Aumento de la lipocalina orosomucoide-1 (ORM1) en sujetos con hiperaldosteronismo primario / Increase of lipocalin ORM1 in primary aldosteronism

El hiperaldosteronismo primario (HAP) es la causa más común de hipertensión arterial secundaria. A pesar de la prevalencia del HAP (6-10%) y sus consecuencias, los mecanismos que median los efectos deletéreos renales y extrarenales originados por la aldosterona más allá de la hipertensión arterial (ej. inflamación renal, alteraciones cardiacas y disfunción vascular), siguen siendo poco conocidos. Estudios previos sugieren que el exceso de aldosterona aumentaría proteínas sensibles a la activación del receptor de mineralocorticoides (MR), como las lipocalinas LCN2 (NGAL) y ORM1. OBJETIVO: Determinar la concentración de las lipocalinas ORM1, NGAL y NGAL-MMP9 en sujetos HAP. SUJETOS Y MÉTODOS: Estudio de cohorte transversal en sujetos adultos (similares en sexo, edad e IMC) separados en controles normotensos (CTL), hipertensos esenciales (HE) y con screening positivo de HAP (aldosterona ≥9 ng/dL y ARP < 1 ng/mL*h acorde a las guías internacionales de HAP). Se determinó la presión arterial sistólica (PAS) y diastólica (PAD), aldosterona plasmática, actividad renina plasmática (ARP) y la relación aldosterona / actividad de renina plasmática (ARR). Se determinó la concentración de NGAL, NGAL-MMP9 y ORM1 en suero por ELISA. RESULTADOS: Detectamos mayores niveles de ORM1 en sujetos HAP. No se detectaron diferencias en NGAL ni NGAL-MMP9 entre los grupos. Detectamos una asociación positiva de ORM1 con ARP (rho= -0,407, p=0,012) y con ARR (rho= 0,380 p= 0,021). CONCLUSIÓN: La mayor concentración de ORM1 en sujetos HAP y las asociaciones de ORM1 con aldosterona, ARP y ARR, proponen a esta proteína como un potencial biomarcador de HAP y de utilidad en el desarrollo de algoritmos diagnósticos de HAP.

Primary hyperaldosteronism (PA) is the most common cause of secondary hypertension. Despite the prevalence of PA (6-10%) and its consequences, the mechanisms that mediate the deleterious renal and extrarenal effects caused by aldosterone beyond arterial hypertension (eg renal inflammation, cardiac alterations and vascular dysfunction), remain barely known. Previous studies suggest that excess aldosterone would increase proteins sensitive to activation of the mineralocorticoid receptor (MR), such as lipocalins LCN2 (NGAL) and ORM1. AIM: To determine the concentration of the lipocalins ORM1, NGAL and NGAL-MMP9 in PA subjects. SUBJECTS AND METHODS: Cross-sectional study in adult subjects (similar in sex, age and BMI) grouped as normotensive controls (CTL), essential hypertensive (HE) and subjects with positive PA screening (aldosterone ≥ 9 ng/dL and PRA <1 ng/mL*h, according to international PA guidelines). Systolic (SBP) and diastolic (DBP) blood pressure, plasma aldosterone, plasma renin activity (PRA), and plasma aldosterone renin ratio (ARR) were determined. The concentration of NGAL, NGAL-MMP9 and ORM1 in serum was determined by ELISA. RESULTS: We detected higher levels Recibido: 03-09-2021 of ORM1 in PA subjects. No differences in NGAL or NGAL-MMP9 were detected between the groups. We detected a positive association of ORM1 with ARP (rho = -0.407, p < 0.05) and with ARR (rho = 0.380 p <0.05). CONCLUSION: The high levels of ORM1 in PA subjects and the associations of ORM1 with aldosterone, ARP and ARR, suggest ORM1 is a potential biomarker of PA, and useful in the development of a diagnostic algorithm for PA.

Guías basadas en la evidencia para el uso de traqueostomía en el paciente crítico / Evidence-based guides in tracheostomy use in critical patients

OBJETIVOS: Proporcionar guías de traqueostomía para el paciente crítico, basadas en la evidencia científica disponible, y facilitar la identificación de áreas en las cuales se requieren mayores estudios. MÉTODOS: Un grupo de trabajo formado con representantes de 10 países pertenecientes a la Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva y a la Latin American Critical Care Trial Investigators Network (LACCTIN) desarrollaron estas recomendaciones basadas en el sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTADOS: El grupo identificó 23 preguntas relevantes entre las 87 preguntas planteadas inicialmente. En la búsqueda inicial de la literatura se identificaron 333 estudios, de los cuales se escogieron un total de 226. El equipo de trabajo generó un total de 19 recomendaciones: 10 positivas (1B=3, 2C=3, 2D=4) y 9 negativas (1B=8, 2C=1). En 6 ocasiones no se pudieron establecer recomendaciones. CONCLUSIÓN: La traqueostomía percutánea se asocia a menor riesgo de infecciones en comparación con la traqueostomía quirúrgica. La traqueostomía precoz solo parece reducir la duración de la ventilación mecánica pero no la incidencia de neumonía, la duración de la estancia hospitalaria o la mortalidad a largo plazo. La evidencia no apoya el uso de broncoscopia de forma rutinaria ni el uso de máscara laríngea durante el procedimiento. Finalmente, el entrenamiento adecuado previo es tanto o más importante que la técnica utilizada para disminuir las complicaciones

OBJECTIVES: Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS: A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION: Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used

Evidence-based guides in tracheostomy use in critical patients

Objetivos: Proporcionar guías de traqueostomía para el paciente crítico, basadas en la evidencia científica disponible, y facilitar la identificación de áreas en las cuales se requieren mayores estudios. Métodos: Un grupo de trabajo formado con representantes de 10 países pertenecientes a la Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva y a la Latin American Critical Care Trial Investigators Network(LACCTIN) desarrollaron estas recomendaciones basadas en el sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE). Resultados: El grupo identificó 23 preguntas relevantes entre las 87 preguntas planteadas inicialmente. En la búsqueda inicial de la literatura se identificaron 333 estudios, de los cuales se escogieron un total de 226. El equipo de trabajo generó un total de 19 recomendaciones: 10 positivas (1B = 3, 2C = 3, 2D = 4) y 9 negativas (1B = 8, 2C = 1). En 6 ocasiones no se pudieron establecer recomendaciones. Conclusión: La traqueostomía percutánea se asocia a menor riesgo de infecciones en comparación con la traqueostomía quirúrgica. La traqueostomía precoz solo parece reducir la duración de la ventilación mecánica pero no la incidencia de neumonía, la duración de la estancia hospitalaria o la mortalidad a largo plazo. La evidencia no apoya el uso de broncoscopia de forma rutinaria ni el uso de máscara laríngea durante el procedimiento. Finalmente, el entrenamiento adecuado previo es tanto o más importante que la técnica utilizada para disminuir las complicaciones.(AU)

OBJECTIVES: Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS: A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION: Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.(AU)

Evidence-based guides in tracheostomy use in critical patients. / Guías basadas en la evidencia para el uso de traqueostomía en el paciente crítico.

OBJECTIVES: Provide evidence based guidelines for tracheostomy in critically ill adult patients and identify areas needing further research. METHODS: A task force composed of representatives of 10 member countries of the Pan-American and Iberic Federation of Societies of Critical and Intensive Therapy Medicine and of the Latin American Critical Care Trial Investigators Network developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The group identified 23 relevant questions among 87 issues that were initially identified. In the initial search, 333 relevant publications were identified of which 226 publications were chosen. The task force generated a total of 19 recommendations: 10 positive (1B=3, 2C=3, 2D=4) and 9 negative (1B=8, 2C=1). A recommendation was not possible in six questions. CONCLUSION: Percutaneous techniques are associated with a lower risk of infections compared to surgical tracheostomy. Early tracheostomy only seems to reduce the duration of ventilator use but not the incidence of pneumonia, the length of stay, or the long-term mortality rate. The evidence does not support the use of routine bronchoscopy guidance or laryngeal masks during the procedure. Finally, proper prior training is as important or even a more significant factor in reducing complications than the technique used.

Respiratory sinus arrhythmia in growth restricted fetuses with normal Doppler hemodynamic indices.

BACKGROUND: The autonomic behavior of growth-restricted fetuses at different evolving hemodynamic stages has not been fully elicited. AIM: To analyze the respiratory sinus arrhythmia (RSA) of growth-restricted fetuses that despite this severe condition show normal Doppler hemodynamics. SUBJECTS: 10 growth-restricted fetuses (FGR group) with normal arterial pulsatility indices (umbilical, uterine, middle cerebral, ductus venosus and aortic isthmus), and 10 healthy fetuses (Control group), 32-37weeks of gestation. METHOD: B-mode ultrasound images for visualizing fetal breathing movements (FBM) or breathing akinesis (FBA), and the simultaneous RR-interval time series from maternal abdominal ECG recordings were obtained. The root-mean-square of successive differences of RR-intervals (RMSSD) was considered as a RSA-related parameter among the instantaneous amplitude of the high-frequency component (AMPHF) and its corresponding instantaneous frequency (IFHF), both computed by using empirical mode decomposition. Mean fetal heart-periods and RSA-related parameters were assessed during episodes of FBM and FBA in 30s length windows. RESULTS: FGR and Control groups presented RSA-related fluctuations during FBM and FBA. Also, both groups showed significant higher (p<0.001) values for the mean heart-period, RMSSD and AMPHF during FBM. No-significant differences (p>0.05) were found for the IFHF regardless of breathing activity (FBM vs. FBA). CONCLUSION: Growth-restricted fetuses without evident hemodynamic compromise exhibit a preserved autonomic cardiovascular regulation, characterized by higher values of RSA and mean heart-period in the presence of FBM. This physiological response reflects a compensatory strategy that may contribute to preserve blood flow redistribution to vital organs.

Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo / Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients

Introducción: El óptimo manejo de la sedación, analgesia y delirium ofrece al paciente crítico comodidad y seguridad, facilita el buen desarrollo de medidas de soporte y manejo integral y disminuye complicaciones, impactando en un mejor desenlace. Objetivo: Actualizar la Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo publicada en Medicina Intensiva en el 2007 y dar recomendaciones para el manejo de la sedación, analgesia y delirium. Metodología: Se reunió un grupo de 21 intensivistas procedentes de 9 países de la Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva, 3 de ellos además especialistas en epidemiología clínica y metodología para elaboración de guías. Se acogió la propuesta del Grading of Recommendations Assessment, Development and Evaluation Working Group para emitir el grado de recomendación y evaluar la calidad de la evidencia. La fuerza de las recomendaciones fue calificada como 1=fuerte, o 2=débil, y la calidad de la evidencia como A=alta, B=moderada, o C=baja. Expertos en búsqueda de literatura apoyaron con esta estrategia de búsqueda: MEDLINE a través de PUBMED, bases de datos de la biblioteca Cochrane a través de The Cochrane Library y la base de datos Literatura Latinoamericana y del Caribe en Ciencias de la Salud. Los miembros asignados a las 11 secciones de la guía, basándose en la revisión de la literatura, presentaron las recomendaciones, sustentadas y discutidas en sesiones plenarias, aprobando aquellas que superaron el 80% del consenso. La elaboración de las guías contó con el soporte de la Asociación Colombiana de Medicina Crítica y Cuidado Intensivo. Resultados: Para la elaboración de la guía fueron finalmente seleccionadas 467 referencias, observándose un importante aumento en el número y calidad de los estudios, permitiendo realizar 64 fuertes recomendaciones con evidencia alta y moderada, contrastando con las 28 de la edición anterior. Conclusiones: Esta guía contiene recomendaciones y sugerencias basadas en la mejor evidencia para el manejo de la sedación, analgesia y delirium del paciente crítico, incluyendo un paquete de medidas (bundle). Se destacan: evaluación del dolor y la agitación/sedación mediante escalas; usar inicialmente opioides para el control de la analgesia, adicionando técnicas multimodales para disminuir consumo de opioides; promover el menor nivel de sedación necesario, evitando la sobresedación; en caso de requerir medicamentos sedantes, escoger el más apropiado, evitando el uso rutinario de benzodiazepinas; por último, identificar factores de riesgo para delirium, prevenirlo, diagnosticarlo y manejarlo, con el medicamento más conveniente, ya sea haloperidol, antipsicóticos atípicos o dexmedetomidina, evitando el uso de benzodiazepinas y disminuyendo el uso de opioides

Introduction: Optimal management of sedation, analgesia and delirium offers comfort and security for the critical care patient, allows support measures to be applied more easily and enables an integral approach of medical care, at the same time that lowers the incidence of complications, wich translates in better patient outcomes. Objective: To update the Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo published in Medicina Intensiva in 2007, and give recommendations for the management of sedation, analgesia, and delirium. Methodology: A group of 21 intensivists from 9 countries of the Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva, 3 of them also specialists in clinical epidemiology and methodology, gathered for the development of guidelines. Assessment of evidence quality and recommendations were made based on the Grading of Recommendations Assessment, Development and Evaluation system. Strength of recommendations was classified as 1=strong, or 2=weak, and quality of evidence as A=high, B=moderate, or C=low. Two authors searched the following databases: MEDLINE through PUBMED, The Cochrane Library and Literatura Latinoamericana y del Caribe en Ciencias de la Salud and retrieved pertinent information. Members assigned to the 11 sections of the guidelines, based on the literature review, formulated the recommendations, that were discussed in plenary sessions. Only those recommendations that achieved more than 80% of consensus were approved for the final document. The Colombian Association of Critical Medicine and Intensive Care (AMCI) supported the elaboration of this guidelines. Results: Four hundred sixty-seven articles were included for review. An increase in number and quality of publications was observed. This allowed to generate 64 strong recommendations with high and moderate quality of evidence in contrast to the 28 recommendations of the previous edition. Conclusions: This Guidelines contains recommendations and suggestions based on the best evidence available for the management of sedation, analgesia and delirium of the critically ill patient, including a bundle of strategies that serves this purpose. We highlight the assessment of pain and agitation/sedation through validated scales, the use of opioids initially to apropiate analgesic control, associated with multimodal strategies in order to reduce opioide consumption; to promote the lowest level of sedation necessary avoiding over-sedation. Also, in case of the need of sedatives, choose the most appropiate for the patient needs, avoiding the use of benzodiazepines and identify risk factors for delirium, in order to prevent its occurrence, diagnose delirium and treat it with the most suitable pharmacological agent, whether it is haloperidol, atypical antipsychotics or dexmedetomidine, once again, avoiding the use of benzodiazepines and decreasing the use of opioids

Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients.

INTRODUCTION: Optimal management of sedation, analgesia and delirium offers comfort and security for the critical care patient, allows support measures to be applied more easily and enables an integral approach of medical care, at the same time that lowers the incidence of complications, wich translates in better patient outcomes. OBJECTIVE: To update the Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo published in Medicina Intensiva in 2007, and give recommendations for the management of sedation, analgesia, and delirium. METHODOLOGY: A group of 21 intensivists from 9 countries of the Federación Panamericana e Ibérica de Sociedades de Medicina Crítica y Terapia Intensiva, 3 of them also specialists in clinical epidemiology and methodology, gathered for the development of guidelines. Assessment of evidence quality and recommendations were made based on the Grading of Recommendations Assessment, Development and Evaluation system. Strength of recommendations was classified as 1=strong, or 2=weak, and quality of evidence as A=high, B=moderate, or C=low. Two authors searched the following databases: MEDLINE through PUBMED, The Cochrane Library and Literatura Latinoamericana y del Caribe en Ciencias de la Salud and retrieved pertinent information. Members assigned to the 11 sections of the guidelines, based on the literature review, formulated the recommendations, that were discussed in plenary sessions. Only those recommendations that achieved more than 80% of consensus were approved for the final document. The Colombian Association of Critical Medicine and Intensive Care (AMCI) supported the elaboration of this guidelines. RESULTS: Four hundred sixty-seven articles were included for review. An increase in number and quality of publications was observed. This allowed to generate 64 strong recommendations with high and moderate quality of evidence in contrast to the 28 recommendations of the previous edition. CONCLUSIONS: This Guidelines contains recommendations and suggestions based on the best evidence available for the management of sedation, analgesia and delirium of the critically ill patient, including a bundle of strategies that serves this purpose. We highlight the assessment of pain and agitation/sedation through validated scales, the use of opioids initially to apropiate analgesic control, associated with multimodal strategies in order to reduce opioide consumption; to promote the lowest level of sedation necessary avoiding over-sedation. Also, in case of the need of sedatives, choose the most appropiate for the patient needs, avoiding the use of benzodiazepines and identify risk factors for delirium, in order to prevent its occurrence, diagnose delirium and treat it with the most suitable pharmacological agent, whether it is haloperidol, atypical antipsychotics or dexmedetomidine, once again, avoiding the use of benzodiazepines and decreasing the use of opioids.

The future of intensive care medicine / El futuro de la medicina intensiva

Intensive care medical training, whether as a primary specialty or as secondary add-on training, should include key competences to ensure a uniform standard of care, and the number of intensive care physicians needs to increase to keep pace with the growing and anticipated need. The organisation of intensive care in multiple specialty or central units is heterogeneous and evolving, but appropriate early treatment and access to a trained intensivist should be assured at all times, and intensivists should play a pivotal role in ensuring communication and high-quality care across hospital departments. Structures now exist to support clinical research in intensive care medicine, which should become part of routine patient management. However, more translational research is urgently needed to identify areas that show clinical promise and to apply research principles to the real-life clinical setting. Likewise, electronic networks can be used to share expertise and support research. Individuals, physicians and policy makers need to allow for individual choices and priorities in the management of critically ill patients while remaining within the limits of economic reality. Professional scientific societies play a pivotal role in supporting the establishment of a defined minimum level of intensive health care and in ensuring standardised levels of training and patient care by promoting interaction between physicians and policy makers. The perception of intensive care medicine among the general public could be improved by concerted efforts to increase awareness of the services provided and of the successes achieved (AU)

La formación en medicina intensiva, ya sea como especialidad primaria o a partir de una troncalidad común para después convertirse en supra-especialidad, debería incluir competencias clave que garanticen un cuidado estándar y homogéneo del paciente crítico, así como proveer al sistema sanitario del número de especialistas en medicina intensiva (intensivistas) de forma ajustada y anticipada al ritmo de crecimiento de la necesidad asistencial. La organización de los cuidados intensivos desde la visión de las distintas especialidades o en unidades centralizadas y jerarquizadas, es heterogénea y está en constante evolución. No obstante el acceso y tratamiento precoz del enfermo crítico por parte de un intensivista, debería estar siempre garantizado, no únicamente en los servicios de medicina intensiva, sino en todos los departamentos de un hospital, actuando el intensivista como elemento central en la comunicación y coordinación entre los diferentes servicios y especialistas, a fin de lograr la más alta calidad y eficacia en la asistencia. La investigación clínica en medicina intensiva está sustentada por la excelencia de conocimiento de sus profesionales, pero son necesarias estructuras de apoyo: la integración de la investigación e innovación en la rutina diaria y un incremento de la investigación traslacional, a fin de identificar áreas que muestren elementos potenciales de avance en el aspecto clínico y la aplicación de los principios de la investigación básica y fisiológica en el entorno de la medicina intensiva. Las tecnologías de la comunicación y la información ofrecen un marco idóneo para compartir y poner en común el conocimiento y apoyar (..) (AU)

The future of intensive care medicine.

Intensive care medical training, whether as a primary specialty or as secondary add-on training, should include key competences to ensure a uniform standard of care, and the number of intensive care physicians needs to increase to keep pace with the growing and anticipated need. The organisation of intensive care in multiple specialty or central units is heterogeneous and evolving, but appropriate early treatment and access to a trained intensivist should be assured at all times, and intensivists should play a pivotal role in ensuring communication and high-quality care across hospital departments. Structures now exist to support clinical research in intensive care medicine, which should become part of routine patient management. However, more translational research is urgently needed to identify areas that show clinical promise and to apply research principles to the real-life clinical setting. Likewise, electronic networks can be used to share expertise and support research. Individuals, physicians and policy makers need to allow for individual choices and priorities in the management of critically ill patients while remaining within the limits of economic reality. Professional scientific societies play a pivotal role in supporting the establishment of a defined minimum level of intensive health care and in ensuring standardised levels of training and patient care by promoting interaction between physicians and policy makers. The perception of intensive care medicine among the general public could be improved by concerted efforts to increase awareness of the services provided and of the successes achieved.

La violencia del padre y su repercusión en el hijo adolescente / How the father's violence influences his teenage son

Deseo exponer, desde una perspectiva psicoanalítica, el problema que supone para el hijo varón adolescente la violencia de su padre, en tanto influye en la asunción de su identidad sexual y en su compromiso con la realidad. La vía privilegiada a través de la cual el adolescente capta la violencia del padre es la de la identificación, sea como identificación con el agresor o instalándose el lugar de víctima pasiva. En este último destino se produce una fijación masoquista en el adolescente a hacerse pegar, a excitar la violencia del otro, a perderse él mismo. A través de un caso clínico se muestra que es esencial que en el vínculo terapéutico se puedan desplegar los fantasmas de la escena primaria, las imagos materna y paterna que marcan la vida del paciente, para hacerlas conscientes y poder transformarlas para que el sujeto no quede fijado en la posición de víctima(AU)

I wish to lay before the problem posed to the teenage son of his father’s violence, whiletaking influences sexual identity and its commitment to reality. The privileged way through which the adolescent captures the father’s violence is the identification, whether as identification with the aggressor or settled place of passive victim. In the latter destination there is a masochistic fixation on the teen to become hit, to excite the violence of another, to loss himself. Through a clinical case shows that it is essential that the therapeutic relationship can be deployed the ghosts of the primal scene, the maternal and paternal imagos that mark the life of the patient, to make them aware and to transform them in order to the teen isn't tight as a victim(AU)

Acute kidney injury in critically ill patients with 2009 influenza A (H1N1) viral pneumonia: an observational study.

OBJECTIVE: To describe the incidence, risk factors, and impact on mortality of acute kidney injury (AKI) in patients with 2009 influenza A (H1N1) viral pneumonia requiring mechanical ventilation. DESIGN: Observational cohort study. PATIENTS AND METHODS: AKI was defined as risk, injury or failure, according to the RIFLE classification. Early and late AKI were defined as AKI occurring on intensive care unit (ICU) day 2 or before, or after ICU day 2, respectively. Demographic data and information on organ dysfunction were collected daily. RESULTS: Of 84 patients, AKI developed in 43 patients (51%). Twenty (24%) needed renal replacement therapy. Early and late AKI were found in 28 (33%) and 15 (18%) patients, respectively. Patients with AKI, as compared with patients without AKI, had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score and ICU mortality (72% versus 39%, p < 0.01) and presented on admission more marked cardiovascular, respiratory, and hematological dysfunction. Patients with early but not late AKI presented on admission higher APACHE II score and more marked organ dysfunction, as compared with patients without AKI. ICU mortality was higher in late versus early AKI (93% versus 61%, p < 0.001). On multivariate analysis, only APACHE II score and late but not early AKI [odds ratio (OR) 1.1 (95% confidence interval 1.0-1.1) and 15.1 (1.8-130.7), respectively] were associated with mortality. CONCLUSIONS: AKI is a frequent complication of 2009 influenza A (H1N1) viral pneumonia. AKI developing after 2 days in ICU appears to be associated with different risk factors than early AKI, and is related to a higher mortality rate.

Comparación de los modelos pronósticos APACHE II y Score Salvador en sepsis abdominal / Comparison of APACHE II and Score Salvador models of prediction in abdominal sepsis

La evolución y pronóstico de la sepsis abdominal están determinados por la rapidez con que se efectúa el diagnóstico, intervención apropiada y la eficacia y oportunidad del tratamiento antibiótico. Los estudios clínicos han identificado algunos factores de mal pronóstico, entre los cuales se encuentran el puntaje APACHE II elevado. Nosotros realizamos un estudio retrospectivo en la Unidad de Cuidados Intensivos del Hospital del Salvador, comparando el Score Apache II con un Score local, denominado Score del Salvador, en los pacientes con diagnóstico de sepsis abdominal. Resultados: Hubo 2.158 ingresos en la UCI del Hospital del Salvador, correspondiendo a 7,6% (n =164) de los casos a sepsis abdominal. Las principales causas de infección abdominal fueron perforación intestinal, colangitis, obstrucción intestinal y pancreatitis aguda. La comparación de las curvas receptor-operador del Score del Salvador y el índice pronóstico Apache II, evidencia que no existen diferencias significativas en el área bajo la curva de ambos índices pronósticos en pacientes con sepsis abdominal. Conclusión: Ambos índices pronósticos fueron comparables plenamente. Dado el escaso número de pacientes enrolados y la gravedad de ellos el valor predictivo es limitado lo que sugiere necesario aumentar el tamaño de la muestra y diversificar la gravedad.

The evolution and presage of the abdominal sepsis are determined by the speed with which it is made the diagnosis, appropriate intervention and the effectiveness and opportunity of the antibiotic treatment. The clinical studies have identified some factors of bad presage, among which are the high score APACHE II. We carry out a retrospective study in the Intensive Care Unit of the Salvador’s Hospital, comparing the Apache Score II with a local score, denominated Score of the Salvador to the patients with the diagnose of abdominal sepsis. Results: There were 2.158 revenues in the ICU of the Salvador’s Hospital, corresponding 7,6% (n =164) of the cases to abdominal sepsis. The main causes of abdominal infection were intestinal perforation, colangitis, intestinal obstruction, and sharp pancreatitis. The comparison of the curves receiver-operator of the Salvador’s Score and the index Apache II, it evidences that significant differences don’t exist in the area under the curve of both index in patient with abdominal sepsis. Conclusion: Both scores were comparable fully. Given the scarce number of signed up patients and the graveness of them, the predictive value is limited what suggests necessary to increase the size of the sample and to diversify the graveness.

Guía de práctica clínica basada en la evidencia para el manejo de la sedo-analgesia en el paciente adulto críticamente enfermo / Clinical practice guideline based on the evidence for the management of sedoanalgesia in the critically ill adult patient

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Cerebral and parotid metachronous metastases from an ovarian carcinoma

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Effect of embryonic knock-down of GABAA receptors on the levels of monoamines and their metabolites in the CNS of the mouse.

In vitro evidence indicates that gamma-aminobutyric acid (GABA), acting at GABA(A) receptors, exerts a positive trophic effect on monoaminergic neurons during embryogenesis. To determine whether in vivo antagonism of GABA(A) receptors during embryogenesis interferes with the development of monoaminergic neurons, we used mice in which the number of GABA(A) receptors was decreased by 50% by targeted deletion of the beta(3) subunit gene of the GABA(A) receptor. Levels of serotonin, dopamine, norepinephrine, and the metabolites 3,4-deoxyphenylacetic acid, homovanillic acid, and 5-hydroxyindoleacetic acid were measured in the brainstem, cortex, striatum and spinal cord of female adult homozygous null (beta3-/-) and wild-type (beta3+/+) mice, as well as progenitor C57BL/6J and Strain 129/SvJ mice. The level of norepinephrine in the spinal cord of beta3-/- mice was 44% less than that of beta3+/+ mice, and did not differ in the brainstem, cortex or striatum. This finding suggests that beta3 subunit-containing GABA(A) receptors mediate the trophic effects of GABA on a subpopulation of spinally-projecting noradrenergic neurons. In contrast, the levels of serotonin, dopamine or their metabolites were unaffected, suggesting that the development of serotonergic and dopaminergic neurons may require activation of only a small fraction of GABA(A) receptors or may not be dependent on beta3 subunit-containing GABA(A) receptors. Finally, Strain 129/SvJ and C57BL/6J mice differed with respect to the levels of dopamine and its metabolites in the brainstem, spinal cord and cortex. These differences may need to be considered when assessing the phenotype of gene-targeted mice for which these mice serve as progenitor strains.

Experiencia del manejo de potenciales donantes cadáver en una UCI polivalente / Experience in the management of cadaver donors in an intensive care unit

Estudiamos a los pacientes que ingresaron con diagnóstico de muerte encéfalica a nuestra unidad entre 9/95 y 12/99: 24 pacientes, 18 varones (75 por ciento) y 6 mujeres (25 por ciento), con una mediana de edad de 33,5 años. El equipo de procuración de órganos no estaba involucrado en las decisiones terapéuticas. El diagnóstico de muerte encefálica fue certificado por un neurólogo ajeno a la procuración ante la ausencia persistente de funciones cerebrales por una etiología bien definida, descartando hipotermia, intoxicación por drogas, encefalopatía metabólica y shock. Las causas de muerte cerebral fueron: accidentes en 14 (10 del tránsito), 5 violencia, 3 accidente cerebro-vascular (ACV) y 2 trauma de cráneo (TEC) por mecanismo ignorado. Se logró la donación en 14 pacientes (58,3 por ciento), ambos riñones en todos y sólo en la mitad, otros órganos. Todos necesitaron ventilación mecánica y reanimación con volumen, 22 drogas vasoactivas y 6 transfusiones. Complicaciones fueron: hipotensión en poliuria en 19, 22, trastornos electrolíticos en 12, hipotermia en 11, oliguria en 7 y sangrado en 1. Concluimos que el porcentaje de potenciales donantes (PD) en los que se concretó la donación es similar a lo descrito en la literatura y el 16,6 por ciento de rechazo por familiares resulta inferior a lo descrito. Consideramos que este alto grado de consentimiento está influenciado por un sistema de procuración organizado y un equipo experimentado; soporte de PD con daño neurológico severo es una actividad que consume tiempo y recursos en una UCI, los que deberían considerarse en los programas de trasplante, y el número total de trasplantes podría incrementarse con la procuración de múltiples órganos de un mismo donante

Sensory thresholds and the antinociceptive effects of GABA receptor agonists in mice lacking the beta3 subunit of the GABA(A) receptor.

A line of mice was recently created in which the gabrb3 gene, which encodes the beta3 subunit of the GABA(A) receptor, was inactivated by gene-targeting. The existence of mice with a significantly reduced population of GABA(A) receptors in the CNS enabled an investigation of the role of GABA and GABA(A) receptors in nociception. The present study examined the sensory thresholds of these mice, as well as the antinociceptive effects of subcutaneously or intrathecally administered GABA(A) and GABA(B) receptor agonists. Homozygous null (beta3-/-) mice displayed enhanced responsiveness to low-intensity thermal stimuli in the tail-flick and hot-plate test compared to C57BL/6J and 129/SvJ progenitor strain mice, and their wild-type (beta3+/+) and heterozygous (beta3+/-) littermates. The beta3-/- mice also exhibited enhanced responsiveness to innocuous tactile stimuli compared to C57BL/6J, 129/SvJ and to their beta3+/+ littermates as assessed by von Frey filaments. The presence of thermal hyperalgesia and tactile allodynia in beta3-/- mice is consistent with a loss of inhibition mediated by presynaptic and postsynaptic GABA(A) receptors in the spinal cord. As expected, subcutaneous administration of the GABA(A) receptor agonist 4,5,6,7-tetrahydroisoxazolo-(5,4-c)pyridin-3-ol did not produce antinociception in beta3-/- mice, whereas it produced a dose-dependent increase in hot-plate latency in C57BL/6J, 129/SvJ, beta3+/+ and beta3+/- mice. However, the antinociceptive effect of the GABA(B) receptor agonist baclofen in the tail-flick and hot-plate tests was also reduced in beta3-/- mice compared to the progenitor strains, beta3+/+ or beta3+/- mice after either subcutaneous or intrathecal administration. This finding was unexpected and suggests that a reduction in GABA(A) receptors can affect the production of antinociception by other analgesic drugs as well.

[Immunophenotype. Clinical and laboratory features of acute lymphoblastic leukemia in Chile. Study of 500 children and 131 adults]. / Inmunofenotipo. características clínicas y laboratorio de la leucemia linfoblástica aguda en chile. Estudio de 500 niños y 131 adultos.

We describe the clinical features and immunophenotype of 500 children and 131 adults with acute lymphoblastic leukemia (ALL), diagnosed between 1984 and 1993. Cases were classified, according to immunophenotype in B-cell ALL with three subtypes (pro-B or null, common and B) and T-cell ALL. Among children, common ALL accounted for 74% of cases and pro-B all was more common in children of less than one year (14%). B ALL was observed in 2% of children. Ten percent of children, mostly males, had T-cell ALL. The third part of these children had high leukocyte counts and a mediastinal mass. Children from Mapuche origin, compared with Caucasian children had a lower proportion of common ALL (36 and 74% respectively) and a higher proportions of T-cell ALL (41 and 10% respectively). Among adults common ALL was the most common phenotype (72%) followed by T-cell ALL (15%), pro-B ALL (11%) and B-cell ALL (2%). There was a lower incidence of children with common ALL with positive cytoplasmic immunoglobulin compared to North American or European studies (2 and 15-33% respectively) and a higher proportion of adults with common ALL compared with pro-B cell ALL, in contrast to European studies that show a higher proportion of patients with pro-B cell ALL. No other immunophenotypic, clinical or laboratory differences were observed with ALL from developed countries. It is concluded that the immunophenotyping of ALL allows a more precise diagnosis of this disease.

[Kidney traumatism in general surgery (65 cases)]. / Traumatismes du rein en chirurgie générale (65 cas).

From September 1989 to September 1994, 65 patients, 15 females and 50 males, with a mean age of 32 +/- 14 years were admitted in the emergency unit for renal trauma. In 38.5% of cases multiple trauma was present. Lesional mechanism was most frequently contusions (49.2%) and deceleration injuries (43.1%). Gross hematuria or microscopic hematuria were presents in 72.3% of cases. The sensibility of systematic abdominal echography was 100% in case of perirenal hematoma and 65% in case of parenchymatous lesions. Only 23 patients were operated (35.3%) because of low blood pressure. None secondary operation was necessary in abstention group. Global mortality was 7.7%. Postoperative morbidity was 20% and specific morbidity in abstention group was 10.7%.