stage renal disease (ESRD), between 1981-1988; (24 adults, 8 of them with diabetic nephropathy (6 non insulin dependent diabetic patients and 4 children) for 3 to 36 months. IPD was well tolerated. The extracellular volume control, haematocrit and plasma protein values, as well as, ac-base equilibrium nutritional status, ureic nitrogen and creatinine plasma levels, were fully satisfactory. There was statistical difference only in the Na+ (p less than 0.001), alkaline phosphatases (p less than 0.005), glucose (p less than 0.05) plasma values and glycosylated hemoglobin (p less than 0.05), between diabetics and non diabetics group. The peritonitis rate was 0.065 and 0.074 peritonitis/patients-month; respectively (NS) and were caused by Gram (-) bacteria. St Aureus and St Epidermides. The survival curves of patients and method, in both groups, were similar (NS). We conclude IPD is a good alternative of therapy for ESRD, also for diabetics patients, whom haven't got more infection rate than non diabetics patients.