Pacientes con diagnóstico de "BRUE" atendidos en hospital pediátrico chileno. Aplicando nueva terminología / Patients with diagnosis of "Sids" treated in chilean pediatric hospital. Applying new terminology

La posible relación entre apneas durante la infancia temprana y Síndrome de Muerte Súbita del Lactante (SMSL) nunca ha sido demostrada, existiendo evidencias de que ambas condiciones podrían no estar relacionadas. La Academia Americana de Pediatría (AAP) define ALTE (Acute Life Threatening Event), como un evento brusco e inesperado que incluye manifestaciones de apnea junto con cambios de coloración cutánea y de tono muscular, donde el observador cree que el niño ha muerto. La AAP ha propuesto recientemente la sustitución del término ALTE por Brief Resolved Unexplained Events (BRUE). El nuevo concepto permite categorizar eventos breves, resueltos e inexplicados, para optimizar mejor el recurso en salud, a través de objetivar el evento y entregando estrategias de manejo categorizando el riesgo. Objetivo: Describir las características clínicas y letalidad de los pacientes menores de 12 meses que consultan por BRUE en un hospital de referencia. Materiales y métodos: Estudio transversal descriptivo con revisión de ficha de 46 pacientes de la Unidad de Lactantes y Nutrición del Hospital Dr. Luis Calvo Mackenna, con diagnóstico de BRUE, entre enero a diciembre de 2017. Resultados: Del total de pacientes con BRUE, 45% fueron hombres y 55% mujeres. La edad promedio fue de 1,37 + 0,51 meses. En 70% se demostró una etiología, de estas 31% con enfermedad por reflujo gastroesofágico (ERGE), siendo ésta la causa más frecuente seguida de un 19% con infecciones respiratorias agudas (IRA) y 9% causas neurológicas. En el 30% fueron causas idiopáticas. Conclusión: En nuestro estudio las causas más frecuentes de BRUE fueron ERGE e infecciones respiratorias. Durante el período de estudio ningún paciente estudiado falleció, por lo que no encontramos relación entre apneas del lactante y síndrome de muerte súbita.

The possible relationship between apneas during early childhood and Sudden Infant Death Syndrome (SIDS) has never been demonstrated, and there is evidence that the two conditions may not be related. The American Academy of Pediatrics (AAP) defines ALTE (Acute Life Threatening Event), as an abrupt and unexpected event that includes manifestations of apnea along with changes in skin color and muscle tone, where the observer believes that the child has died. The AAP has recently proposed replacing the term ALTE with Brief Resolved Unexplained Events (BRUE). The new concept makes it possible to categorize brief, resolved and unexplained events, to better optimize the health resource, through objectifying the event and delivering management strategies by categorizing the risk. Objective: To describe the clinical characteristics and lethality of patients younger than 12 months who consult for BRUE in a referral hospital. Materials and methods: Descriptive cross-sectional study with revision of the file of 46 patients from the Infant and Nutrition Unit of the Dr. Luis Calvo Mackenna Hospital, with a diagnosis of BRUE, between January and December 2017. Results: Of the total number of patients with BRUE, 45% were men and 55% women. The average age was 1.37 + 0.51 months. An etiology was demonstrated in 70%, of these 31% with gastroesophageal reflux disease (GERD), this being the most frequent cause, followed by 19% with acute respiratory infections (ARI) and 9% with neurological causes. In 30% they were idiopathic causes. Conclusion: In our study, the most frequent causes of BRUE were GERD and respiratory infections. During the study period, no patient studied died, so we found no relationship between apnea in the infant and sudden death syndrome.

Association between hospital-diagnosed atopic dermatitis and psychiatric disorders and medication use in childhood.

BACKGROUND: While adult atopic dermatitis (AD) is associated with anxiety and depression, and paediatric AD is linked to attention deficit hyperactivity disorder (ADHD), the relationship between AD in childhood and other psychiatric disorders is largely unknown. OBJECTIVES: To determine the relationship between AD and diagnosis and treatment of psychiatric disorders in children. METHODS: All Danish children born between 1 January 1995 and 31 December 2012 with a hospital diagnosis of AD (n = 14 283) were matched 1 : 10 with children without a hospital diagnosis of AD. Endpoints were psychotropic medication use, hospital diagnoses of depression, anxiety, ADHD, or self-harming behaviour, accidental/suicidal death, and consultation with a psychiatrist or psychologist. RESULTS: Significant associations were observed between hospital-diagnosed AD and antidepressant [adjusted hazard ratio (aHR) 1·19, 95% confidence interval (CI) 1·04-1·36], anxiolytic (aHR 1·72, 95% CI 1·57-1·90), and centrally acting sympathomimetic (aHR 1·29, 95% CI 1·18-1·42) medication use. Consultation with a psychiatrist (aHR 1·33, 95% CI 1·16-1·52) or psychologist (aHR 1·25, 95% CI 1·11-1·41) was also associated with AD. No association with a hospital diagnosis of depression (aHR 0·58, 95% CI 0·21-1·56), anxiety (aHR 1·47, 95% CI 0·98-2·22) or self-harming behaviour (aHR 0·88, 95% CI 0·27-2·88) was observed, but a diagnosis of ADHD (aHR 1·91, 95% CI 1·56-2·32) was significantly associated with AD. The absolute risks were generally low. CONCLUSIONS: The increased risk of treatment, but not of a hospital diagnosis of psychiatric disorders in children with hospital-diagnosed AD, suggests that psychiatric issues in children with AD could be of a transient, reversible or mild-moderate nature.

Paresia radial bilateral secundaria a exposición crónica a plomo: reporte de un caso / Bilateral radial paresis secondary to chronic lead exposure: a case report

La exposición ocupacional al plomo continúa siendo un problema de salud pública que afecta mayoritariamente a trabajadores de países en vías de desarrollo. La exposición crónica produce síntomas similares a otras patologías clínicas motivo por el cual es importante poseer alto grado de sospecha. De acuerdo con los síntomas, signos y valor de plumbemia inicial, será necesario el alejamiento de la fuente y posterior tratamiento quelante con edetato cálcico disódico y/o dimercaprol. Presentamos un caso clínico de paresia radial bilateral por exposición crónica a plomo

Occupational exposure to lead continues to be a public health problem, affecting mainly workers of developing countries. Chronic exposure produces symptoms that can be confused with other clinical pathologies, which is why it is important to have a high degree of suspicion. According to the symptoms, signs and value of initial blood lead concentration, it will be necessary to remove from the source and posterior chelation with edetate calcium disodium and/or dimercaprol. We present a clinical case of bilateral radial paresis due to chronic lead exposure

Disease trajectories in childhood atopic dermatitis: an update and practitioner's guide.

BACKGROUND: Atopic dermatitis (AD) is a heterogeneous disease with a multifactorial aetiology and complex pathophysiology. This heterogeneity translates into different trajectories of disease progression with respect to severity, persistence and risk of development of atopic comorbidities. Determining which possible disease trajectories or comorbidities any individual child might develop is challenging in clinical practice. Tools that help identify paediatric patients at higher risk of disease progression would greatly aid clinicians. METHODS: We reviewed recent cohort studies to synthesize and simplify the epidemiological data to try to identify shared clinically relevant characteristics that may help physicians estimate the risk of disease progression in paediatric patients with AD. RESULTS: Despite the variability in data collection and methods of analysis and their limitations, there are common patterns of early-childhood AD that may aid in the estimation of risk for disease progression. Factors associated with risk of AD progression include younger age of onset, family history of atopy, greater AD severity, filaggrin mutations, urban environment and polysensitization and/or allergic multimorbidity. Based on these factors, we provide a practitioner's guide for identifying, counselling and/or referring infants and children with AD at potentially higher risk of developing persistent AD and atopic comorbidities. We also present clinical scenarios to illustrate how these data relate to real-life situations. CONCLUSIONS: Useful insights are provided for physicians and patients to inform them better about the risk of AD progression and to help guide care pathways for the paediatric population with AD. What's already known about this topic? The complex pathophysiology of atopic dermatitis (AD) translates into a heterogeneous clinical presentation and trajectories of disease progression. Although the consensus is that most paediatric patients with AD will eventually 'outgrow' the disease or follow the longitudinal trajectory known as the 'atopic march', a significant proportion will develop persistent AD and/or other atopic conditions. No known factors conclusively predict the risk of progression or development of comorbidities. What does this study add? Recent analyses of data from large cohorts of paediatric patients with AD have suggested the existence of potentially discrete clusters of patients who present with relatively common AD phenotypes. These studies have shed some light onto the factors associated with risk of progression, which we review in this article. A practitioner's guide with clinical scenarios is provided to help identify patients at high risk of progression to determine whether a patient should be monitored and/or would require specialist referral.

Report from the fifth international consensus meeting to harmonize core outcome measures for atopic eczema/dermatitis clinical trials (HOME initiative).

This is the report from the fifth meeting of the Harmonising Outcome Measures for Eczema initiative (HOME V). The meeting was held on 12-14 June 2017 in Nantes, France, with 81 participants. The main aims of the meeting were (i) to achieve consensus over the definition of the core domain of long-term control and how to measure it and (ii) to prioritize future areas of research for the measurement of the core domain of quality of life (QoL) in children. Moderated whole-group and small-group consensus discussions were informed by presentations of qualitative studies, systematic reviews and validation studies. Small-group allocations were performed a priori to ensure that each group included different stakeholders from a variety of geographical regions. Anonymous whole-group voting was carried out using handheld electronic voting pads according to predefined consensus rules. It was agreed by consensus that the long-term control domain should include signs, symptoms, quality of life and a patient global instrument. The group agreed that itch intensity should be measured when assessing long-term control of eczema in addition to the frequency of itch captured by the symptoms domain. There was no recommendation of an instrument for the core outcome domain of quality of life in children, but existing instruments were assessed for face validity and feasibility, and future work that will facilitate the recommendation of an instrument was agreed upon.

Esplenectomía laparoscópica en pacientes con púrpura trombocitopénica idiopática: primera experiencia en el Hospital Regional de Arica / Laparoscopic splenectomy in patients with idiopathic thrombocytopenic purpura: first experience at the Regional Hospital of Arica

Introducción: La púrpura trombocitopénica idiopática (PTI) es una de las trombocitopenias más frecuentes en adultos. La esplenectomía corresponde a uno de sus tratamientos de segunda línea en pacientes refractarios a otras terapias médicas. Objetivo: Presentar nuestra primera experiencia en esplenectomía laparoscópica en el servicio de cirugía del Hospital Regional de Arica. Materiales y métodos: Se realizó una revisión transversal retrospectiva de pacientes con PTI a quienes se les indicó esplenectomía por falla en el tratamiento médico. Se tabularon los exámenes preoperatorios, plaquetas 24 h pre y posquirúrgicas, plaquetas al inicio del estudio (3 meses preoperatorios) y al mes del postoperatorio, complicaciones quirúrgicas y características histopatológicas. Resultados: Se realizaron 5 esplenectomías. El 100% de los pacientes presentaron mejoría a las 24 h de postoperados. Al cabo de un mes, sólo 3 de 5 pacientes tuvieron una mejoría de su trombocitopenia. No hubo complicaciones mayores como hemoperitoneo o fístulas pancreáticas. Un paciente presentó equimosis en un puerto. Conclusiones: La esplenectomía laparoscópica es una técnica factible de realizar en nuestro centro, con una tasa de complicaciones y resultados comparables con centros de mayor volumen.

Introduction: Idiopathic thrombocytopenic purpura (ITP) is one of the most common acquired thrombocytopenia in adults. Splenectomy is as second line treatment in medical refractory patients. Aim: The aim of this study is to present our first initial experience in laparoscopic splenectomy of the surgical department of Arica's local hospital. Materials and methods: This is a transversal prospective review of patients with ITP which splenectomy was performed due medical treatment failure. Preoperative blood test: platelet count at the beginning of the study, 24 h pre op, 24 h post op and a month post surgery were tabulated. Postoperative complications and histopathology characteristics were reported. Results: We performed 5 splenectomies, 100% of the patients presented a recovery platelet count at 24 h postop. In the first month only 3 patients had an improvement of their thrombocytopenia. There were no major complications, like hemoperitoneum or pancreatic leaks, only one patient presented port site ecchymosis. Conclusions: Laparoscopic splenectomy is a feasible technique in our center with a complication rate and outcomes comparable to high volume center.

Técnicas «Lean» para la mejora del flujo de los pacientes críticos de una región sanitaria con epicentro en el servicio de medicina intensiva de un hospital de referencia / Lean techniques to improve the flow of critically ill patients in a health region with its epicenter in the intensive care unit of a reference hospital

OBJETIVO: Analizar si la aplicación de técnicas «Lean» mejora el flujo de pacientes críticos de una región sanitaria, tomando como epicentro el servicio de medicina intensiva (UCI) del hospital de referencia. DISEÑO: Estudio observacional con análisis pre y postintervención. ÁMBITO: UCI del hospital de referencia. PACIENTES: Diseñamos proyectos y un mapa de flujo y comparamos características pre y postintervención. INTERVENCIONES: Registramos datos demográficos, de traslados de pacientes por el SEM por falta de camas y los tiempos de demora en la hora de alta de la UCI a planta de hospitalización. Realizamos reuniones multidisciplinarias y panel visual diario, con priorización de altas de UCI. Promovimos la reubicación temporal de pacientes críticos en otras áreas especiales del hospital. Cuestionario de satisfacción profesional con valoración pre y postintervención. Análisis estadístico de las comparaciones pre y postintervención. RESULTADOS: Se planificó durante 2013 y se implementó de forma progresiva en 2014. Las medidas principales fueron: 1) análisis de la entrada de pacientes al flujo del proceso de críticos, evaluando los pacientes que deben trasladarse por falta de camas, centrados en un diagnóstico y un área: 10/22 pre vs. 3/21 post (p = 0,045); 2) análisis del tiempo de demora en la hora de alta de UCI a planta de hospitalización: 360,8 ± 163,9 min en el primer periodo vs. 276,7 ± 149,5 en el segundo (p = 0,036); y 3) cuestionario de satisfacción profesional personal, con 6,6 ± 1,5 puntos pre vs. 7,5 ± 1,1 en post (p = 0,001). Análisis de los indicadores de UCI, como son las infecciones adquiridas, los días de estancia, la tasa de reingresos y la mortalidad, sin diferencias significativas entre ambos periodos. CONCLUSIONES: La aplicación de técnicas ‘Lean’ en el proceso de críticos tuvo un impacto positivo en la mejora del flujo de pacientes dentro de la región sanitaria, observando una disminución de los traslados fuera de la región por falta de camas, una reducción en la demora del alta de UCI a hospitalización convencional y un aumento de la satisfacción de los profesionales de la UCI de referencia

OBJECTIVE: To analyze whether the application of Lean techniques to improve the flow of critically ill patients in a health region with its epicenter in the intensive care unit (ICU) of a reference hospital. DESIGN: Observational study with pre and post intervention analysis. SETTING: ICU of a reference hospital. PATIENTS: We design projects and a value stream map of flow and compared pre and post intervention. INTERVENTIONS: We recorded demographic data, patient transfers by EMS for lack of beds and delay times in the discharge from ICU to ward. Multidisciplinary meetings and perform daily visual panel, with high priority ICU discharge. We promote temporary relocation of critically ill patients in other special areas of the hospital. We performed a professional satisfaction questionnaire with pre and post implementation of process. We make a statistical analysis of pre and post-intervention comparisons. Results: We planned for 2013 and progressively implemented in 2014. Analysis of patients entering the critical process flow 1) evaluate patients who must transfer for lack of beds, focusing on a diagnosis: pre 10/22 vs. 3/21 post (P = .045); 2) analysis of time delay in the discharge from the ICU to ward: 360.8 ± 163.9 minutes in the first period vs. 276.7 ± 149.5 in the second (P = .036); and 3) personal professional satisfaction questionnaire, with 6.6 ± 1.5 points pre vs. 7.5 ± 1.1 in post (P = .001). Analysis of indicators such as the ICU acquired infections, length of ICU stay, the rate of re-admissions and mortality, with no significant differences between the two periods. Conclusions: The application of Lean techniques in the critically ill process had a positive impact on improving patient flow within the health region, noting a decrease of transfers outside the region due to lack of beds, reduced delayed discharge from ICU to conventional ward and increased satisfaction of ICU professionals

Lean techniques to improve the flow of critically ill patients in a health region with its epicenter in the intensive care unit of a reference hospital. / Técnicas «Lean¼ para la mejora del flujo de los pacientes críticos de una región sanitaria con epicentro en el servicio de medicina intensiva de un hospital de referencia.

OBJECTIVE: To analyze whether the application of Lean techniques to improve the flow of critically ill patients in a health region with its epicenter in the intensive care unit (ICU) of a reference hospital. DESIGN: Observational study with pre and post intervention analysis. SETTING: ICU of a reference hospital. PATIENTS: We design projects and a value stream map of flow and compared pre and post intervention. INTERVENTIONS: We recorded demographic data, patient transfers by EMS for lack of beds and delay times in the discharge from ICU to ward. Multidisciplinary meetings and perform daily visual panel, with high priority ICU discharge. We promote temporary relocation of critically ill patients in other special areas of the hospital. We performed a professional satisfaction questionnaire with pre and post implementation of process. We make a statistical analysis of pre and post-intervention comparisons. RESULTS: We planned for 2013 and progressively implemented in 2014. Analysis of patients entering the critical process flow 1) evaluate patients who must transfer for lack of beds, focusing on a diagnosis: pre 10/22 vs. 3/21 post (P=.045); 2) analysis of time delay in the discharge from the ICU to ward: 360.8±163.9minutes in the first period vs. 276.7±149.5 in the second (P=.036); and 3) personal professional satisfaction questionnaire, with 6.6±1.5 points pre vs. 7.5±1.1 in post (P=.001). Analysis of indicators such as the ICU acquired infections, length of ICU stay, the rate of re-admissions and mortality, with no significant differences between the two periods. CONCLUSIONS: The application of Lean techniques in the critically ill process had a positive impact on improving patient flow within the health region, noting a decrease of transfers outside the region due to lack of beds, reduced delayed discharge from ICU to conventional ward and increased satisfaction of ICU professionals.

Stochastic dynamic causal modelling of FMRI data with multiple-model Kalman filters.

INTRODUCTION: This article is part of the Focus Theme of Methods of Information in Medicine on "Biosignal Interpretation: Advanced Methods for Neural Signals and Images". BACKGROUND: Dynamic Causal Modelling (DCM) is a generic formalism to study effective brain connectivity based on neuroimaging data, particularly functional Magnetic Resonance Imaging (fMRI). Recently, there have been attempts at modifying this model to allow for stochastic disturbances in the states of the model. OBJECTIVES: This paper proposes the Multiple-Model Kalman Filtering (MMKF) technique as a stochastic identification model discriminating among different hypothetical connectivity structures in the DCM framework; moreover, the performance compared to a similar deterministic identification model is assessed. METHODS: The integration of the stochastic DCM equations is first presented, and a MMKF algorithm is then developed to perform model selection based on these equations. Monte Carlo simulations are performed in order to investigate the ability of MMKF to distinguish between different connectivity structures and to estimate hidden states under both deterministic and stochastic DCM. RESULTS: The simulations show that the proposed MMKF algorithm was able to successfully select the correct connectivity model structure from a set of pre-specified plausible alternatives. Moreover, the stochastic approach by MMKF was more effective compared to its deterministic counterpart, both in the selection of the correct connectivity structure and in the estimation of the hidden states. CONCLUSIONS: These results demonstrate the applicability of a MMKF approach to the study of effective brain connectivity using DCM, particularly when a stochastic formulation is desirable.

Estado nutricional, niveles de actividad física y factores de riesgo cardiovascular en estudiantes de la Universidad Santo Tomás / Nutritional status, levels of physical activity and cardiovascular risk factors in college students of Santo Tomas University

Introduction: Non-communicable chronic diseases (NCCD) increase the presence of risk factors (RF) of cardiovascular disease (CVD) in young people. Objective: To analyze the relation among the nutritional status (NS), physical activity (PA) and the prevalence of cardiovascular RF in students from Santo Tomas University in Temuco enrolled in year 2010. Subjects and methods: A cross-sectional descriptive study was carried out; 177 out of 348 students of both genders were chosen as the sample, 32.2% males and 68.8 % females. The age ranged between 18 and 25 years old. Anthropometric and blood pressure measurements, blood samples, PA surveys and obesity backgrounds were taken. The study outcomes helped to estimate the NS, the practice of PA, the prevalence of the different RF. Outcomes: The study showed that the 34.5% of the students present malnutrition by excess, 70.6% are sedentary, and a 9.6% is at risk of CVD by presence of metabolic syndrome (MS). The risk by abdominal obesity reached 53.1%. Parameters which showed significant differences were HDL cholesterol lowered in active students (p= 0.027). When the PA together with BMI variables, triglycerides, LDL cholesterol, glycaemia and blood pressure were analyzed, no significant differences were observed. Conclusions: A high prevalence of malnutrition by excess, for being sedentary and RF of CVD was present with a predominance in female students.

Introducción: Las enfermedades crónicas no transmisibles (ECNT) incrementan la presencia de factores de riesgo (FR) de enfermedad cardiovascular (ECV) en jóvenes. Objetivo: Analizar la relación entre estado nutricional (EN), actividad física (AF) y prevalencia de FR cardiovascular en estudiantes de la Universidad Santo Tomás sede Temuco, ingreso 2010. Sujetos y métodos: Se realizó un estudio descriptivo de corte trasversal; de un total de 348 estudiantes, se obtuvo una muestra de 177 sujetos, de los cuales 32,2% correspondió a hombres y 68,8% a mujeres, la edad fluctuó entre 18 y 25 años. Se realizaron mediciones antropométricas, de presión arterial, muestras sanguíneas, encuestas de AF y antecedentes de morbilidad. Los resultados permitieron estimar el EN, la práctica de AF y la prevalencia de los distintos FR. Resultados: El estudio reveló que 34,5% de los estudiantes presentaban tiene malnutrición por exceso, 70,6% eran sedentarios y 9,6% tenían riesgo de enfermedad cardiovascular por presencia de Síndrome Metabólico (SM); mientras, el riesgo por obesidad abdominal fue de 53,1%. Los parámetros que evidenciaron diferencias significativas fueron el colesterol HDL que se mostró disminuido en los estudiantes activos (p= 0,016) y el colesterol total, que se observó levemente aumentado en los sedentarios (p= 0,027). Al analizar la AF con las variables IMC, triglicéridos, colesterol LDL, glicemia y presión arterial, no se observaron diferencias significativas. Conclusiones: Se observó alta prevalencia de malnutrición por exceso, sedentarismo y factor de riesgo de ECV con predominio en las mujeres.

Percretismo placentario: manejo con oclusión de arterias ilíacas internas, embolización de arterias uterinas y oclusión de arterias ilíacas comunes / Placenta previa percreta: handling with occlusion of internal iliac artery, uterine artery embolization and occlusion of common iliac arteries

Presentamos el caso de una embarazada con placenta ístmica, percreta, previa central, con extensas anastomosis vasculares y flujo de alta velocidad. En la resolución mediante cesárea-histerectomía, para prevenir la hemorragia intraoperatoria, se utilizó una intervención radiológica en secuencia de oclusión temporal de las ilíacas internas, embolización de las arterias uterinas, reposicionamiento e insuflación de balones en ilíacas comunes. Se logró mantener estabilidad hemodinámica y el control del sangrado; estando ocluida la circulación uterina hubo pérdidas moderadas en la parte final de la operación. Se discuten la característica poco común de la implantación y percretismo ístmico, y el beneficio del uso combinado de la oclusión vascular con la cirugía expedita para minimizar el riesgo materno.

We present a patient with placenta previa percreta and oclusive. It had extensive vascular anastomosis with high velocity flow, in which resolution by cesarean-hysterectomy was done for bleeding control and followed by temporal occlusion of iliac arteries, embolization of uterine arteries, reposition and insuflation of balloons in common iliac arteries. The patient was stable and moderated bleeding happened to the end of intervention when the uterine arterial circulation was occluded. We discuss the uncommon of isthmic implantation and percretism and the benefits of both vascular occlusion and expedite surgery for to minimize maternal compromise or damage.

Soluble TNFα receptor type I and hepcidin as determinants of development of anemia in the long-term follow-up of heart failure patients.

BACKGROUND: Anemia is common in patients with chronic heart failure (CHF) and is associated with a worse prognosis. This study aims to identify the biological mechanisms which reflect evolutionary changes in the hemoglobin concentrations in heart failure patients who are still not anaemic. METHODS: Fifty-nine patients (54 ± 14 years, 83% males) with CHF (LVEF 28 ± 10%), who did not have anemia, and had not received any previous transfusions, were included. The parameters studied were: iron metabolism (ferritin, iron, transferrin, soluble transferrin receptor (sTfR), hepcidin); inflammation (C-reactive protein, soluble TNFα receptor I (sTNFRI), interleukin 6); and myocardial stress (NT-proBNP, high sensitivity TnT, growth differentiation factor 15). All parameters were measured on inclusion and 1 year after inclusion. RESULTS: Baseline hemoglobin (g/dL) was 14.7 ± 1.5 and at 1 year of follow-up it showed a significant decrease of -0.4 (RIC: -0.7 to -0.06) (p=0.02). At baseline, only the sTNFRI was a predictor of a decrease in hemoglobin 1 year later (p=0.007). During follow-up, the increase in sTNFRI (p=0.002, r=-0.39) and hepcidin (p=0.006, r=-0.35) were both associated with a decrease in hemoglobin. Similarly, the patients who became anemic (13%) had higher levels of hepcidin (p=0.001) and sTNFRI (p=0.008). The remaining parameters did not show any relationship with the evolution in the hemoglobin. CONCLUSIONS: In CHF patients without anemia, the increase in the inflammatory state (sTNFRI) and the following deterioration in the iron metabolism (hepcidin) were the main determinants of a decrease in hemoglobin and the appearance of anemia in the long term follow-up period.

Oclusión temporal de arterias ilíacas internas en cesárea-histerectomía por placenta acreta: enfoque multidisciplinario / Temporary occlusion of internal iliac arteries in cesarean section-hysterectomy for placenta accreta: a multidisciplinary approach

OBJETIVO: Evaluar la eficacia y resultados del tratamiento de la placenta acreta previa central en un caso clínico. Durante el embarazo los métodos diagnósticos por imágenes (ultrasonido y resonancia nuclear magnética) precisaron la localización y penetración de la placenta en la pared uterina. En el período inmediato antes del parto, para disminuir la hemorragia, evitar la hipotensión materna y facilitar el procedimiento quirúrgico, se colocaron balones intraarteriales en ambas ilíacas internas por radiólogo intervencionista, catéteres para monitoreo hemodinámico invasivo por anestesiólogo y catéteres ureterales por urólogo. La resolución del parto fue por cesárea-histerectomía sin remoción de la placenta. El caso correspondió a una paciente de 32 años con cesárea en dos partos anteriores, metrorragia episódica y que fue interrumpida en la semana 36. Durante toda la intervención permaneció hemodinámicamente estable requiriendo 1 unidad de glóbulos rojos, 4 litros entre coloides y cristaloides y el posoperatorio fue sin incidentes. El examen histo-patológico demostró percretismo de la pared uterina sin invasión vesical, concordante con las imágenes de lagunas vasculares y la citoscopia. CONCLUSIÓN: El caso demuestra el beneficio del tratamiento especializado multidisciplinario de embarazos con complicaciones graves como la placenta previa con diferentes grados de acretismo.

OBJECTIVE: To report the treatment of a clinical case with central placenta previa accreta. During pregnancy image diagnosis (ultrasound and magnetic resonance imaging) revealed localization and penetration of the placenta into the uterine wall. Just before delivery to reduce the bloss loss and avoid maternal hypotension and facilitate surgery, intra arterial balloons were placed on both hypogastric arteries by the radiologist; intravascular monitoring was installed by anesthesist and urologist put in ureteral catheters. The delivery was by cesarean section and followed by histerectomy leaving the placenta in situ. The case correspond to a woman of 32 years old that had 2 previous cesarean section. During this pregnancy bled a few times and was delivered at weeks 36th. During surgery she was stable, requiring one unit of red blood cells and four liters of coloids and crystaloids. Post-operative course was with no problems. The pathologist report a placenta percreta with no bladder involvement, agreeing with the vascular lakes image and the cystoscopy. CONCLUSION: This case reveals the benefits of multidisciplinary approach to manage severe complications of pregnancy such as placenta previa and the degree of accretism.

Embarazo ístmico y acretismo placentario: diagnóstico en I trimestre: caso clínico / Isthmic pregnancy and placental accretism: clinical case

The diagnosis of placenta accreta is oftenmade during the second half of pregnancy, usually associated with previous placenta. Here we present acase of pregnancy implantation in the uterine isthmus diagnosed during the 8th week of gestation. Among the ultrasound findings to highlight we found isthmic bulging by the gestational sac with fetal heartbeats, empty uterine cavity and cervical canal, absence ofmyometrium along the vesico-uterine septum and posterior signs of early placental accretism. At thirteen weeks dilated vessels and irregularly shaped lacunae with turbulent blood flow were seen in the placenta. Expectant management was made confirming accretism with placenta percreta involving the parametrium and respecting the bladder. Cesarean section with hysterectomy was made at 34th weeks in conjunction with interventional radiology (Vascular ballooning of the internal and common iliac arteries) with good maternal and perinatal outcomes. Pathology analysis confirmed prenatal findings.

El diagnóstico de acretismo placentario se realiza en la segunda mitad del embarazo, asociado frecuentemente a placenta previa. Presentamos uncaso clínico en el que se observó una implantación ístmica en la semana 8, destacando los signos de abombamiento ístmico global con saco gestacionaly embrión vivo, cavidad corporal uterina vacía, canal cervical vacío, ausencia de miometrio en tabique vesico-uterino y posteriormente signos sugerentes deacretismo en semana 13 con desarrollo de vasculatura subplacentaria y luego lagunas vasculares de flujo turbulento.Se hizo un manejo espectante confirmando durante la evolución signos de acretismo y percretismo miometrial, extenso desarrollo vascular en parametrios y sin invasión vesical. Fue interrumpida con semanas, por cesárea-histerectomía, optimizada con técnica radiológica intervencional (oclusiónvascular intraoperatoria en secuencia de arterias ilíacas internas e íliacas comunes) con buen resultado materno y perinatal. La anatomía patológica confirmó diagnósticos ultrasónicos.

Comparación del rendimiento productivo de pollos de carne suplementados con un probiótico versus un antibiótico / Comparison of the productive performance in broilers supplemented with probiotic or antibiotic

El estudio comparó parámetros productivos de pollos de carne suplementados con un probiótico Biomin® Poultry 5 Star (Enterococcus faecium, Pediococcus acidilactici, Bifidobacterium animalis, Lactobacillus salivarius y Lactobacillus reuteri) versus un antibiótico (Zinc Bacitracina). Se usaron 333 aves divididas en tres tratamientos de 111 animales con 3 repeticiones por tratamiento: 1, control; 2, antibiótico; y 3, probiótico. En las seis semanas de crianza no se encontró diferencia significativa entre tratamientos para peso corporal, consumo de alimento, conversión alimenticia (ICA), porcentaje de mortalidad y el índice de eficiencia productiva (IEP).

The present study compared productive parameters in broilers supplemented with a probiotic Biomin® Poultry 5 Star (Enterococcus faecium, Pediococcus acidilactici, Bifidobacterium animalis, Lactobacillus salivarius y Lactobacillus reuteri) versus an antibiotic (Bacitracin). A total of 333 chicks were divided into three treatments of 111 animals with 3 repetitions for group: 1 control; 2 antibiotic; 3 probiotic. During the six weeks of the study no statistical differences were found between treatments for body weight, feed consumption, feed conversion, mortality rate, and productive efficiency index.

Low troponin-I levels on admission are associated with worse prognosis in patients with fulminant myocarditis.

BACKGROUND: The clinical outcomes of patients with fulminant acute myocarditis (FAM) range from death to complete recovery. We sought to identify clinical, biological, and echocardiographic characteristics of prognostic value for this population. METHODS AND RESULTS: We prospectively included 185 patients with the diagnosis of acute myocarditis who were admitted to our institution between 2000 and 2007, selecting 15 who displayed FAM, namely, severe congestive heart failure or cardiogenic shock, requiring inotropic and/or mechanical circulatory support. Their mean age was 27.9 +/- 12.4 years (range, 12-52) and mean left ventricular ejection fraction (LVEF) was 22 +/- 8.4% (range, 10-35). Seven subjects had poor outcomes, defined as death (n = 4), urgent transplantation (x = 2), or persistent left ventricular dysfunction (n = 3). The other 6 individuals experienced complete recovery of ventricular function. Troponin-I values below 1 ng/mL on admission were significantly associated with greater in-hospital (P = .05) and mid-term poor outcomes (P = .001). Additionally, patients with poor outcomes showed significantly lower LVEF (17.6 +/- 6.2% vs 28.8 +/- 6.9%; P = .006). CONCLUSION: Among patients with FAM, normal or minimal elevation of troponin-I and low LVEF on admission were associated with worse in-hospital and mid-term prognosis.

[Late amniotic fluid embolism among the diferential diagnosis of acute respiratory failure in the postpartum: case report and review]. / Embolia tardía de líquido amniótico como diagnóstico diferencial de la insuficiencia respiratoria aguda en el posparto: caso clínico y revisión.

The amniotic fluid embolism is an uncommon condition with a high mortality. The cardinal symptoms are hypoxia, hypotension, altered mental status and disseminated intravascular coagulation. This syndrome occurs during delivery or in the immediate postpartum period, and its onset in the late postpartum is very unusual. We describe a case of a primigravida who, after an uneventful delivery, suffers an acute respiratory failure in the late postpartum period. Exclusion of other causes of acute respiratory failure occurring during delivery or in the postpartum period led to establish the diagnosis.

Embolia tardía de líquido amniótico como diagnóstico diferencial de la insuficiencia respiratoria aguda en el posparto: caso clínico y revisión / Late amniotic fluid embolism among the diferential diagnosis of acute respiratory failure in the postpartum: case report and review

La embolia de líquido amniótico es un síndrome poco frecuente, y a menudo fatal, cuyas principales manifestaciones clínicas son la hipoxia, la hipotensión, la alteración del estado de consciencia y la coagulación intravascular diseminada. Tiene lugar durante el parto o en el posparto inmediato, siendo excepcional su aparición en el posparto tardío. Presentamos el caso de una primigrávida que tras un parto sin complicaciones desarrolla un cuadro de insuficiencia respiratoria aguda en el posparto tardío. La exclusión de otras causas de insuficiencia respiratoria aguda durante el parto y posparto permitió establecer el diagnóstico

The amniotic fluid embolism is an uncommoncondition with a high mortality. The cardinalsymptoms are hypoxia, hypotension, alteredmental status and disseminated intravascular coagulation.This syndrome occurs during deliveryor in the immediate postpartum period, and its onsetin the late postpartum is very unusual. We describea case of a primigravida who, after an uneventfuldelivery, suffers an acute respiratory failurein the late postpartum period. Exclusion ofother causes of acute respiratory failure occurringduring delivery or in the postpartum periodled to establish the diagnosis (AU)