Multiprotease improves amino acid release in vitro, energy, and nutrient utilization in broilers fed diets varying in crude protein levels.

Low crude protein (CP) diets can reduce nitrogen (N) excretion and costs by increasing N utilization efficiency. Exogenous proteases may further improve protein digestibility in low CP diets. This study first evaluated in vitro the efficacy of a multiprotease on amino acid (AA) release from feedstuffs and broiler feed. Later, a broiler study evaluated the effect of feeding corn-soybean meal diets containing 3 CP levels (17, 19, and 21% CP) with supplementation on top of 0 or 2,400 U/kg multiprotease on chicken growth performance, total tract CP, and ileal AA digestibilities, and energy utilization. Ross 708 male chickens were placed in 42 cages and assigned to 6 treatments resulting from a 3 × 2 factorial arrangement. Three isocaloric basal diets were formulated to reduce CP, but all diets maintained digestible Lys:CP in 5.47% and the same ideal protein profile. Data were analyzed in a completely randomized design. On average, the multiprotease increased (P < 0.05) in vitro free AA release by 27.81% in most feedstuffs evaluated compared to the control. For broiler feed, 1,200 U/g multiprotease addition improved (P < 0.001) in vitro free AA release by 18.90%. This multiprotease showed interaction effects (P < 0.05) on chicken FCR, energy, and CP digestibility. As expected, BW at 24 d, BW gain, and FCR (8-24 d) worsened (P < 0.001) as dietary CP reduced from 21 to 17%, and multiprotease addition did not improve (P > 0.05) these parameters. BW gain decreased by 12.9% when N intake was reduced from 49.32 to 38.49 g/bird. Multiprotease supplementation improved (P < 0.01) AMEn by 71 kcal/kg, CP digestibility from 59.45 to 63.51%, ileal AA digestibility, and DM digestibility from 67.08 to 73.49%, but only in the 21% CP diet. No differences in ileal AA digestibility due to CP level (P > 0.05) were detected, except for Cys digestibility (P < 0.01). In conclusion, low CP diets reduced growth performance and improved N utilization but negatively affected energy utilization efficiency. Exogenous multiprotease supplementation improved AME, AMEn, protein, ileal AA, and DM digestibility in the 21% CP diet without significantly affecting growth performance.

Influence of extruded soybean meal with varying fat and oleic acid content on nitrogen-corrected apparent metabolizable energy in broilers.

High oleic (HO) soybeans may serve as a value-added feed ingredient; providing amino acids and estimating their dietary energy value for broilers is essential. In this study, we determined the apparent metabolizable energy (AME), AME corrected for zero nitrogen retention (AMEn), digestibility, and nitrogen (N) retention of HO full-fat (HO-FF) soybean as compared to solvent-extracted soybean meal (SE-SBM), normal oleic full-fat (NO-FF) and extruded expeller (NO-EE) soybean. A total of 240 Ross-708 male broilers were selected, with 8 replicates per treatment and 6 chicks per cage. The AME and AMEn were estimated using the difference method with a 30% inclusion of test ingredients using a corn-soy reference diet with partial and total excreta collection. The index method with partial excreta collection used titanium dioxide as an inert marker. The same starter diet was provided for all birds for 14 d, followed by the reference and assay diets for the next 6 adaptation days. Total excreta were collected twice a day for 3 d. The AME and AMEn values determined for the HO-FF and NO-FF were higher (P < 0.001) than the NO-EE and SE-SBM. The AME of SE-SBM and NO-EE were similar with both methods, but the AMEn of SE-SBM was lower than the NO-EE only with the partial collection method. The agreement between AME and AMEn values determined by partial and total excreta collection analysis was 98%. Data from the total excreta collection method yielded higher AME and AMEn values (P < 0.001) than those from the partial collection method. In summary, HO-FF and NO-FF soybean meals had similar AME and AMEn values. The HO-FF soybean had 39 and 24% higher AME and AMEn than SE-SBM. Hence, high oleic full-fat soybean meal could serve as a valuable alternative feed ingredient to conventional SE-SBM meals in broiler diets, providing additional energy while providing amino acids and more oleic acid to enrich poultry meat products.

Effects of high oleic full-fat soybean meal on broiler live performance, carcass and parts yield, and fatty acid composition of breast fillets.

The effects of high oleic oil full-fat (HO-FF) soybean meal (SBM) on broiler meat quality could lead to value-added food products. This experiment evaluated the effects of dietary normal oleic extruded expelled (NO-EE), normal oleic full-fat (NO-FF), or HO-FF SBM on live performance, carcass and parts yield, and breast fatty acid composition. Diets were formulated to be isoenergetic and isonitrogenous. A total of 540 Ross-708 male broilers were raised on floor pens with 18 broilers/pen and 10 replicates/treatment. Data were analyzed in a completely randomized design. Chickens were fed with a starter (0-14 d), grower (15-35 d), or a finisher diet (36-47 d) up to 47 d. Chickens were weighed at 7, 14, 35, and 47 d. At 48 d, 4 broilers per pen were processed. Breast samples were collected and evaluated for quality and fatty acid content. Broilers fed diets with NO-EE were heavier (P < 0.05) than chickens fed diets with full-fat SBM (NO-FF and HO-FF) at d 7, 14, 35 while feed conversion ratio (FCR) of NO-EE was best (P < 0.05) at 7 and 47 d. Carcass yield was also higher for broilers fed NO-EE than the other treatments. Diet did not affect parts yield, breast meat color, cooking, drip loss, white stripping, or SM quality parameters. More breast fillets without wooden breast (score 1) were observed (P < 0.05) for NO-FF than the other 2 treatments. The breast meat fatty acid profile (g fatty acid/100 g of all fatty acids) was significantly affected (P < 0.001) by diet. Broilers fed the HO-FF SBM diet had 54 to 86% more oleic acid, 72.5% to 2.2 times less linoleic acid, and reduced stearic and palmitic acid levels in the breast meat than NO-FF and NO-EE. In conclusion, feeding HO-FF to broilers enriched the oleic acid content of their breast meat while reducing the saturated fatty acid content relative to the NO-FF and NO-EE treatment groups.

Effect of Environmental and Farm-Associated Factors on Live Performance Parameters of Broilers Raised under Commercial Tropical Conditions.

Although temperature, relative humidity, and farm-associated factors are known to affect broiler live performance, data about the impact of these variables under commercial operations are still scarce. This study aimed to evaluate the effect of temperature, relative humidity, a thermal humidity index, management, and farm-associated factors on BW, BW gain, feed conversion ratio (FCR), and mortality of broilers raised to 35 d under commercial tropical conditions. The data analyzed included performance records of Ross 308 AP broiler flocks placed between 2018 and 2020. Environmental monitoring information was obtained from electronic sensors that captured data hourly from 80 flocks in 29 farms. Farm-associated factors were gathered using a survey of 86 farms. Three data analyses were conducted in parallel. Correlation analyses, one-way ANOVA, and machine learning techniques were employed. Results indicated that BW and BW gain were reduced, and FCR worsened (p < 0.001) up to 21 d when chickens were mainly exposed to temperatures 2.5 °C lower than the recommended optimums for each age period. At the same time, mortality at 28 and 35 d increased. In conclusion, all farm-associated factors affected chicken live performance. Variable importance analysis indicated that performance results at 14 and 21 d were significant to predict BW at 35. At the same time, sex, distance between the hatchery and farm, and farm altitude accounted for the most significant contributions from the farm-associated factors.

Standardized ileal amino acid digestibility of high-oleic full-fat soybean meal in broilers.

High-oleic (HO) soybean may serve as a value-added feed ingredient to enrich poultry meat due to its fatty acid content. However, the amino acid (AA) nutrient digestibility of soybean meal (SBM) made from these soybeans has yet to be determined. The objective of this study was to determine apparent ileal AA digestibility (AID) and standardized ileal AA digestibility (SID) of high-oleic full-fat (HO-FF) SBM compared to normal oleic full-fat (NO-FF), normal oleic extruded expeller (NO-EE), and solvent-extracted SBM (SE-SBM) in broilers. A nitrogen-free basal diet (NFD) was fed to 1 treatment group with 10 chicks/cage to determine basal endogenous losses (BEL). Titanium dioxide was used as an inert marker. The test diets contained 57.5% of the basal NFD and 42.5% of 1 of the 4 soybean sources. A total of 272 Ross-708 male broilers were placed in 40 battery cages with 5 treatments and 8 replicates per treatment. A common starter diet was provided to all the chickens for 14 d. Experimental diets were provided as a mash for 9 d before sample collection. Chickens were euthanized with CO2 on d 23, and contents of the distal ileum were collected, frozen, and freeze-dried. The BEL were similar to the values found in the literature. At d 23, broilers fed the SE-SBM had the highest body weight gain and best FCR compared to chickens fed the HO-FF and NO-FF treatments (P < 0.001). Broilers fed the SE-SBM and NO-EE experimental diets had (P < 0.001) higher apparent ileal AA digestibility and AA SID than broilers fed the HO-FF and NO-FF treatments. In conclusion, the SID of AA from HO-FF is similar to the digestibilities of other full-fat soybeans found in the literature and is lower than that of NO-EE and SE-SBM.

Data Analytics of Broiler Growth Dynamics and Feed Conversion Ratio of Broilers Raised to 35 d under Commercial Tropical Conditions.

Data collection is standard in commercial broiler production; however, growth modeling is still a challenge since this data often lacks an inflection point. This study evaluated body weight (BW) dynamics, feed intake, BW gain, feed conversion ratio (FCR), and mortality of broiler flocks reared under commercial tropical conditions with controlled feeding to optimize FCR. The data analyzed included performance records of 1347 male and 1353 female Ross 308 AP broiler flocks with a total of 95.4 million chickens housed from 2018 to 2020. Decision trees determined high- and low-feed-efficiency groups using FCR at 35 d. Logistic, Gompertz-Laird, and von Bertalanffy growth models were fitted with weekly BW data for each flock within performance groups. The logistic model indicated more accurate estimates with biological meaning. The high-efficiency males and females (p < 0.001) were offered less feed than the low-efficiency group and were consistently more efficient. In conclusion, greater feeding control between the second and the fourth week of age, followed by higher feed allowance during the last week, was associated with better feed efficiency at 35 d in males and females. Additionally, models demonstrated that a reduced growth rate resulted in heavier chickens at 35 d with better feed efficiency and greater BW gain.

Effects of amino acid levels during rearing on Cobb 500 slow-feathering broiler breeders: 2. Reproductive performance.

Crude protein and amino acid (AA) content in rearing diets affect body composition and reproductive performance. This study evaluated the effects of 4 dietary AA levels during rearing on BW, egg production and composition, fertility, hatchability, and embryo mortality up to 65 wk of age on Cobb 500 slow-feathering (SF) broiler breeders. The treatments consisted in 80% (low-AA), 90% (moderate-AA), 100% (standard-AA), and 110% (high-AA) of the AA recommendations for Cobb 500 SF pullets from 5 to 24 wk. AA was guided by an ideal protein profile based on digestible Lys. A total of 1,360 pullets and 288 Cobb MV cockerels were randomly placed in 16 pullets and 16 cockerel floor-pens. At 22 wk, 1,040 females and 112 males were transferred into 16-floor pens in a laying house. BW increased linearly (P < 0.01) as AA augmented at 25, 36, and 40 wk. No effects (P > 0.05) at the onset of lay were observed. Moderate-AA and standard-AA resulted in the best hen-housed egg production (HHEP) at 65 wk with 174.3 and 176.5 eggs, respectively. The optimum level of AA for HHEP at 65 wk was estimated (P < 0.001) in 96.7% and 94.7% by the quadratic and broken line models, respectively. Overall, the lightest egg weight (P = 0.022) was obtained with 89%AA during rearing, and the heaviest eggs (P < 0.001) were found at 54 wk. Response surface regression indicated linear effects on albumen and yolk percentages (P < 0.01) increasing and decreasing, respectively, as AA levels augmented; consequently, AA had a negative linear effect on Y:A ratio (P = 0.004) with quadratic effects (P < 0.01) of age (R2 = 0.92). No statistical effect of treatments was observed in fertility (P > 0.05), but AA had a quadratic effect (P = 0.046) on hatchability up to 50 wk of age with 97% as optimum, and decreased linearly (P = 0.004) from 51 to 65 wk. A few effects of treatments (P < 0.05) on embryo mortality were observed. In conclusion, AA levels during rearing affect broiler breeder reproductive performance.

Effects of amino acid levels during rearing on Cobb 500 slow-feathering broiler breeders: 1. Growth and development.

Adequate pullet nutrition is essential to reach BW and suitable body composition for reproduction. An experiment was conducted to determine the effects of 4 dietary amino acid (AA) levels on BW, flock uniformity, body conformation, organ, leg, and feathering development of broiler breeder pullets during the rearing phase from 5 to 24 wk. A total of 1,360 Cobb-500 slow-feathering (SF) pullets were randomly placed in 16-floor pens with 85 females per pen. Diets with corn, soybean meal, and wheat-midds were formulated without protein restriction maintaining minimum ratios between essential AA and Lys on a digestible (dig) ideal basis. Treatments consisted of 4 dietary AA levels with 80% (low-AA), 90% (moderate-AA), 100% (standard-AA), and 110% (high-AA) of the Cobb-Vantress recommendations guided by dig Lys using balanced protein. Up to 4 wk, all pullets were fed a common starter crumble diet. Grower and developer mash diets were fed to pullets from 5 to 15 wk and from 16 to 24 wk, respectively. Pullets fed standard-AA and high-AA diets were heavier (P < 0.001) than those fed low-AA diets at 10, 15, and 20 wk of age. High-AA diets resulted in better (P = 0.040) flock uniformity at 10 wk. Pullets fed a high-AA diet had the highest (P = 0.041) relative breast weight at 20 wk of age and the lowest (P = 0.044) deposits of abdominal fat at 15 wk of age. Fleshing increased (P < 0.05) as AA content rise in the diet, while the relative shank length (P < 0.001) and the number of wing juvenile feathers (P = 0.004) decreased. Pullets fed the lowest dietary AA level had the longest (P = 0.007) small intestine relative to BW at 10 wk of age, but a smaller (P = 0.001) liver than those fed moderate and standard-AA diets at 20 wk of age. Dietary AA levels have important effects on pullet BW, fleshing, and organ development during rearing with potential reproductive performance impacts.

Early infection with Histomonas meleagridis has limited effects on broiler breeder hens' growth and egg production and quality.

A study was conducted to determine differences between Histomonas meleagridis-infected and control pullets based on disease signs, hen growth, and egg production and quality. Ross 708SF females were weighed and then placed in pens on the day of hatch (92 chicks/pen). At 25 D, 4 pens were infected with H. meleagridis in the cloaca, whereas 4 pens were control. At 5, 10, and 20 D after inoculation, 5 birds per pen (2 birds per pen at 20 D) were subjectively scored for blackhead disease. Birds were feed restricted based on BW and/or egg production. Individual BW were collected at 3, 5, 13, 15, 20, and 64 wk. Egg production was recorded at 24-63 wk. Egg quality was measured at 30, 34, 39, 42, and 56 wk and included shell and vitelline membrane strength, shell thickness, egg weight, and Haugh units. Hatchability was measured at 27, 37, and 60 wk and fertility at 27 and 37 wk. Treatment effects were determined by JMP Pro 14 using GLM with means separated using the Student t test (P ≤ 0.05). Cecal lesions were apparent on 5, 10, and 20 D and liver lesions on 10 and 20 D for the infected birds. The control had no histomoniasis lesions. Flock uniformity differed on wk 13 and 20 (P = 0.04; 0.04). Infected birds weighed less at 64 wk (P = 0.002). The onset of lay was not delayed. Infected birds produced more eggs during 1 period (P = 0.02). The infected birds produced heavier eggs at 30 wk (P = 0.04), eggs with a stronger and thicker shell at 42 wk (P = 0.05, 0.03), and eggs with a stronger vitelline membrane at 56 wk (P = 0.049). Hatchability and fertility did not differ (P > 0.05). H. meleagridis was observed in the infected birds' cecal samples at trial termination. This study indicates early infection with H. meleagridis has limited effects on pullet egg production and quality.

A User-Centered design and usability testing of a web-based medication reconciliation application integrated in an eHealth network.

BACKGROUND: Medication discrepancies, which are a threat to patient safety, can be reduced by medication reconciliation (MedRec). MedRec is a complex process that can be supported by the use of information technology and patient engagement. Therefore, the SEAMPAT project aims to develop a MedRec IT platform based on two applications. The application for the professionals is called: the "MedRec app". OBJECTIVE: In the present study, we aimed to describe the development and usability testing of the MedRec app, reporting results of a three iterations user-centered usability evaluation. METHODS: We used a three phase iterative user-centered study spread over 16 months. At each phase, the usability evaluation included several methods (observations, questionnaires, and follow-up discussions with participants) to collect quantitative and qualitative data in order to improve the current prototype and evolve to the next prototype. RESULTS: In total, 48 healthcare professionals (25 general practitioners and 23 hospital clinicians) participated to the MedRec app evaluation. There were 14, 32 and 5 participants for phases 1, 2 and 3 respectively. At each phase, many design modifications were done to strengthen usability. Concerning usability, participants considered the prototypes as an acceptable interface with a median System Usability Score of 73 at phase 2 and 75 at phase 3. Participants emphasized the need for improvements concerning workflow integration, usefulness and interoperability. CONCLUSION: The MedRec app was perceived as being useful, usable and satisfying. However, further improvements are required in several usability aspects. Our study demonstrates the importance of conducting usability assessments before investing time and resources in a large study evaluating the effect of an eMedRec approach on clinical outcomes. Our findings may also increase the chances of acceptability and sustained use over time by clinicians.

A web application to involve patients in the medication reconciliation process: a user-centered usability and usefulness study.

Objective: Medication reconciliation (MedRec) can improve patient safety by resolving medication discrepancies. Because information technology (IT) and patient engagement are promising approaches to optimizing MedRec, the SEAMPAT project aims to develop a MedRec IT platform based on two applications: the "patient app" and the "MedRec app." This study evaluates three dimensions of the usability (efficiency, satisfaction, and effectiveness) and usefulness of the patient app. Methods: We performed a four-month user-centered observational study. Quantitative and qualitative data were collected. Participants completed the system usability scale (SUS) questionnaire and a second questionnaire on usefulness. Effectiveness was assessed by measuring the completeness of the medication list generated by the patient application and its correctness (ie medication discrepancies between the patient list and the best possible medication history). Qualitative data were collected from semi-structured interviews, observations and comments, and questions raised by patients. Results: Forty-two patients completed the study. Sixty-nine percent of patients considered the patient app to be acceptable (SUS Score ≥ 70) and usefulness was high. The medication list was complete for a quarter of the patients (7/28) and there was a discrepancy for 21.7% of medications (21/97). The qualitative data enabled the identification of several barriers (related to functional and non-functional aspects) to the optimization of usability and usefulness. Conclusions: Our findings highlight the importance and value of user-centered usability testing of a patient application implemented in "real-world" conditions. To achieve adoption and sustained use by patients, the app should meet patients' needs while also efficiently improving the quality of MedRec.

Impact of Enzyme Replacement Therapy in a Patient Younger Than 2 Years Diagnosed With Maroteaux-Lamy Syndrome (MPS VI)

Abstract Introduction: Mucopolysaccharidosis type VI, also known as Maroteaux-Lamy syndrome (#OMIM 253200), is a rare autosomal recessive genetic disorder due to deficient activity of the enzyme N-acetylgalactosamine 4-sulfatase (arylsulfatase B) required for the breakdown of dermatan sulfate and chondroitin sulfate. Patient: Report of a female patient started on enzyme replacement therapy at 17 months of age. At the time of diagnosis (14 months), the patient presented mild corneal opacity and significant thoracolumbar kyphosis, but no visceral involvement or growth arrest. At 73 months of treatment, weight was normal, although the patient was in a low height percentile. The patient showed adequate neural development, with improvement in lumbar spine and joint involvement. Corneal compromise or valvular disease progression was not evident. Conclusion: Early and timely diagnosis and treatment with enzyme replacement therapy are essential, as the means to change the natural history of the disease, avoiding comorbidities and improving final prognosis.

Enfoque de las gestaciones múltiples de diagnóstico difícil durante la autopsia perinatal / Approach to Perinatal Autopsies in Multiple Gestations with Difficult Diagnoses / Enfoque das gestações múltiplas de diagnóstico difícil durante a autopsia perinatal

Resumen Introducción: Durante el examen de pediatría, genética, ecográfico o de anatomía patológica de fetos de gestaciones gemelares, suelen aparecer interrogantes en el diagnóstico diferencial, especialmente cuando los casos se asocian con maceración, malformaciones o duplicación de estructuras. Objetivo: Proponer un algoritmo para el enfoque de la autopsia perinatal en gestaciones múltiples de difícil diagnóstico. Materiales y Métodos: Estudio observacional descriptivo del universo de gestaciones gemelares vistas en el Departamento de Patología del Hospital Universitario San Ignacio (HUSI) entre 2007 y 2013. Definimos como "gestación múltiple de difícil diagnóstico" aquella en la que el examen del (de los) feto(s) planteó uno de los diagnósticos diferenciales: feto macerado/evanescente, gemelo siamés, fetus in fetu, feto acárdico o teratoma congénito. Se realizó el estudio anatomopatológico y junto con la literatura revisada, los gemelos se analizaron y clasificaron según el algoritmo propuesto. Resultados: Hubo 59 casos de gestaciones gemelares en las que al menos uno de los fetos requirió autopsia perinatal. Las principales causas de muerte fueron las infecciones ascendentes seguidas del síndrome de transfusión feto-fetal. Como gestaciones múltiples de difícil diagnóstico observamos tres fetos acárdicos y ocho fetos macerados. Se aplicó el algoritmo propuesto en este artículo. Conclusiones: El diagnóstico en las gestaciones gemelares puede ser en ocasiones difícil. Identificamos los aspectos más importantes a tener en cuenta de la historia clínica y de la autopsia perinatal para llegar al diagnóstico definitivo. Desarrollamos un algoritmo para ser aplicado en estas circunstancias durante las autopsias perinatales.

Abstract Introduction: During pediatric, genetic, sonographic, or pathological anatomy examination on complicated twin gestational fetuses, questions arise concerning differential diagnosis, especially when cases are associated with malformations, maceration of several months duration, or complex structural duplications. Objective: To propose an algorithm for approaching perinatal autopsy in complicated multiple gestations. Materials and Methods: Descriptive observational study on twin gestations seen in the Hospital Universitario San Ignacio (HUSI) in 2007-2013. We defined "complicated twin gestation" as one in which an examination of the fetus or fetuses raised one of the following differential diagnoses: macerated fetus, conjoined fetuses, fetus in fetu, acardiac fetus, or congenital teratoma. An anatomopathological study was performed and twins were classified according to the proposed algorithm. Results: Analysis of 59 cases in which at least one fetus required a perinatal autopsy. The leading causes of death were ascending infections and fetal-twin transfusion syndrome. Among complicated multiple gestations we observed eight fetuses including three acardiac macerated fetuses. We applied the algorithm proposed in this article. Conclusion: Diagnosis in twin pregnancies can sometimes be difficult. We identify the most important aspects of medical records and perinatal autopsy to be considered in reaching a definitive diagnosis; we develop an algorithm to be applied in these circumstances.

Resumo Introdução: Durante o exame de pediatria, genética, ecográfico ou de anatomia patológica de fetos de gestações gemelares, costumam aparecer interrogantes no diagnóstico diferencial, especialmente quando os casos se associam com maceração, com malformações ou com duplicação de estruturas. Objetivo: Propor um algoritmo para o enfoque da autopsia perinatal em gestações múltiplas de difícil diagnóstico. Materiais e Métodos: Estudo observacional descritivo do universo de gestações gemelares vistas no Departamento de Patologia do Hospital Universitário San Ignacio (HUSI) entre 2007 e 2013. Definimos como "gestação múltipla de difícil diagnóstico" aquela na que o exame do(s) feto(s) apresentou um dos diagnósticos diferenciais: feto macerado/evanescente, gêmeo siamês, fetus in fetu, feto acárdico ou teratoma congênito. Realizou-se o estudo anatomopatológico e junto com a literatura revisada, os gêmeos se analisaram e classificaram segundo o algoritmo proposto. Resultados: Houve 59 casos de gestações gemelares nas que pelo menos um dos fetos requereu autopsia perinatal. As principais causas de morte foram as infeções ascendentes seguidas da síndrome de transfusão feto-fetal. Como gestações múltiplas de difícil diagnóstico observamos três fetos acárdicos e oito fetos macerados. Aplicou-se o algoritmo proposto neste artigo. Conclusões: O diagnóstico nas gestações gemelares pode ser em ocasiões difícil. Identificamos os aspectos mais importantes a ter em conta da história clínica e da autopsia perinatal para chegar ao diagnóstico definitivo; desenvolvemos um algoritmo para ser aplicado nestas circunstâncias durante as autopsias perinatais.

The 1-2-3 approach to abdominal packing.

BACKGROUND: Abdominal packing (AP) in damage-control laparotomy (DCL) is a lifesaving technique that controls coagulopathic hemorrhage in severely injured trauma patients. However, the impact of the duration of AP on the incidence of re-bleeding and on intra-abdominal infections in penetrating abdominal trauma is not clear. The objective of the present study was to evaluate the complications related to the duration of AP and to determine the optimal time for AP removal. METHODS: Prospectively collected/retrospectively analyzed data at an urban level I trauma center from January 2003 to December 2010 were used as the basis for this study. Inclusion criteria were adults (≥18 years old) with penetrating abdominal trauma, who had survived both the initial DCL procedure and their first re-laparotomy. All initial DCL patients included in the study underwent abdominal packing for coagulopathic hemorrhage control. The outcome measures of this study were re-bleeding after packing removal, intra-abdominal infection, and 30-day cumulative mortality. We considered time after packing as an independent variable. This was defined as the total amount of time (in days) that the packs were left in the patient's abdomen. Patients were grouped according to the duration in days of their AP in <1, 1-2, 2-3, and >3 days. RESULTS: Of 503 patients with penetrating abdominal trauma, 121 underwent DCL and AP. The mean age was 30.1± 11.5 years, and the male to female ratio was 9:1. The mean Acute Physiology and Chronic Health Evaluation (APACHE II) score was 17.6±7.2. The mean Injury Severity Score (ISS) score was 24.9±9.1. The right upper quadrant was packed in 39 (32.2%) patients, retroperitoneum in 70 (57.8%), pelvis in 13 (10.7%), and left upper quadrant in 9 (7.4%). Fifty-one patients (42.1%) had associated colon injuries and 58 (47.9%) had small bowel injuries. Twenty-six patients (21.5%) had AP<1 day, 42 patients (34.7%) had AP between 1 and 2 days, 35 patients (28.9%) had AP between 2 and 3 days, and 18 patients (14.8%) had AP>3 days. The re-bleeding rate in patients packed for 1-2 days compared to those packed for <1 day was a third lower, 14.3%, (95% confidence interval [95% CI]: 8.06, 20.5) versus 38.5% (95% CI: 25.4, 51.5). Conversely, an increasing trend toward intra-abdominal infection occurred as time after packing increased. The infection rate tripled from 16.7% (95% CI: 6.6, 26.7) to 44.4% (95% CI: 31.03, 57.7) when comparing 1-2 days versus >3 days. Overall mortality was 16.5%. Of these deaths, 8.26% were attributable to re-bleeding, and 13.2% to intra-abdominal infection. Deaths secondary to re-bleeding seemed to decrease with time of AP, whereas intra-abdominal infection deaths increased with time of AP (Chi square for trend p value=0.04). CONCLUSIONS: The present study suggests that AP used in the setting of DCL for coagulopathic hemorrhage control should not be removed prior to the first postoperative day because of the increased risk of re-bleeding. The ideal length of AP is 2-3 days, and AP left in longer than 3 days is associated with a significantly increased risk of infectious complications.

Improving mortality predictions in trauma patients undergoing damage control strategies.

The increased use of damage control surgery in complex trauma patients requires accurate prognostic indicators. We compared the discriminatory capacity of commonly used trauma and intensive care unit (ICU) scores, including revised trauma score, injury severity scores, trauma score-injury severity scores, acute physiology and chronic health evaluations II, and clinical and laboratory parameters, on 83 consecutive trauma patients admitted to the ICU, undergoing damage control. Logistic regressions were built for mortality prediction within 30 days. Performances of the models were assessed in terms of discrimination and calibration. Areas under the receiver operating characteristic curve from the models were compared. Overall mortality was 38.5 per cent. A "clinical" model was constructed including ICU admission pH and hypothermia (≤ 35 C °) and the number of packed red blood cells during the first 24 hours. This model was adjusted for age and demonstrated better discrimination for mortality prediction (areas under the receiver operating characteristic curve = 0.8054) than injury severity score (P value = 0.049), abdominal trauma index (P value = 0.049), and acute physiology and chronic health evaluations II (P value = 0.001). There was no statistically significant difference in discrimination for mortality prediction between the "clinical" model and revised trauma score (P value = 0.4) and trauma score-injury severity score (P value = 0.4). We concluded that the combination of ICU admission pH and hypothermia and blood transfusions during 24 hours provided an excellent discriminatory capacity for mortality prediction in this complex patient population.

Prevalencia al nacimiento de síndrome de down en la ciudad de Manizales (Caldas-Colombia) durante el período 2004-2005 / Prevalence at birth of down syndrome in Manizales, Caldas, Colombia, during 2004-2005

Objetivo: conocer la prevalencia al nacimiento y factores de riesgo asociados con el síndrome de Down en Manizales (Caldas) durante el periodo Enero 2004 - Diciembre 2005. Materiales y métodos: se hizo un estudio descriptivo en el que se revisó la información de las historias clínicas de los principales hospitales en donde se atienden partos en la ciudad de Manizales, entre el periodo Enero 2004 - Diciembre 2005. Se aplicó un instrumento para recolectar la información necesaria, entre ellas: año de nacimiento, sexo del recién nacido, alteración citogenética diagnosticada, edad materna al momento del nacimiento, edad paterna al momento del nacimiento y antecedentes familiares de síndrome de Down. Resultados: se encontraron 11.209 nacimientos, de los cuales 17 fueron casos de síndrome de Down, obteniéndose una prevalencia de 1/659 al nacimiento. Conclusiones: en esta población la prevalencia del síndrome de Down concuerda con las tasas globales reportadas en diferentes países del mundo. La edad materna por encima de los 35 años es un factor de riesgo asociado con el desarrollo de este síndrome.

The objective of this study is to find out the prevalence at birth of Down syndrome in Manizales (Caldas) from January 2004 to December 2005. It was a descriptive study covering the information in clinical records of the major hospitals where births are handled in the city of Manizales. The instruments applied to gather the necessary information include: year of birth, sex of the newborn, diagnosed citogenetic alteration, maternal age at birth, paternal age at birth, and family history of Down syndrome. The results showed that 17 cases of Down syndrome were diagnosed from the 11,209 births studied for this time period, with a birth prevalence of 1/659. In this population, the prevalence rates agree with the rates reported around the world. The majority of cases were from mothers older than 35 years old.

Síndrome retroviral agudo Vs sífilis secundaria / Acute retroviral syndrome versus secondary syphillis

Resumen: Paciente de 16 años, hombre. Ingresa a laFundación Valle del Lili (FCVL) el 12-XI-2000 conun cuadro clínico de 10 días de evolución deaparición de lesiones ulcerativas en pene asociadoposteriormente a la aparición de fiebre, rash ypérdida del estado general. Tenía el antecedentede haber presentado lesiones similares en losgenitales meses atrás, las cuales habían sidomanejadas con penicilina benzatínica, con mejoría.En ese entonces tenía un VDRL positivo nocuantificado y un FTA-abs positivo. Comoantecedentes importantes adicionales, era adicto amúltiples sustancias ilícitas, entre ellas cocaína ymarihuana y tenía varias compañeras sexuales

Sepsis por Salmonella enteritidis en una paciente con lupus eritomatoso sistemico / Sepsis for salmonella enteritidis in patient with Lupus erythematosus

Presentamos el caso clínico de una paciente de 28 años de edad con Lupus Eritematoso Sistémico (LES), con compromiso a nivel neurológico central, riñon y sistema hematológico, con tratamiento crónico de esferoides y desnutrición avanzada, quien desarrolla sepsis por Salmonella enteritidis, germen aislado en muestras tomadas en lavado bronco alveolar, sangre y materia fecal. Presentó un absceso pulmonar izquierdo y severa dificultad respiratoria. Recibió tratamiento con Ciprofloxacina con mejoría favorable. Pocas semanas después fallece en sepsis y con deterioro de su estado general. Se realiza una discusión en relación con la asociación de LES e infecciones por salmonelas, sus factores predisponentes y su papel en la mortalidad en este tipo de casos

Diagnóstico por imágenes: Tuberculoma en el Sistema Nervioso Central / Diagnostic Images: tuberculoma of the Central Nervous System

Resumen: Mujer de 25 años, que ingresa por cuadro de convulsiónparcial simple con compromiso motor del miembro superior derecho y posterior generalización hacia status convulsivo. Se le realiza escanografía cerebral y posteriormente resonancia magnética (RMN) (Fig. 1). Una prueba de anticuerpos antinucleares fue negativa y el ELISA para VIH fue negativo, al igual que los anticuerpos anticardiolipina. Ante la sospecha de una lesión tumoral maligna del SNC se le realiza una gammagrafía 99 Tc MIBI que reportó lesiones hipercaptantes en hemisferio cerebral izquierdo, región temporoparietal izquierda y otras periventriculares posteriores (Fig. 2). Una biopsia de la lesión reveló inflamación crónica granulomatosa con necrosis caseosa y la tinción y posteriormente el cultivo fue positivo para Mycobacterium tuberculosis