Tratamiento del embarazo ectópico en cicatriz de cesárea: revisión de la literatura a propósito de 3 casos / Treatment of ectopic pregnancy in a cesarean scar: review of the literature regarding 3 cases

INTRODUCCIÓN Y OBJETIVOS: El embarazo en cicatriz de cesárea previa (ECC) es una entidad poco frecuente que puede tener graves consecuencias. Hasta la fecha no existen esquemas estandarizados de tratamiento y su manejo óptimo sigue siendo controvertido. Nuestro objetivo es realizar una revisión de la literatura publicada sobre el manejo del ECC y proponer un algoritmo. También exponemos tres casos de ECC resueltos con diferentes tratamientos en el Hospital Universitario Infanta Elena MÉTODOS: Búsqueda de la literatura en bases de datos utilizando las palabras clave: "embarazo en cicatriz cesárea"," gestación ectópica en cicatriz cesárea", "tratamiento", "manejo". RESULTADOS: Las opciones terapéuticas pueden ser médicas, quirúrgicas o una combinación de ambas. Los tratamientos quirúrgicos tienen altas tasas de éxito, sin embargo, son más invasivos y no están exentos de riesgo. La combinación de tratamientos parece aumentar la tasa de éxito, no obstante, podría implicar un mayor riesgo de efectos secundarios y costes. CONCLUSIONES: El manejo de los ECC debe de ser individualizado, basado en la evidencia científica, en los medios disponibles y la experiencia de los profesionales en los distintos procedimientos, guiándonos por el tipo de ECC y su grado de vascularización e invasión, grosor del miometrio, niveles de beta-hCG, presencia de actividad cardiaca, clínica y estabilidad hemodinámica de la paciente. Deben tenerse en cuenta las circunstancias y patología intercurrente de la mujer, así como su deseo genésico o de preservación del útero.

INTRODUCTION AND OBJECTIVES: Cesarean scar pregnancy (CSP) is a rare entity that can cause serious consequences. Up to now, there are no standardized treatment schemes, and its optimal management remains controversial. Our objetive is to review the literature regarding CSP management and propose an algorithm. We also present three cases of CSP resolved with different treatments at Hospital Universitario Infanta Elena. METHODS: Literature search in databases using the following keywords: pregnancy with cesarean section, ectopic pregnancy with cesarean section, treatment, management. RESULTS: The therapeutic options can be medical, surgical or a combination of both. Surgical treatments have high success rates; however, they are more invasive and are not without risk. The combination of treatments seems to increase the success rate; however, it could imply a higher risk of side effects and costs. CONCLUSIONS: The management of CSP must be individualized; based on scientific evidence, on the means available, and on the experience of the professionals in the different procedures; guided by the type of CSP and its degree of vascularization and invasion, by the thickness of the myometrium, beta-hCG levels, presence of cardiac activity, and by clinical and hemodynamic stability of the patient. The circumstances and intercurrent pathology of the patient must be considered, as well as her desire for future pregnancy or preservation of the uterus.

A propósito de un caso: útero miomatoso gigante torsionado / Torsion of a giant miomatous uterus: report of a clinical case autores

OBJETIVO: Reportar el caso de una torsión de útero, trompas y ambos ovarios a nivel de cuello uterino. Describir la patogenia, sintomatología y tratamiento, como un caso infrecuente y potencialmente grave, en la práctica clínica diaria. MATERIAL Y MÉTODOS: Analizar el curso de esta extremadamente rara patología, en una mujer postmenopáusica de 59 años. Se trata de un caso raro de torsión uterina en un útero no gestante, reportando los hallazgos en los exámenes previos a la cirugía y los hallazgos intraoperatorios e histopatológicos postcirugía. La resonancia magnética fue fundamental en el diagnóstico de la paciente y la laparotomía realizada demostró una torsión de cuerpo uterino de 360 ° a nivel de cérvix, y un gran mioma pediculado con signos de necrosis. Hemos revisado los últimos artículos de esta rara patología RESULTADOS Y DISCUSIÓN: La paciente fue operada. Se realizó una histerectomía total mediante una laparotomía media supra e infraumbilical. Los ovarios no tenían signos de necrosis. CONCLUSIONES: Debemos tener en cuenta esta posibilidad diagnóstica, en pacientes con aumento de tamaño uterino y clínica de dolor abdominal, ya que aunque es muy infrecuente, su diagnóstico es importante, ya que puede ser peligroso para la vida de la paciente.

OBJECTIVE: To report a case of torsion of the uterus, fallopian tubes and both ovaries around the uterine collum and the symptomatology, pathogenesis and treatment of this uncommon pathology. MATERIAL AND METHODS: The article analyses the course of this extremely rare pathology in a postmenopausical woman of 59 years. It is a rare case like a non gravid uterine torsion in a postmenopausical woman. We have the exams previous to the surgery, the finds intraoperative and the histolopathological reports postsurgery. RMN was the most important in diagnosis and the laparotomy showed a 360° an uterus increased on size and a big pedunculated myoma with signs of necrosis We have reviewed the latest articles on this strange pathology RESULTS AND DISCUSSION: The patient was operated. A infra-supra medium laparotomy was practiced and a total hysterectomy was made. Ovarians had not signs of necrosis. CONCLUSIONS: We must take into account, in patients with pathologies that increase uterine size and abdominal pain, the possibility of uterine torsion. Although it is a very infrequent pathology, its diagnosis is important, since it can be dangerous for the life of the patient

Bupivacaine Toxicity Increases Transmural Dispersion of Repolarization, Developing of a Brugada-like Pattern and Ventricular Arrhythmias, Which is Reversed by Lipid Emulsion Administration. Study in an Experimental Porcine Model.

Unintentional administration of bupivacaine may be associated with electrocardiogram changes that promote the development cardiac arrhythmias. Ventricular repolarization markers (corrected QT, QT dispersion, Tpeak-Tend and Tpeak-Tend dispersion) are useful to predict cardiac arrhythmias. We aim to investigate the effects of bupivacaine on the transmural dispersion of repolarization and their reversion following intravenous lipid emulsion (ILE) administration. Fourteen pigs were anaesthetized with thiopental and sevoflurane and underwent tracheal intubation. After instrumentation, a 4 mg kg-bolus of bupivacaine was administrated followed by an infusion of 100 µg kg-1 min-1. QT interval, QTc:QT corrected by heart rate, Tpeak-to-Tend interval and QT and Tpeak-to-Tend dispersion were determined in a sequential fashion: after bupivacaine (at 1 min, 5 min and 10 min) and after ILE (1.5 mL kg-1 over 1 min followed by an infusion of 0.25 mL kg-1 min-1). Three additional animals received only ILE (control group). Bupivacaine significantly prolonged QT interval (∆:36%), QT dispersion (∆:68%), Tpeak-to-Tend (∆:163%) and Tpeak-to-Tend dispersion (∆:98%), from baseline to 10 min. Dispersion of repolarization was related to lethal arrhythmias [three events, including asystole, sustained ventricular tachycardia (VT)] and repeated non-sustained VT (4/14, 28%). A Brugada-like-ECG pattern was visualized at V1-4 leads in 5/14 pigs (35%). ILE significantly decreased the alterations induced by bupivacaine, with the termination of VT within 10 min. No ECG changes were observed in control group. Bupivacaine toxicity is associated with an increase of transmural dispersion of repolarization, the occurrence of a Brugada-like pattern and malignant VA. ILE reverses the changes in dispersion of repolarization, favouring the disappearance of the Brugada-like pattern and VT.

Radiological study to evaluate the spreading of two volumes (10 vs. 20ml) of radiological contrast in the block of cutaneous branches of intercostal nerves in medial axillary line (BRILMA) in a porcine experimental model. / Estudio radiológico para evaluar la difusión de dos volúmenes (10 vs. 20ml) de contraste radiopaco en el bloqueo de las ramas cutáneas de los nervios intercostales en la línea medio axilar (BRILMA) en un modelo experimental porcino.

OBJECTIVE: Interfascial blocks of the thoracic wall are being developed as an alternative to central blocks in breast surgery. However, there are few studies that have evaluated the anatomical extension of the local anaesthetic. The objective of this study was to analyse, using fluoroscopy, the spreading of two volumes (10 vs. 20ml) of radiological contrast in the serratus-intercostal plane block in an experimental pig model. MATERIAL AND METHODS: Ten Large-White breed pigs were selected to have a bilateral ultrasound serratus-intercostal plane block performed, with the administering of 10ml and 20ml of iopamidol in the right and left hemithorax, respectively. The spreading of contrast was analysed by fluoroscopy. The Spearman test correlation was used to evaluate the relationship between the administered volume and radiological spreading. A value of P<.05 was considered significant. RESULTS: Twenty anaesthetic blocks were performed, being able to analyse 18 of them. The administration of 10ml of contrast was associated with a mean spreading of 2.28±0.31 (95% CI; 2.01-2.54) intercostal spaces, while the administration of 20ml showed a spreading of 3±0.25 (95% CI; 2.81-3.18) intercostal spaces. There was a significant correlation between the injected volume and the spreading of the contrast (Spearman correlation coefficient of 0.81; P=.0001). CONCLUSION: The results showed a spreading of volume subject to the serratus-intercostal plane block, although not maintaining a 1:1 ratio. Doubling the volume increased the blocked segments by 31%. These findings, if corroborated in the clinical practice, would allow a more precise adjustment in the anaesthetic volume administered.

A stroke care management system prevents outcome differences related to time of stroke unit admission.

INTRODUCTION: Evidence supports that admitting patients with stroke during different hospital work periods is related to distinct outcomes. We aimed to analyse outcomes in patients according to the period and time of admission to the stroke unit. METHODS: Retrospective study. For purposes of data analysis, patients were grouped according to the following time periods: a) day of the week, b) period of the year, c) shift. We analysed demographic characteristics, stroke type and severity, and the percentage undergoing thrombolysis in each group. The measures used to evaluate early outcomes were the National Institutes of Health Stroke Scale (NIHSS), neurological complications (NC), and in-hospital mortality. Functional outcome at 3 months was determined using the modified Rankin scale. RESULTS: The stroke unit admitted 1250 patients. We found NC to be slightly more frequent for weekend admissions than for weekday admissions, but this trend does not seem to have influenced in-hospital mortality. Regarding functional outcome at 3 months, 67.0% of weekday vs. 60.7% of weekend admissions were independent (P=.096), as were 65.5% of patients admitted during the academic months vs. 63.5% of those admitted during summer holidays (P=.803). We identified no significant differences in 3-month mortality linked to the day or period of admission; however, for the variable 'shift', 13.2% of the patients died during the morning shift, 11.5% during the afternoon shift, and 6.0% during the night shift (P=.017). We identified a trend toward higher rates of thrombolysis administration on weekdays, during the morning shift, and during the academic months. CONCLUSIONS: Time of admission to the stroke unit did not affect early outcomes or functional independence at 3 months.

Association between subclinical carotid atherosclerosis, hyperhomocysteinaemia and mild cognitive impairment.

OBJECTIVE: Evidence suggests that intima-media thickness (IMT) and plasma homocysteine (Hcy) levels are associated with one another, and both appear to be related to cognitive dysfunction. However, no connection between both factors taken together and mild cognitive impairment (MCI) has been established. This study analysed potential relationships between IMT, Hcy and MCI. METHODS: We included 105 patients with MCI and 76 controls with no history of vascular disease. All participants underwent laboratory analyses, a carotid ultrasound, and clinical and neuropsychological assessment. We used the Mantel-Haenszel test (MHT), ANCOVA and multiple linear regression models (MLRM) to examine any associations between IMT, Hcy and cognitive state. RESULTS: The MHT revealed a significant association between IMT and risk of MCI (z = 4.285, P < 0.0001). The OR for the upper quartile vs the lower quartile was 5.12 (95% CI: 2.12-12.36). MHT also showed a clear association between Hcy levels and risk of MCI (z = 3.01, P = 0.003). OR for the upper vs the lower quartile was 3.39 (95% CI: 1.41-8.12). Additionally, we found a correlation between IMT and Hcy (r = 0.162, P = 0.032). CONCLUSIONS: Our results suggest that there is a connection between IMT, Hcy levels and presence of amnestic MCI in a population with no history of clinically manifest atherosclerosis. Furthermore, there is also a connection between the IMT and Hcy levels themselves.

Analysis of the temporal regression of the QRS widening induced by bupivacaine after Intralipid administration. Study in an experimental porcine model.

OBJECTIVE: The principal mechanism of cardiac toxicity of bupivacaine relates to the blockade of myocardial sodium channels, which leads to an increase in the QRS duration. Recently, experimental studies suggest that lipid emulsion is effective in reversing bupivacaine cardiac toxicity. We aimed to evaluate the temporal evolution of the QRS widening induced by bupivacaine with the administration of Intralipid. MATERIAL AND METHODS: Twelve pigs were anesthetized with intravenous sodium thiopental 5mg kg(-1) and sevoflurane 1 MAC (2.6%). Femoral artery and vein were canalized for invasive monitoring, analysis of blood gases and determination of bupivacaine levels. After instrumentation and monitoring, a bupivacaine bolus of 4-6 mg kg(-1) was administered in order to induce a 150% increase in QRS duration (defined as the toxic point). The pigs were randomized into two groups of six individuals. Intralipid group (IL) received 1.5 mL kg(-1)of IL over one minute, followed by an infusion of 0.25 mL kg min(-1). Control group (C) received the same volume of a saline solution. The electrocardiographic parameters were recorded, and blood samples were taken after bupivacaine and 1, 5, 10 and 30 minutes after Intralipid/saline administration. RESULTS: Bupivacaine (4.33±0.81 mg/kg in IL group and 4.66±1.15 mg/kg in C group) induced similar electrocardiographic changes in both groups; mean maximal percent increase in QRS interval was 184±62% in IL group, and 230±56% in control group (NS). Lipid administration reversed the QRS widening previously impaired by bupivacaine. After ten minutes of the administration of IL, the mean QRS interval decreased to 132±56% vs. 15±76% relative to the maximum widening induced by bupivacaine, in IL and C group, respectively. CONCLUSION: Intralipid reversed the lengthening of QRS interval induced by the injection of bupivacaine. Time to normalization of electrocardiographic parameters can last more than 10 minutes. While the phenomena of cardiac toxicity persist, resuscitation measures and adequate monitoring should be continued until adequate heart conduction parameters are restored.

[The impact of neurological and medical complications on the mortality and functional situation of acute stroke patients]. / Impacto de las complicaciones neurologicas y medicas sobre la mortalidad y situacion funcional de pacientes con ictus agudo.

INTRODUCTION: Stroke patients have a high risk of presenting complications, the appearance of which can condition the prognosis of the stroke. We studied the frequency and impact of the onset of several different complications on the early and mid-term prognosis of these patients. PATIENTS AND METHODS: We conducted an observation-based study of the patients admitted to a stroke unit. The complications that occurred while hospitalised were recorded, a distinction being drawn between neurological and medical complications. The study examined their influence, according to the subtype of stroke, on intra-hospital mortality and that at 90 days, as well as on the functional situation at 90 days, by analysing the clinical factors that are predictive for the appearance of complications. RESULTS: The sample consisted of 847 patients. Altogether, 29.5% of the patients presented complications, which were more frequent in haemorrhagic stroke (50.5% versus 26.6%; p < 0.0001). The most usual complications were of a neurological nature (21%). For both subtypes, the presence of complications was associated with a higher rate of mortality both in hospital (2.1% versus 12.6%; p < 0.0001) and at 90 days (5.7% versus 29.6%; p < 0.0001), and a lower probability of independence at 90 days (72.9% versus 30.4%; p < 0.0001). The severity of the stroke on admission revealed itself as the most powerful predictor of the onset of any type of complication. CONCLUSIONS: The appearance of complications during the acute phase of the stroke has an adverse influence on mortality and on the functional prognosis. The identification of predictive factors could reduce the impact upon the progress of acute stroke patients.

TITLE: Impacto de las complicaciones neurologicas y medicas sobre la mortalidad y situacion funcional de pacientes con ictus agudo.Introduccion. Los pacientes con ictus presentan un elevado riesgo de presentar complicaciones. Su aparicion puede condicionar el pronostico del ictus. Estudiamos la frecuencia y el impacto de la aparicion de diversas complicaciones en el pronostico precoz y a medio plazo en estos pacientes. Pacientes y metodos. Estudio observacional de los pacientes ingresados en una unidad de ictus. Se registraron las complicaciones durante su estancia, distinguiendose entre complicaciones neurologicas y medicas. Se estudio la influencia de estas segun subtipo de ictus en la mortalidad intrahospitalaria y a los 90 dias, y en la situacion funcional a los 90 dias, analizandose los factores clinicos predictores para la aparicion de complicaciones. Resultados. Muestra de 847 pacientes. Un 29,5% de los pacientes presento complicaciones, que fueron mas frecuentes en el ictus hemorragico (50,5% frente a 26,6%; p < 0,0001). Las complicaciones mas habituales fueron las neurologicas (21%). Para ambos subtipos, la presencia de complicaciones se asocio a mayor mortalidad intrahospitalaria (2,1% frente a 12,6%; p < 0,0001) y a 90 dias (5,7% frente a 29,6%; p < 0,0001), y menor probabilidad de independencia a 90 dias (72,9% frente a 30,4%; p < 0,0001). La gravedad del ictus al ingreso se mostro como el predictor mas potente en la aparicion de cualquier tipo de complicacion. Conclusiones. La aparicion de complicaciones durante la fase aguda del ictus influye de forma adversa en la mortalidad y en el pronostico funcional. La identificacion de factores predictores podria disminuir el impacto sobre la evolucion del paciente con un ictus agudo.

Comparison of gas exchange after lung resection with a Boussignac CPAP or Venturi mask.

BACKGROUND: Postoperative continuous positive airway pressure (CPAP) can improve lung function. The aim of our study was to assess the efficacy of prophylactic CPAP on the Pa(O2)/FI(O2) ratio measured the day after surgery in patients undergoing lung resection surgery (LRS). METHODS: The study population comprised 110 patients undergoing LRS. On arrival in the postanaesthesia care unit (PACU), patients were randomized to receive CPAP at 5-7 cm H2O during the first 6 h after surgery (CPAP group) or supplemental oxygen through a Venturi mask (Venturi group). The Pa(O2)/FI(O2) ratio was measured on arrival in the PACU, 7 h after admission, and the day after surgery. The Pa(O2)/FI(O2) ratio is the primary endpoint of our study. We also analysed the chest radiograph and assessed the postoperative course. We then analysed the impact of ventilatory management in the PACU depending on the respiratory risk of the patient. RESULTS: Baseline characteristics were similar in both groups. Patients who received CPAP had significantly higher Pa(O2)/FI(O2) at 24 h after surgery compared with patients managed conventionally (Venturi group) (48.6±14 vs 42.3±12, P=0.031), but there were no differences at 7 h. On subgroup analysis, we found that the benefits of CPAP were greater in higher risk patients. The incidence of postoperative pulmonary complications and stay in the PACU and hospital were similar in both groups. CONCLUSIONS: In patients undergoing LRS, prophylactic CPAP during the first 6 h after surgery with a pressure of 5-7 cm H2O improved the Pa(O2)/FI(O2) ratio at 24 h. This effect was more evident in patients with increased risk of postoperative pulmonary complications.

Functional outcome of stroke and the cumulative experience of a stroke unit.

OBJECTIVE: Patients with acute stroke are more likely to survive and achieve independence if they are treated in a stroke unit. Available information in our setting is scarce. We analyse the outcomes of our patients on the basis of cumulative experience in a stroke unit. PATIENTS AND METHODS: A retrospective cohort study of patients admitted to a stroke unit. We differentiate between two groups according to the year of admission: group A (July 2007-December 2009) and group B (January 2010-December 2011), analysing early outcome based on the score on the National Institute of Health stroke scale and mortality at discharge, and medium-term outcome in terms of mortality and functional status according to the modified Rankin scale at three months. RESULTS: A total 1070 patients were included. There were no differences between groups with respect to favourable outcome (68.3% vs 63.9), hospital mortality (5.1% vs 6.6%), or 90-day mortality (12.8% vs 13.1%). The percentage of patients who were independent at 90 days was greater in group B (56.3% vs 65.5%, P=.03). In the multivariate analysis adjusted for stroke subtype and fibrinolytic therapy, the association between patient independence and admission period remained present. CONCLUSIONS: The probability of functional independence in our patients increased alongside accumulated experience in our stroke unit with no differences in mortality.

[Predictors of patient satisfaction with the food services in a public hospital in Madrid]. / Predictores de la satisfacción de los pacientes con la alimentación de un hospital público de Madrid.

OBJECTIVE: To describe patients satisfaction with the food services during hospitalisation, and to determine the predictors. METHODOLOGY: A cross-sectional study was conducted in the "Clínico San Carlos" Hospital, between May and September 2010. A self-completion questionnaire was given to patients with both regular and therapeutic diets after their hospital discharge. We included socio-demographic variables, overall satisfaction, and satisfaction regarding different aspects and types of food. Descriptive and multivariable analyses were performed, with the overall satisfaction with food as the dependent variable using binary logistic regression. RESULTS: A total of 549 questionnaires were returned (rate 29%), of which 60.7% received a therapeutic diet. 55.4% were men, and the median age was 68 years. Three-quarters (75%) were satisfied or very satisfied. Statistically significant variables associated with patient satisfaction with the food services received were the meal's taste and temperature, as well as being satisfied with the fish and soups on the menu. CONCLUSIONS: Despite the high level of satisfaction with food services, there is scope for improvement. We have identified some of the aspects on which action would be more beneficial.

Clinical and neuroradiological signs in adults with type 1 neurofibromatosis.

INTRODUCTION: Type 1 neurofibromatosis is the most common neurocutaneous syndrome. Most published case series study the paediatric population. MATERIAL AND METHODS: Cross-sectional study of cases of type 1 neurofibromatosis from neurology departments that were recorded in a database. We analysed the different clinical variables providing the diagnosis as well as demographic and neuroradiological variables. RESULTS: We found a total of 31 patients with type 1 neurofibromatosis. The mean age was 28.9 years and 58.4% were women. Subjects with unidentified bright objects (UBOs) were younger than those without them (22.45±8.22 years vs. 32.5±10.64; P=.011). In contrast, subjects with neurofibromas were older than those without them (30.56±10.68 years vs. 18.25±4.34; P=.032). No sex differences were found in the presentation of clinical or radiological variables. Seven patients (22.6%) had tumours; 3 were optic pathway gliomas (1 bilateral), 3 were plexiform neurofibromas, and 1 was a pilocytic astrocytoma in the brainstem. CONCLUSIONS: Patients with type 1 neurofibromatosis presented both peripheral neurofibromas and tumorous lesions of the central nervous system. Subjects with neurofibromas were older than those who did not present them, while subjects with UBOs were younger than those without such lesions.

["CLAPSEN", a global approach to the rehabilitation of severe childhood malnutrition in Bolivia]. / Le <>, une démarche globale pour la réhabilitation nutritionnelle de l'enfant gravement mal nourri en Bolivie.

The "CLAPSEN" approach was developed at the Hospital Materno Infantil German Urquidi in Cochabamba, to provide a global response for the study and treatment of childhood malnutrition. "CLAPSEN" is short for Clinical, Laboratory, Anthropometry, Psychology, Sociology, Nursing (Enfermera in Spanish) and Nutritional care. Most of the malnourished children admitted to Cochabamba Hospital are from poor families, more than three quarters of whom have only recently arrived in the city. Acute malnutrition is just one of the manifestations of a generally unfavorable environment. Malnutrition should not be considered as a simple deficiency in energy, protein or micronutrients, but rather as a multi-deficiency syndrome, also involving a lack of basic health and social care. This study demonstrates that malnourished children display a considerable degree of psychological retardation and of immune system depression. After five weeks of rehabilitation, the children were considered to have recuperated physically, as assessed by anthropometry, but not psychologically, as assessed by the adapted Dewer Score, or immunologically, as shown by the size of the thymus or the extent of maturation of lymphocytes. This strategy was not designed as a long-term approach for treating malnutrition, but rather as a research project to characterize the children arriving at the hospital, to determine the reasons for their malnutrition and to identify strategies that could be implemented earlier by health centers of social services, to prevent deterioration in the condition of these children to severe malnutrition requiring hospital admission. We believe that, in this Latin American context, in which the rate of acute malnutrition is low, the hospital should continue to be involved in the treatment of severely malnourished children with associated diseases. The child's stay in hospital should be short and once the child has recovered clinically, he should be sent home. In light of the observed levels of social deprivation, psychosocial and immune deficits, there appears to be a need for continued support for the family, to ensure the full recovery of the child and to prevent relapses.

Immune recovery of malnourished children takes longer than nutritional recovery: implications for treatment and discharge.

Protein-energy malnutrition decreases cellular immunity yet immune recovery has rarely been investigated during nutritional rehabilitation. Malnourished children from low income families of Cochabamba (Bolivia) were hospitalized for 2 months in the Center for Immune and Nutritional Rehabilitation (CRIN), of the German Urquidi Materno-Infantil Hospital. They received a special four-step diet. Nutritional status was determined by a daily clinical examination and weekly anthropometric measurements. Immune status was assessed by weekly ultrasonography of the thymus. The classical criterion for discharge (90 per cent of median reference weight for height) was reached after the first month, whereas a 2-month period was required for complete immunologic recovery. The children belonged to disadvantaged population groups with high exposure to disease. In such an environment, discharge based only on nutritional status after 1 month of treatment could explain frequent relapses because the children were still immunodepressed.

[Immuno-nutritional recovery of children with severe malnutrition]. / Réhabilitation immunonutritionnelle d'enfants atteints de malnutrition sévère.

In developing countries, more than 12 million children die each year from the combined effects of malnutrition and infection. Malnourished children have impaired cellular immunity and are particularly sensitive to opportunistic infections. However, immune recovery has rarely been investigated during nutritional rehabilitation. Indeed, mortality remains high during renutrition, and relapses are frequent. We established a center in Cochabamba, Bolivia, specifically to save these children by treating both clinical and nutritional problems and restoring immune function. The CRIN (center for immuno-nutritional recovery) admits children with severe malnutrition from the Cochabamba suburban area. They are from low income families, in crowded living conditions with poor sanitation and are weaned early. Nutritional diagnosis was based on weight-for-height, arm to head circumference ratio and clinical examination for edema, loss of subcutaneous tissue and diminished muscle mass. The children were examined daily, and first treated for respiratory and intestinal infections. Sociological and psychological aspects were also included in our holistic approach to treating severe malnutrition. Children received a four-stage diet lasting 2 months. During the initial phase (1 week) they were given an oil-sugar-milk based diet, with half lactose concentration, seven times a day. This supplied 1.5 to 2.5 g of protein and 120 to 150 kcal/kg of body weight, according to the PEM pattern. Protein and energy intake was then slowly increased during the transition phase (1 week). During the next, 'calorific-protein bombing' phase (6 weeks) 5 g of protein and 200 kcal/kg of body weight were given daily, such that there was sufficient energy for protein accumulation. During the last, discharge phase (1 week), the protein and energy contents were slowly decreased. Weight, height, arm and head circumferences, and triceps skin-fold thickness were measured weekly by standardized methods. Thymus size was assessed weekly by mediastinal ultrasound scanning with a portable scanner (ALOKA SSD-210 DXII, Tokyo) using a 5 MHz linear pediatric probe. Lymphocyte subpopulations in peripheral blood were investigated monthly using monoclonal antibodies. Compared to controls, the malnourished group had severe involution of the thymus, a significantly higher proportion of circulating immature T lymphocytes and a lower proportion of mature T lymphocytes. The two month longitudinal study showed that normal anthropometric values (90% NCHS weight for height) were recovered after one month of rehabilitation. However, immune recovery (thymic area of 350 nm2) required two months. This may explain the frequent relapses among malnourished children discharged after one month on the basis of 'apparent nutritional health'. Such children may remain immunodepressed, and should therefore be considered as high risk children. To test an immunostimulatory treatment, we designed a historical cohort study of malnourished children who received 2 mg of zinc per day. The children were matched for age, sex, anthropometric criteria and nutritional status with malnourished control children (treated previously with zinc). Anthropometric recovery was obtained in both groups in one month. Children receiving zinc attained immunological recovery within one month, whereas children not receiving zinc took two months. Thus zinc hastened immunological recovery concomitant with nutritional recovery such that the duration of hospitalization could be halved: after one month of this immuno-nutritional treatment, malnourished children appear to be sufficiently healthy to face their pathogenic home environment.

In vitro lymphocyte-differentiating effects of thymulin (Zn-FTS) on lymphocyte subpopulations of severely malnourished children.

This work investigates how thymic dysfunction contributes to the depression of cell-mediated immunity in protein-energy malnutrition (PEM). In Bolivian children hospitalized for severe PEM, the size of the thymus was measured by echography, and the lymphocyte subpopulations were detected by using monoclonal antibodies. These data were compared with those obtained from healthy control subjects. Regardless of the clinical form of PEM, our results show a high degree of T lymphocyte immaturity in severely malnourished children, which correlates with a severe involution of the thymus. Before in vitro incubation with thymulin, this significant increase in the percentage of circulating immature T lymphocytes was concomitant with a decrease in mature T lymphocytes and a slight increase in cytotoxic T subpopulations. After in vitro incubation with thymulin, immature T lymphocytes decreased and mature T lymphocytes increased.

[Acquired immunodeficiency syndrome in childhood. Report of 3 cases and review of the literature]. / Síndrome de inmunodeficiencia adquirida (SIDA) en la edad pediátrica. Aportación de tres casos y revisión de la literatura.

Three infants with the acquired immunodeficiency syndrome (AIDS) are reported. Two cases belong to infants died with AIDS; one of them have as infection source multiple transfusions of blood during the neonatal period and the other case was an haemophilic children transfused several times with commercial factor VIII. The third case belong to an infant, four months old, with AIDS-related complex, born of mother intravenous drug abuser. The authors comments some characteristics about pediatric AIDS and the present problems.