Sustainability of high flow in a Peruvian PICU: A qualitative analysis.

AIM: To describe nurse and physician perspectives on enabling factors that promote sustainability of high flow use in resource-limited settings. BACKGROUND: Over 650 000 children died from respiratory infections in 2016 globally. Many deaths could be prevented with access to advanced paediatric respiratory support, but sustainability of technology in resource-limited settings remains challenging. INTRODUCTION: Local providers have expertise related to site-specific barriers to sustainability. Engaging local providers during implementation can identify strategies to promote ongoing technology use beyond initial deployment. METHODS: This qualitative descriptive study was conducted five focus groups with nineteen nurses and seven individual interviews with physicians in a Peruvian paediatric intensive care unit. Data were analysed using a realist thematic approach. RESULTS: Providers described five important factors for high flow sustainability: (i) Applying high flow to a broader patient population, including use outside the paediatric intensive care unit to increase opportunities for practice; (ii) Establishing a multidisciplinary approach to high flow management at all hours; (iii) Willingness of nurses and physicians to adopt standardization; (iv) Ongoing high flow leadership; (v) Transparency of high flow impact, including frequent reporting of clinical outcomes of high flow patients. DISCUSSION: Local providers described strategies to overcome barriers to sustainability of high flow in their clinical setting, many of which are generalizable to implementation projects in other resource-limited settings. CONCLUSION AND POLICY IMPLICATIONS: These findings provide nursing, administrative leaders and policymakers with strategies to promote sustainability of new technology in resource-limited settings, including development of guidelines for appropriate clinical use, change management support, leadership development and clinical outcome reporting procedures. Administrative support and oversight are paramount to foster successful implementation in these settings.

Key considerations prior to nasal high flow deployment in a Peruvian PICU from providers' perspectives.

AIM: Implementation of healthcare interventions in resource-limited settings remains challenging. This exploratory qualitative study describes social and institutional factors to consider prior to nasal high flow deployment in a middle-income country. METHODS: Researchers conducted eight nursing focus groups and four semi-structured physician interviews at Instituto Nacional de Salud del Niño in Lima, Peru. Participants were identified via purposive sampling. Data were transcribed, translated and coded using a rigorous and iterative process. Pertinent themes were identified using thematic analysis with Dedoose software. RESULTS: Thirty-nine nurses and four physicians participated in focus groups and interviews, respectively. Participants identified five major factors: (i) Adequate training, (ii) Clinician buy-in, (iii) Resource-limited setting, (iv) Local social context and (v) Organizational change management. To create buy-in, physicians and nurses emphasised the need to recognise benefit of the intervention and agree with clinical practice standardization. Physicians and nurses described barriers specific to resource-limited settings, including unreliable supply chain, whereas nurses shared concerns about increasing workload and physician-nurse social hierarchy. Participants recognised the importance of team commitment and ongoing interdisciplinary communication for sustainability. CONCLUSION: While some factors to consider prior to deployment of healthcare technology are universal, resource-limited settings have unique implementation barriers.

A novel homozygous mutation at the GAA gene in Mexicans with early-onset Pompe disease.

Glycogen-storage disease type II, also named Pompe disease, is caused by the deficiency of the enzyme acid alpha-glucosidase, which originates lysosomal glycogen accumulation leading to progressive neuromuscular damage. Early-onset Pompe disease shows a debilitating and frequently fulminating course. To date, more than 300 mutations have been described; the majority of them are unique to each affected individual. Most early-onset phenotypes are associated with frameshift mutations leading to a truncated alpha-glucosidase protein with loss of function. Founder effects are responsible from many cases from few highprevalence world regions. Herein we described two apparently unrelated cases affected with classical early-onset Pompe disease, both pertaining to a small region from Central Mexico (the State of San Luis Potosí), the same novel homozygous frameshift mutation at gene GAA (c.1987delC) was demonstrated in both cases. This GAA gene deletion implies a change of glutamine to serine at codon 663, and a new reading frame that ends after 33 base pairs, which leads to the translation of a truncated protein. This report contributes to widen the knowledge on the effect of pathogenic mutations in Pompe disease. Here we postulate the existence of a founder effect.

Targeted neonatal echocardiography and lung ultrasound in preterm infants with chronic lung disease with and without pulmonary hypertension, screened using a standardized algorithm.

Introduction: Increased recognition of the development of chronic pulmonary hypertension (cPH) in preterm infants with chronic lung disease (CLD) has prompted enhanced monitoring for the identification of different phenotypes. Methods: All newborns consulted for oxygen/respiratory support dependency (CLD assessment) from January 2018 to December 2021 were included. TnECHO and LUS screening for cPH-CLD were performed at 36 weeks postmenstrual age. Cases of cPH related to increased pulmonary blood flow (cPH-IPBF) were referred to Pediatric Cardiology. The objective of the study was to identify all cases of cPH (cPH-CLD/IPBF) in the CLD patients screened and to compare outcomes. Following a standardized algorithm, cPH-CLD patients were treated with diuretics; ultrasounds taken before and after treatment were analyzed. Results: Seventy-two patients with CLD were screened. Twenty-two (30%) had cPH-CLD, and nine (12%) had cPH-IPBF. cPH infants underwent more days of mechanical ventilation, were more likely to have retinopathy of prematurity, and showed increased mortality. The LUS pattern observed in the 72 CLD patients consisted of a thickened pleural line and a B-line interstitial heterogeneous pattern; 29% of patients were found to have lung consolidations. After diuretic therapy, step-down in respiratory support occurred in 59% of neonates with cPH-CLD. A decrease in respiratory rate (RR), right ventricular output (RVO), markers of pulmonary vascular resistance (PVR), and B-line pattern was observed. In tissue Doppler imaging, biventricular diastolic function was found to be modified after diuretics. Conclusions: CLD infants with cPH showed increased morbidity and mortality. In cPH-CLD patients, a decrease in RR and step-down in respiratory support was observed after diuretic treatment. Follow-up ultrasound showed a decrease in RVO, markers of PVR, and B-lines.

A Modified Sonographic Algorithm for Image Acquisition in Life-Threatening Emergencies in the Critically Ill Newborn.

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h equipment availability. In 2018, the sonographic algorithm for life-threatening emergencies (SAFE) protocol was published, which allows the assessment of neonates with sudden decompensation to identify abnormal contractility, tamponade, pneumothorax, and pleural effusion. In the study unit (with a consulting neonatal hemodynamics and POCUS service), the algorithm was adapted by including consolidated core steps to support at-risk newborns, aiding clinicians in managing cardiac arrest, and adding views to verify correct intubation. This paper presents a protocol that can be applied in the NICU and the delivery room (DR) in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; the image acquisition protocol is carefully detailed. This method was designed to be learned as a general competence to obtain the timely diagnosis of life-threatening scenarios; the method aims to save time but does not represent a substitute for comprehensive and standardized hemodynamic and radiological analyses by a multidisciplinary team, which might not universally be on call but needs to be involved in the process. From January 2019 to July 2022, in our center, 1,045 hemodynamic consultation/POCUS consults were performed with 25 patients requiring the modified SAFE protocol (2.3%), and a total of 19 procedures were performed. In five cases, trained fellows on call resolved life-threatening situations. Clinical examples are provided that show the importance of including this technique in the care of critical newborns.

Knowledge acquisition and retention after a high flow training programme in Peru: a quasi-experimental single group pre-post design.

OBJECTIVE: Respiratory infections remain the leading infectious cause of death in children under 5 and disproportionately affect children in resource-limited settings. Implementing non-invasive respiratory support can reduce respiratory-related mortality. However, maintaining competency after deployment can be difficult. Our objective was to evaluate the effectiveness of a comprehensive multidisciplinary high-flow training programme in a Peruvian paediatric intensive care unit (PICU). DESIGN: Quasi-experimental single group pre-post intervention study design. SETTING: Quaternary care PICU in a resource-constrained setting in Lima, Peru. PARTICIPANTS: Attending physicians, fellows, paediatric residents, registered nurses, respiratory therapists and medical technicians working in the PICU were invited to participate. INTERVENTIONS: Concurrent with initial high-flow deployment, we implemented a training programme consisting of lectures, case-based discussion and demonstrations with baseline, 3-month and 12-month training sessions. Pre-training and post-training assessment surveys were distributed surrounding all training sessions. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was achieving minimum competency (median score of 80%) on the high flow training assessment tool. Secondary outcomes included knowledge acquisition (differences in pre-baseline and post-baseline training assessments), short-term retention (differences in post-baseline and pre-3-month refresher training assessments) and long-term retention (differences in post-3-month refresher and pre-12-month refresher training assessments). RESULTS: Eighty participants (50% nurses, 15% ICU physicians and 34% other providers) completed the baseline assessment. Participants showed improvement in overall score and all subtopics except the clinical application of knowledge after baseline training (p<0.001). Participants failed to retain minimum competency at 3-month and 12-month follow-up assessments (70% (IQR: 57-74) and 70% (IQR: 65-74), respectively). After repeat training sessions, overall knowledge continued to improve, exceeding baseline performance (78% (IQR: 70-87), 83% (IQR: 74-87) and 87% (IQR: 83-91) at baseline, 3 and 12 months, respectively). CONCLUSION: This study suggests the need for repeat training sessions to achieve and maintain competency after the implementation of new technology.

[Tetralogy of fallot and total anomalous pulmonary venous drainage to coronary sinus. Case report]. / Tetralogía de Fallot con conexión anómala total de venas pulmonares a seno coronario. Reporte de un caso con esta rara asociación.

We report the case of an infant 3 months old with a rare association, tetralogy of Fallot with total anomalous pulmonary veins connection the diagnosis was made by echocardiography and a successful complete reparation was achieved.

Successful Deployment of High Flow Nasal Cannula in a Peruvian Pediatric Intensive Care Unit Using Implementation Science-Lessons Learned.

Acute lower respiratory infections are the leading cause of death outside the neonatal period for children less than 5 years of age. Widespread availability of invasive and non-invasive mechanical ventilation in resource-rich settings has reduced mortality rates; however, these technologies are not always available in many low- and middle-income countries due to the high cost and trained personnel required to implement and sustain their use. High flow nasal cannula (HFNC) is a form of non-invasive respiratory support with growing evidence for use in pediatric respiratory failure. Its simple interface makes utilization in resource-limited settings appealing, although widespread implementation in these settings lags behind resource-rich settings. Implementation science is an emerging field dedicated to closing the know-do gap by incorporating evidence-based interventions into routine care, and its principles have guided the scaling up of many global health interventions. In 2016, we introduced HFNC use for respiratory failure in a pediatric intensive care unit in Lima, Peru using implementation science methodology. Here, we review our experience in the context of the principles of implementation science to serve as a guide for others considering HFNC implementation in resource-limited settings.

[Prevalence and spectrum of diseases that predispose to sudden cardiac death in Mexican children: a sample obtained from The Federico Gomez Children's Hospital of Mexico]. / Prevalencia y espectro de las enfermedades que predisponen a la muerte súbita cardiaca en niños mexicanos: una muestra obtenida del Hospital Infantil de México Federico Gómez.

OBJECTIVE: To determine the prevalence and spectrum of diseases that predispose to sudden cardiac death in Mexican children, and to identify the main early signs and symptoms that can enable the health personnel to suspect these diseases and to refer the patients to a tertiary hospital in a timely manner. METHODS: Incidence, prevalence, and period prevalence, as well as early symptoms, clinical data, and follow-up were recorded on all children found with diseases that predispose to sudden cardiac death in The Children's Hospital of Mexico. RESULTS: The study included 59 patients, with a mean age of 8 ± 5 years old, with 40 cardiomyopathies, and 19 with inherited arrhythmogenic diseases. The period prevalence was 9.5/1,000 patients/year. The most common early symptoms were dyspnoea, palpitations, and syncope. A Mendelian inheritance pattern was found in 9 cases. Three patients died of sudden cardiac death during the period of the study. CONCLUSION: Diseases that predispose to sudden cardiac death in children are not very well known by the general medical community. Every child with dyspnoea, palpitations and/or syncope, should be referred for the intensive search of these diseases. A complete cardiological evaluation in all members of the family is indicated.

[Right-side aortic arch with aberrant left subclavian artery and Kommerell's diverticulum. A cause of vascular ring]. / Arco aórtico derecho con subclavia izquierda aberrante y divertículo de Kommerell. Una causa de anillo vascular.

The right-side aortic arch may be associated with aberrant left subclavian artery, in some cases this artery originates from an aneurismal dilation of the aorta called Kommerell's diverticulum. A report is presented on 2 cases of vascular ring formed by a right-side aortic arch, anomalous left subclavian artery, Kommerell's diverticulum and left patent ductus arteriosus. A review the literature was also performed as regards the embryological development and the imaging methods used to help in the diagnosis of this rare vascular anomaly.

[Functional echocardiography in the neonatal intensive care unit; experience in a tertiary level hospital]. / Ecocardiografía funcional en cuidados intensivos neonatales: experiencia en un hospital de tercer nivel.

BACKGROUND: The Hospital Infantil de Mexico Federico Gómez is a tertiary level hospital with a neonatal intensive care unit (NICU), which is one of the most important units in the treatment of newborn's diseases in México. In this unit, the decisions are taken based on some clinic parameters such as respiratory rate, heart rate, arterial pressure, urinary output and lactate levels. The functional echocardiography is a useful tool which improves the hemodynamic evaluation and decisions in neonatal care. Data on its use in neonatal units in Mexico is lacking. METHODS: A prospective study conducted in NICU patients during 3 months from August to October 2015 at the Hospital Infantil de Mexico Federico Gómez. Gestational age, birth weight, admission criteria, days of life at examination, indication for functional echocardiography and changes in treatment were evaluated and finally, we performed a new study 24hours later. Echocardiographic evaluation included: assessment of presence/hemodynamic significance of PDA; myocardial function: ejection fraction/shortening fraction, left ventricular output, right ventricular output, systemic blood flow; and signs of pulmonary hypertension. RESULTS: 30 echocardiographic studies were performed in 15 patients. The average age was 9.6 days, the variability in gestational ages were 37 to 42 weeks; the average weight was 2.583kg. The most frequent diagnosis was respiratory distress, and the principal indications for echocardiography were hemodynamic instability and sepsis (53.3%). In 11 cases (73.3%), the treatment was modified posteriorly to functional echocardiography, and in 10 cases we observed improvements in the 24hours after control. CONCLUSIONS: Functional echocardiography is a useful tool in NICU, which may assist with clinical decision-making.

[Quadricuspid aortic valve in a patient with d-transposition of the great arteries]. / Válvula aórtica cuadricúspide (VAC) en transposición de grandes arterias. Reporte de un caso diagnosticado por ecocardiografía bidimensional.

In this report we present the case of a patient with ventricular-arterial discordance in which a QAV was diagnosed by bidimensional echocardiogram with the purpose of expanding the anatomical spectrum of the anomalies associated with d-TGA and to manifest the clinical awareness of the consequence that the QAV has on the evolution of the patients that undergo to anatomic correction.

[Persistent fifth aortic arch with patent ductus arteriosus]. / Persistencia del quinto arco aórtico asociado a persistencia del conducto arterioso.

Persistent fifth aortic arch is a rare congenital vascular anomaly, with no clinical impact, so diagnosis is usually an incidental finding occasionally associated with other congenital heart defects. We report a case of persistent fifth aortic arch associated with patent ductus arteriosus.

[Treatment of patent ductus arteriosus. Comparison of costs between surgical and trans-catheter closures in a public institution]. / Tratamiento de conducto arterioso permeable. Comparación de costos del cierre quirúrgico y transcateterismo en una institución pública.

UNLABELLED: The costs of transcatheter closure of patent ductus arteriosus in relation to the surgical closure still a controvertial issue in our hospitals. The aim of the study was compared the costs of both treatments. METHODS: We included 57 patients treated with transcatheter occlusion and 26 underwent surgery. Information about laboratory tests, average in hospital days of stay, anesthesia type and duration, operating and hemodinamic room costs, was gather. A database containing the costs from the institution unitary costs system in force was designed. RESULTS: sociodemographyc characteristics were similar in both groups. Ductus size was larger in patients treated with surgery (p<0.05). In hospital stay, as well as, the number of complications after the procedure were less in the patients treated with transcatheter occlusion (p<0.05). The closure with Amplatzer device was more expensive than the surgical one, and both were more expensive than coil. With surgical treatment, 86.5% of the costs are due to in hospital stay, with the Amplatzer this issues represented a 36%, however, the cost of the devices by itself represents a 40% of the total treatment cost. CONCLUSIONS: Even though total charges of Amplatzer devices are more expensive than surgery, transcatheter occlusion represents advantages in relation to less in hospital stay, resources used and number of complications, which allows hospital resources optimization.

[Intracardiac echocardiography (ICE) in the operating room as a support measure in the evaluation of immediate surgical results in congenital cardiopathies]. / Ecocardiografía intracardíaca (EIC) en sala de operaciones como método de apoyo en la evaluación de resultados quirúrgicos inmediatos en cardiopatías congénitas.

The utilization of intracardiac echocardiography (ICE) is a recent alternative in the control of procedures in the Cath Lab. In this paper we presents the results of a pilot study, in 10 patients submitted to total correction of its congenital heart disease, in who the analysis of the surgical results was done in base to the application of intracardiac echocardiography in operations room. In all the patients it was possible to obtain adequate images with ICE, there was a case false negative, a Total anomalous return Pulmonary Veins, in whom there not indentified a obstruction in right pulmonary veins flow. We conclude that ICE is a good alternative in the evaluation of surgical results.

Prevalencia y espectro de las enfermedades que predisponen a la muerte súbita cardiaca en niños mexicanos: una muestra obtenida del Hospital Infantil de México Federico Gómez / Prevalence and spectrum of diseases that predispose to sudden cardiac death in Mexican children: a sample obtained from The Federico Gomez Children's Hospital of Mexico

Resumen Objetivo: Determinar la prevalencia y espectro de las enfermedades que predisponen la muerte súbita cardiaca en niños mexicanos e identificar los principales signos y síntomas tempranos que pueden permitir al personal de salud sospechar acerca de estas enfermedades y referir a los pacientes a un hospital de tercer nivel de manera temprana. Métodos: La incidencia, prevalencia y prevalencia de periodo, así como los primeros síntomas, los datos clínicos y el seguimiento, se describen en todos los niños con enfermedades que predisponen a la muerte súbita cardiaca en el Hospital Infantil de México. Resultados: Cincuenta y nueve pacientes de 8 ± 5 años, 40 con miocardiopatías y 19 con enfermedades arritmogénicas hereditarias. La prevalencia del periodo fue de 9.5/1,000 pacientes/año. Los primeros síntomas más comunes fueron disnea, palpitaciones y síncope. En 9 casos se encontró un patrón de herencia mendeliana. Tres pacientes fallecieron de muerte súbita cardiaca durante el periodo de estudio. Conclusión: Las enfermedades que predisponen a la muerte súbita cardiaca en los niños no son muy conocidas por la comunidad médica y general. Todo niño con disnea, palpitaciones y/o síncope debe referirse para la búsqueda intensiva de estas enfermedades. Una evaluación cardiológica completa en todos los miembros de la familia está indicada.

Abstract Objective: To determine the prevalence and spectrum of diseases that predispose to sudden cardiac death in Mexican children, and to identify the main early signs and symptoms that can enable the health personnel to suspect these diseases and to refer the patients to a tertiary hospital in a timely manner. Methods: Incidence, prevalence, and period prevalence, as well as early symptoms, clinical data, and follow-up were recorded on all children found with diseases that predispose to sudden cardiac death in The Children's Hospital of Mexico. Results: The study included 59 patients, with a mean age of 8 ± 5 years old, with 40 cardiomyopathies, and 19 with inherited arrhythmogenic diseases. The period prevalence was 9.5/1,000 patients/year. The most common early symptoms were dyspnoea, palpitations, and syncope. A Mendelian inheritance pattern was found in 9 cases. Three patients died of sudden cardiac death during the period of the study. Conclusion: Diseases that predispose to sudden cardiac death in children are not very well known by the general medical community. Every child with dyspnoea, palpitations and/or syncope, should be referred for the intensive search of these diseases. A complete cardiological evaluation in all members of the family is indicated.

Arco aórtico derecho con subclavia izquierda aberrante y divertículo de Kommerell. Una causa de anillo vascular / Right-side aortic arch with aberrant left subclavian artery and Kommerell's diverticulum. A cause of vascular ring

Resumen: El arco aórtico derecho puede estar asociado a subclavia izquierda aberrante, en algunos casos esta se origina de una dilatación aneurismática que se conoce como divertículo de Kommerell. Se presentan 2 casos de anillo vascular formado por un arco aórtico derecho, subclavia izquierda anómala con divertículo de Kommerell y persistencia del conducto arterioso izquierdo con una revisión de la literatura acerca del desarrollo embriológico y los métodos de imagen que ayudan al diagnóstico de esta rara anomalía vascular.

Abstract: The right-side aortic arch may be associated with aberrant left subclavian artery, in some cases this artery originates from an aneurismal dilation of the aorta called Kommerell's diverticulum. A report is presented on 2 cases of vascular ring formed by a right-side aortic arch, anomalous left subclavian artery, Kommerell's diverticulum and left patent ductus arteriosus. A review the literature was also performed as regards the embryological development and the imaging methods used to help in the diagnosis of this rare vascular anomaly.

Ecocardiografía funcional en cuidados intensivos neonatales: experiencia en un hospital de tercer nivel / Functional echocardiography in the neonatal intensive care unit; experience in a tertiary level hospital

Resumen: Introducción: El Hospital Infantil de México es un hospital de tercer nivel y centro de referencia nacional que cuenta con una unidad de cuidados intensivos neonatales (UCIN), en la cual la toma de decisiones se realiza en base a parámetros clínicos y datos como la frecuencia respiratoria, frecuencia cardiaca, tensión arterial, gasto urinario y nivel de lactato. El Ecocardiograma Funcional (EcoF) es un estudio que permite complementar los datos hemodinámicos de estos pacientes, logrando una integración de parámetros clínicos y hemodinámicos con el objetivo de mejorar las decisiones terapeúticas y evolución de los pacientes. Metodología: Estudio descriptivo prospectivo sobre la implementación del EcoF en pacientes de la UCIN durante el período de agosto a octubre del 2015 en el Hospital Infantil de México Federico Gómez. Las variables fueron la edad gestacional, los diagnósticos de ingreso, peso, las indicaciones para realizar el estudio y los días de vida en el momento del estudio. En cada estudio se determinaron los parámetros ecocardiográficos que conforman el EcoF, se anotaron las modificaciones al tratamiento posterior al estudio y se realizó un nuevo control a las 24 horas para determinar la evolución del paciente. Resultados: Se realizaron un total de 30 estudios en 15 pacientes durante el período previamente señalado. La media de edad a la que se realizó el estudio ecocardiográfico fue de 9.6 días de vida (28-2 días). En un 66% el rango de semanas de gestación fue entre 37 a 42 y con una media de peso de 2583 g (4000-1010 g). El diagnóstico más frecuente de los pacientes valorados fue síndrome de dificultad respiratoria y prematurez (26.6%). La indicación más frecuente para solicitar el estudio fue inestabilidad hemodinámica y sepsis representando el 53.3%. En 11 pacientes (73.3%) hubo modificaciones al tratamiento posterior al EcoF, con mejoría en 10 casos en el control que se realizó a las 24 horas. Conclusiones: La EF es una herramienta útil en UCIN aportando información complementaria que apoya las decisiones terapéuticas. Hace falta la diseminación de programas de formación y acreditación conforme a las recomendaciones existentes para asegurar un uso correcto y seguro de esta técnica.

Abstract: Background: The Hospital Infantil de Mexico Federico Gómez is a tertiary level hospital with a neonatal intensive care unit (NICU), which is one of the most important units in the treatment of newborn's diseases in México. In this unit, the decisions are taken based on some clinic parameters such as respiratory rate, heart rate, arterial pressure, urinary output and lactate levels. The functional echocardiography is a useful tool which improves the hemodynamic evaluation and decisions in neonatal care. Data on its use in neonatal units in Mexico is lacking. Methods: A prospective study conducted in NICU patients during 3 months from August to October 2015 at the Hospital Infantil de Mexico Federico Gómez. Gestational age, birth weight, admission criteria, days of life at examination, indication for functional echocardiography and changes in treatment were evaluated and finally, we performed a new study 24 hours later. Echocardiographic evaluation included: assessment of presence/hemodynamic significance of PDA; myocardial function: ejection fraction/shortening fraction, left ventricular output, right ventricular output, systemic blood flow; and signs of pulmonary hypertension. Results: 30 echocardiographic studies were performed in 15 patients. The average age was 9.6 days, the variability in gestational ages were 37 to 42 weeks; the average weight was 2.583 kg. The most frequent diagnosis was respiratory distress, and the principal indications for echocardiography were hemodynamic instability and sepsis (53.3%). In 11 cases (73.3%), the treatment was modified posteriorly to functional echocardiography, and in 10 cases we observed improvements in the 24 hours after control. Conclusions: Functional echocardiography is a useful tool in NICU, which may assist with clinical decision-making.

Persistencia del quinto arco aórtico asociado a persistencia del conducto arterioso / Persistent fifth aortic arch with patent ductus arteriosus

La persistencia del quinto arco aórtico es una rara anomalía congénita vascular que consiste en la presencia de una comunicación entre la aorta ascendente y la aorta descendente a través de un conducto arterial; se diagnostica de manera incidental. Informamos de un caso asociado a persistencia de conducto arterioso.

Persistent fifth aortic arch is a rare congenital vascular anomaly, with no clinical impact, so diagnosis is usually an incidental finding ocasionally associated with other congenital heart defects. We report a case of persistent fifth aortic arch associated with patent ductus arteriosus.

Diagnóstico oportuno del daño al miocardio en pacientes tratados con antraciclinas: un reto para el siglo XXI / Timely diagnosis of myocardial damage in patients treated with anthracyclines: a challenge for the 21st century

Introducción. Los métodos utilizados actualmente para la valoración del daño miocárdico en pacientes tratados con antraciclinas presentan deficiencias para la detección del daño incipiente. La troponina I forma parte de las proteínas reguladoras de la maquinaria de contracción en la miofibrilla y se ha utilizado como biomarcador específico de daño miocárdico. El objetivo de este trabajo fue comparar los niveles de troponina I en pacientes tratados con antraciclinas, antes y después de un nuevo ciclo de quimioterapia. Métodos. Se incluyeron pacientes con diagnóstico de cáncer, de 9 a 18 años, que recibían tratamiento con antraciclinas en el Hospital Infantil de México Federico Gómez. Se midieron los niveles séricos de troponina I (antes y después de un nuevo ciclo de quimioterapia) y se compararon los resultados obtenidos. Resultados. El promedio de la dosis acumulada de antraciclinas en la población estudiada fue de 234 mg/m²SC para daunorrubicina y 269 mg/m²SC para doxorrubicina. No se observó una disfunción sistólica importante mediante el ecocardiograma pero, mediante uso de SPEC-CT, sí se observaron alteraciones en la movilidad de las paredes ventriculares izquierdas. No se evidenció un aumento de niveles de troponina I en el suero después de la aplicación de una nueva dosis de antraciclinas. Conclusiones. Se ha investigado mucho acerca de biomarcadores que ayuden al diagnóstico temprano de la cardiopatía secundaria a antraciclinas, pero se han obtenido resultados contradictorios. Tomar en cuenta la cinética de la troponina I en el daño miocárdico, es un paso fundamental para su evaluación. Bajo esta premisa, no se observaron aumentos de este biomarcador en sangre después del daño miocárdico secundario al uso de antraciclinas.

Background. Currently used methods for assessment of myocardial damage in patients treated with anthracyclines are deficient in detecting mild myocardial damage. Troponin I is part of the protein contractile machinery in the myofibril and is used as a specific biomarker of myocardial damage. The aim of the study was to compare troponin I levels in patients with prior anthracycline use after a new cycle of chemotherapy. Methods. We included patients from 9 to 18 years of age who were diagnosed with cancer and being treated with anthracyclines at the Hospital Infantil de Mexico Federico Gomez. We analyzed serum troponin I prior to and after the new cycle of chemotherapy and compared the results, always in a blinded manner. Results. The mean cumulative dose of anthracyclines in the study population was 234 mg/m² SC for daunorubicin and 269 mg/m² SC for doxorubicin. There was no significant systolic dysfunction according to echocardiography. Impaired mobility of left ventricular walls was observed using SPECT-CT. There was no evidence of increased levels of troponin I in serum after application of a new dose of anthracyclines. Conclusions. Extensive research has been carried out in regard to biomarkers that aid in the early diagnosis of cardiomyopathy secondary to anthracycline, with mixed results. Taking into account the kinetics of troponin I in myocardial damage is a critical step for evaluation. Using this premise, we did not find an increase of this biomarker in blood after myocardial damage secondary to administration of anthracyclines.