Proteinuria in Hantavirus Cardiopulmonary Syndrome: A Frequent Finding Linked To Mortality.

OBJECTIVES: To determine the relative frequency and prognosis value of proteinuria in hantavirus cardiopulmonary syndrome (HCPS) due to Andes virus. METHODS: This observational analytical study prospectively obtained data from patients admitted to 12 health centers in nine Chilean cities between 2001 and 2018. Only patients with confirmed Andes virus HCPS and laboratory characterization that included qualitative proteinuria determination at admission were considered. RESULTS: The database involved 175 patients, 95 of them had a measurement of urine protein at the time of hospital admission. They were mainly male (71%) and the median age was 35 [22-47] years. Median duration of the febrile prodromal time was 5 [4-7] days. Hospital length of stay and hospital mortality rate were 10 [7-14] days and 21.1%, respectively. Seventy-three patients (77%) were identified with proteinuria at admission, which was associated with increased mortality rate (26% versus 5%, p=0.036) and the relative risk was 1.3 [1.1-1.6], p=0.002. CONCLUSIONS: Proteinuria is a frequent finding in patients with HCPS, which is associated with a higher mortality rate.

Targeted high volume hemofiltration could avoid extracorporeal membrane oxygenation in some patients with severe Hantavirus cardiopulmonary syndrome.

BACKGROUND: Hantavirus cardiopulmonary syndrome (HCPS) has a high lethality. Severe cases may be rescued by venoarterial extracorporeal membrane oxygenation (VA ECMO), alongside substantial complications. High volume hemofiltration (HVHF) is a depurative technique that provides homeostatic balance allowing hemodynamic stabilization in some critically ill patients. METHODS: We implemented HVHF before VA ECMO consideration in the last five severe HCPS patients requiring mechanical ventilation and vasoactive drugs admitted to our intensive care unit. Patients were considered HVHF-responders if VA ECMO was avoided and HVHF-nonresponders if VA ECMO support was needed despite HVHF. A targeted-HVHF strategy compounded by aggressive hyperoncotic albumin, sodium bicarbonate, and calcium supplementation plus ultrafiltration to avoid fluid overload was implemented on three patients. RESULTS: Patients had maximum serum lactate of 8.8 (8.7-12.8) mmol/L and a lowest cardiac index of 1.8 (1.8-1.9) L/min/m2 . The first two required VA ECMO. They were connected later to HVHF, displayed progressive tachycardia and declining stroke volume. The opposite was true for HVHF-responders who received targeted-HVHF. All patients survived, but one of the VA ECMO patients suffered a vascular complication. CONCLUSION: HVHF may contribute to support severe HCPS patients avoiding the need for VA ECMO in some. Early connection and targeted-HVHF may increase the chance of success.

Mobile teleradiology system suitable for m-health services supporting content and semantic based image retrieval on a grid infrastructure.

Teleradiology systems tackle the problem of transferring radiological images between medical image workstations for facilitating different medical activities, e.g., diagnosis, treatment and follow up a patient, medical training, or consulting second opinion. Nowadays, m-Health (aka mobile health) is becoming popular because of high quality of mobile displays, although remains a work in progress. In this paper a mobile teleradiology system is reported, which main contribution is the development of a platform: (1) supported by a Grid infrastructure, (2) using biomedical ontologies for adding semantic annotations on medical images, and (3) supporting semantic and content-based image retrieval. Images are located physically in different repositories like; hospitals and diagnostic imaging centers. All these features make the system ubiquitous, portable, and suitable for m-Health services.

[Characteristics and factors associated with mortality in patients receiving mechanical ventilation: first Chilean multicenter study]. / Características de los pacientes que reciben ventilación mecánica en unidades de cuidados intensivos: primer estudio multicéntrico chileno.

BACKGROUND: The outcome of mechanically ventilated patients can be influenced by factors such as the indication of mechanical ventilation (MV) and ventilator parameters. AIM: To describe the characteristics of patients receiving MV in Chilean critical care units. MATERIAL AND METHODS: Prospective cohort of consecutive adult patients admitted to 19 intensive care units (ICU) from 9 Chilean cities who received MV for more than 12 hours between September lst, 2003, and September 28th, 2003. Demographic data, severity of illness, reason for the initiation of MV, ventilation modes and settings as well as weaning strategies were registered at the initiation and then, daily throughout the course of MV for up to 28 days. ICU and hospital mortality were recorded. RESULTS: Of 588 patients admitted, 156 (26.5%) received MV (57% males). Mean age and Simplified Acute Physiology Score-II (SAPS II) were 54.6+/-18 years and 40.6+/-16.4 points respectively The most common indications for MV were acute respiratory failure (71.1%) and coma (22.4%). Assist-control mode (71.6%) and synchronized intermittent mandatory ventilation (SIMV) (14,2%) were the most frequently used. T-tube was the main weaning strategy. Mean duration of MV and length of stay in ICU were 7.8+/-8.7 and 11.1+/- 14 days respectively. Overall ICU mortality was 33.9% (53 patients). The main factors independently associated with increased mortality were (1) SAPS II > or =60 points (Odds Ratio (OR), 10.5; 95% CI, 1.04-106.85) and (2) plateau pressure > or =30 cm H2O at second day (OR, 3.9; 95% CI, 1.17-12.97). CONCLUSIONS: Conditions present at the onset of MV and ventilator management were similar to those reported in the literature. Magnitude of multiorgan dysfunction and high plateau pressures are the most important factors associated with mortality.

Características de los pacientes que reciben ventilación mecánica en unidades de cuidados intensivos: primer estudio multicéntrico chileno / Characteristics and factors associated with mortality in patients receiving mechanical ventilation

Background: The outcome oí' mechanically ventilated patients can be inñuenced byfactors such as the indication of mechanical ventilation (MV) and ventilator parameters. Aim: To describe the characterístics of patients receiving MV in Chilean critical care uníts. Material and methods: Prospective cohort of consecutive adult patients admitted to 19 intensive care uníts ([CU) from 9 Chilean cities who received MV for more than 12 hours between September lst, 2003, and September 28th, 2003. Demographic data, severity of illness, reason for the initiation of MV, ventilation modes and settings as well as weaning strategies were registered at the initiation and then, daily throughout the course of MV for up to 28 days. ¡CU and hospital mortality were recorded. Resulte: Of 588 patients admitted, 156 (26.5 percent) received MV (57 percent males). Mean age and Simplified Acute Physiology Score-II (SAPSII) were 54.6±18years and 40.6±16.4 points respectively The most common indications for MV were acute respiratory failure (71.1 percent) and coma (22.4 percent). Assist-control mode (71.6 percent) and synchronized intermittent mandatory ventilation (SIMV) (14,2 percent) were the most frequently used. T-tube was the main weaning strategy. Mean duration of MV and length of stay in ICU were 7.8±8.7 and 11.1± 14 days respectively. OverallICUmortality was 33.9 percent (53patients). The main factors independently associated with increased mortality were (1) SAPS II ≥ 60 points (Odds Patio (OR), 10.5; 95 percent CI, 1.04-106.85) and (2) plateaupressure ≥ 30 cm Hfi atsecond day (OR, 3.9; 95 percent CI, 1.17-12.97). Conclusions: Conditionspresent at the onsetofMVand ventilator management were similar to those reported in the literature. Magnitude ofmultiorgan dysfunction and high plateau pressures are the most important factors associated with mortality).

[Mechanical ventilatory parameters guided by the low flow pressure-volume curve in patients with acute lung injury/acute respiratory distress syndrome]. / Ajuste a la ventilación mecánica guiado por curvas presión-volumen de flujo lento en pacientes con síndrome de distress respiratorio agudo e injuria pulmonar aguda.

BACKGROUND: Mechanical ventilation may contribute to lung injury and then enhance systemic inflammation. Optimal ventilatory parameters such as tidal volume (VT) and positive end expiratory pressure (PEEP) can be determined using different methods. Low flow pressure volume (P/V-LF) curve is a useful tool to assess the respiratory system mechanics and set ventilatory parameters. AIM: To set VT and PEEP according P/V-LF curve analysis and evaluate its effects on gas exchange and hemodynamic parameters. MATERIALS AND METHODS: Twenty seven patients underwent P/V-LF within the first 72 hours of acute lung injury/acute respiratory distress syndrome (ALI/ARDS). P/V-LF curves were obtained from the ventilator and both lower and upper inflexion points determined. Gas exchange and hemodynamic parameters were measured before and after modifying ventilator settings guided by P/V-LF curves. RESULTS: Ventilatory parameters set according P/V-LF curve, led to a rise of PEEP and reduction of VT: 11.6+/-2.8 to 14.1+/-2.1 cm H2O, and 9.7+/-2.4 to 8.8+/-2.2 mL/kg (p<0.01). Arterial to inspired oxygen fraction ratio increased from 158.0+/-66 to 188.5+/-68.5 (p<0.01), and oxygenation index was reduced, 13.7+/-8.2 to 12.3+/-7.2 (p<0.05). Cardiac output and oxygen delivery index (IDO2) were not modified. Demographic data, gas exchange improvement and respiratory system mechanics showed no significant difference between patients with extra-pulmonary and pulmonary ALI/ARDS. There was no evidence of significant adverse events related with this technique. CONCLUSION: P/V-LF curves information allowed us to adjust ventilatory parameters and optimize gas exchange without detrimental effects on oxygen delivery in mechanically ventilated ALI/ARDS patients.

[Addition of an arterio-venous shunt during veno-arterial extracorporeal life support in a patient with Hantavirus pulmonary syndrome]. / Adición de un cortocircuito arterio-venoso durante el soporte vital extracorpóreo veno-arterial de un paciente con síndrome cardiopulmonar por Hantavirus. Caso clínico.

A subgroup of patients infected with the Hantavirus develops a pulmonary syndrome (HPS) characterized by severe acute respiratory failure and myocardial depression, that has a high mortality rate. Extracorporeal life support (ECLS) could be a valuable therapeutic tool in such patients. We report a 24 years old male with HPS that was successfully managed when an arterio-venous shunt was added to a conventional veno-arterial ECLS technique. Precise criteria have been developed to predict which patients should be considered for this treatment.

[Intrathoracic blood volume versus pulmonary artery occlusion pressure as estimators of cardiac preload in critically ill patients]. / Volumen sanguíneo intratorácico versus presión arterial de oclusión pulmonar como estimadores de precarga cardíaca en pacientes críticos.

BACKGROUND: Monitoring of cardiac preload by determination of pulmonary artery occlusion pressure (PAOP) has been traditionally used to guide fluid therapy to optimize cardiac output (CO). Since factors such as intrathoracic pressure and ventricular compliance may modify PAOP, volumetric estimators of preload have been developed. The PiCCO system is able to measure CO and intrathoracic blood volume (ITBV) by transpulmonary thermodilution. AIM: To compare a volumetric (ITBV) versus a pressure (PAOP) determination to accurately estimate cardiac preload in severely ill patients. PATIENTS AND METHODS: From June 2001 to October 2003, 22 mechanically ventilated patients with hemodynamic instability underwent hemodynamic monitoring with pulmonary artery catheter (PAC) and PiCCO system. ITBV index (ITBVI), PAOP and CI were measured simultaneously by both methods. One hundred thirty eight deltas (D) were obtained from the difference of ITBVI, PAOP, CI-PAC and CI-PiCCO between 6-12 am and 6-12 pm. Linear regression analysis of DITBVI versus Eth CI-PiCCO and Eth PAOP versus DCI-PAC were made. RESULTS: Mean age of patients was 60.8 +/- 19.4 years. APACHE II was 23.9 +/- 7. Fifteen patients met criteria for acute respiratory distress syndrome (ARDS). Delta ITBVI significantly correlated with DCI-PiCCO (r=0.54; 95% confidence interval = 0.41-0.65; p <0.01). There was no correlation between DPAOP and DCI-PAC. CONCLUSION: ITBVI correlated better with CI than PAOP, and therefore it seems to be a more accurate estimator of preload in unstable, mechanically ventilated patients.

Amelogenesis imperfecta: alternativas de tratamiento / Amelogenesis imperfecta: treatment alternatives

La comprensión y entendimiento de trastornos del desarrollo que afectan a las estructuras bucales, se logra mediante el conocimiento de su embriología, histología y la revisión de conceptos genéticos actuales. Estos defectos se pueden presentar desde el nacimiento y algunos de ellos siguen patrones de herencia por lo que se debe de ser cuidadoso al diferenciar trastornos hereditarios de los congénitos. La amelogénesis imperfecta es un desarrollo defectuoso del esmalte, representa el clásico trastorno hereditario que afecta a esta estructura, teniendo presente su no incidencia con cualquier otro trastorno de tipo sindromico, metabólico o sistémico. Actualmente se conocen tres tipos de amelogénesis imperfecta; de tipo hipoplásico, hipomaduración e hipocalcificado, las cuales pueden presentar una variedad de hasta once fenotipos, según el tipo de herencia mendeliana. El aspecto del esmalte afectado puede presentar defectos que van desde los imperceptibles hasta los que afectan muy notablemente la apariencia y función dental. Según David Bixler, este tipo de trastornos ocasionan en el paciente severos daños en su desarrollo psicológico y social, llegando a afectar en la mayoría de los casos la autoestima del niño o adolescente. (David Bixler, 1998). El odontólogo debe conocer alternativas de tratamiento que brinden al paciente una solución estética y funcional a este padecimiento. Antiguamente, la única alternativa de solución que se le ofrecía al paciente era la extracción total o parcial de la dentadura afectada y posteriormente la confección de una prótesis total o parcial, situación que además de drástica resultaba traumática para el paciente. (Dominique Bouvier, 1999). La presente investigación bibliografica describe alternativas de tratamiento que proporcionan soluciones estéticas y funcionales a pacientes que presentan amelogénesis imperfecta; revisando materiales y técnicas antiguas de restauración como lo son las amalgamas de plata y coronas de acero cromado, y materiales mas recientemente desarrollados como cementos de ionómero de vidrio, compomeros, resinas composites y la porcelana dental en sus diferentes aplicaciones clínicas (carillas y coronas); que son esencialmente las mejores alternativas para tratar la amelogénesis imperfecta. Es necesario mencionar la ausencia de referencias documentales en cuanto a los tratamientos y/o técnicas específicas para cada tipo de amelogénesis imperfecta, ya que en cada caso es el odontólogo quien debe decidir el material y la técnica adecuada, según las características clínicas y condiciones bajo las que se presenta el paciente.

The understanding and understanding of developmental disorders that affect oral structures is achieved through knowledge of their embryology, histology and the review of current genetic concepts. These defects can occur from birth and some of them follow inheritance patterns, so care must be taken when differentiating inherited from congenital disorders. Amelogenesis imperfecta is a defective development of the enamel, it represents the classic hereditary disorder that affects this structure, taking into account its non-incidence with any other syndromic, metabolic or systemic disorder. Three types of amelogenesis imperfecta are currently known; hypoplastic, hypomaturated and hypocalcified, which can present a variety of up to eleven phenotypes, depending on the type of Mendelian inheritance. The appearance of the affected enamel can present defects that range from the imperceptible to those that affect the appearance and tooth function in a very noticeable way. According to David Bixler, this type of disorder causes serious damage to the psychological and social development of the patient, affecting in most cases the self-esteem of the child or adolescent. (David Bixler, 1998). The dentist must know treatment alternatives that provide the patient with an aesthetic and functional solution to this condition. In the past, the only alternative solution that was offered to the patient was the total or partial extraction of the affected teeth and later the realization of a total or partial prosthesis, a situation that was also drastic for the patient. (Dominique Bouvier, 1999). The present bibliographic research describes treatment alternatives that provide aesthetic and functional solutions to patients with amelogenesis imperfecta; review old restorative materials and techniques such as silver amalgams and chrome steel crowns, and more recently developed materials such as glass ionomer cements, compomers, composite resins and dental porcelain in their different clinical applications (veneers and crowns); which are essentially the best alternatives for the treatment of amelogenesis imperfecta. It is necessary to mention the absence of documentary references on the treatments and / or specific techniques for each type of amelogenesis imperfecta, since in each case it is the dentist who must decide the appropriate material and technique, according to the clinical characteristics and conditions under those presented by the patient.

Gastrointestinal and pancreatic function in peritoneal dialysis patients: their relationship with malnutrition and peritoneal membrane abnormalities.

BACKGROUND: Malnutrition is frequent in peritoneal dialysis (PD) patients, but the contribution of gastrointestinal (GI) dysfunction has not been well established. METHODS: We studied GI function in 49 stable PD patients to ascertain its relationship with malnutrition. After an overload fat diet, fecal fat, sugar, starch and nitrogen, intestinal protein permeability (alpha(1)-antitrypsin fecal clearance [C-alpha(1)-AT]), fecal chymotrypsin (CT), GI hormones and gastrin, pepsinogen I and II, cholecystokinin (CCK), gastrin releasing peptide (GRP), and neuropeptide Y (NPY) were measured. Vasoactive intestinal polypeptide (VIP), substance P (SP), and tumor necrosis factor (TNF-alpha) and biochemical nutritional markers were evaluated. RESULTS: All patients showed high fecal sugar. Elevated fecal nitrogen was found in 21 patients, 6 with high C-alpha(1)-AT. High fecal starch levels appeared in 21, fat in 20, and low fecal CT in 39 patients. These determinations showed inverse relation with nutritional markers. Increased fecal C-alpha(1)-AT values were associated with lower serum albumin. Fecal CT values showed a negative linear correlation with serum albumin and were inversely associated with retinol-binding protein, normalized protein nitrogen appearance, and serum iron. High plasma levels of pancreatic stimulating hormones were found: gastrin, CCK, and VIP. These levels were higher in patients with a worse pancreatic exocrine function. Higher values of other GI hormones, gastrin, pepsinogen I and II, CCK, GRP, and TNF-alpha. Normal concentrations of NPY, VIP, and PS were observed. CONCLUSION: GI abnormalities (malabsorption, maldigestion, pancreatic dysfunction, and protein losing enteropathy) are present in an important number of PD patients. These features are negatively associated to nutrition.

[Hemolytic-uremic syndrome and Streptococcus pneumoniae]. / Síndrome hemolítico-urémico y Streptococcus pneumoniae.

Hemolytic-uremic syndrome (HUS) is an uncommon complication of pneumococcal infection. Highly suggesting findings in a patient with Streptococcus pneumoniae infection are: microangyopatic hemolytic anemia, thrombocytopenia and acute renal failure. We report a 41 years old woman, admitted to the hospital due to a severe pneumonia, that required the surgical drainage of an empyema. On admission, a drop in packed red cell volume from 41 to 25%, the presence of schistocytes in the blood smear, an elevation of LDH to 1,700 IU/L, a fall in haptoglobin to 5.8 mg/dL and a thrombocytopenia of 72,000 per mm3 were detected. These alterations coincided with an oliguric acute renal failure. She was treated with hemodialysis and the hemolytic syndrome was managed with plasmapheresis. She was discharged 35 days after admission and in the follow up, after 2.5 months, her serum creatinine is 1.2 mg/dL and her packed red cell volume is 41%.