Divide et Vinces, Therapeutic Apheresis in Nephrological Clinical Practice.

Therapeutic plasma exchange (TPE) or plasmapheresis has been used in various life-threatening diseases as a primary treatment or in combination with other therapies. It was first successfully employed in the 1960s for diseases like Waldenström's disease and myeloma. Since then, TPE techniques using apheresis membranes have been introduced. Apheresis therapies separate plasma components from blood using membrane screening or centrifugation methods. TPE aims to remove substances involved in the pathophysiology of diseases. It selectively removes high-molecular-weight molecules, substances with prolonged half-life, and those associated with disease pathogenesis. TPE can be performed using membranes or centrifugation, with replacement of extracted plasma volume using albumin or fresh frozen plasma. TPE requires specific competencies in nephrology and can be prescribed and monitored by nephrologists and performed by dialysis nursing staff. TPE can be combined with adsorption-based therapies to enhance its effect, and this approach is called plasma filtration adsorption. Another variation is double plasma filtration, which selectively removes substances based on molecular size. TPE can also be combined with lipoprotein removal strategies for managing familial hypercholesterolemia. TPE is an affordable extracorporeal therapy that benefits patients with life-threatening diseases. It requires collaboration between nephrologists and other specialists, and our results demonstrate successful TPE without anticoagulation in general hospitalization or outpatient settings.

Impact of Medium Cut-Off Dialyzers on Patient-Reported Outcomes: COREXH Registry.

INTRODUCTION: A new generation of hemodialysis (HD) membranes called medium cut-off (MCO) membranes possesses enhanced capacities for middle molecule clearance, which have been associated with adverse outcomes in this population. These improvements could potentially positively impact patient-reported outcomes (PROs). OBJECTIVE: The objective of this study was to evaluate the impact of MCO membranes on PROs in a cohort of HD patients in Colombia. METHODS: This was a prospective, multicenter, observational cohort study of 992 patients from 12 renal clinics in Colombia who were switched from high-flux HD to MCO therapy and observed for 12 months. Changes in Kidney Disease Quality of Life 36-Item Short Form Survey (KDQoL-SF36) domains, Dialysis Symptom Index (DSI), and restless legs syndrome (RLS) 12 months after switching to MCO membranes were compared with time on high-flux membranes. Repeated measures of ANOVA were used to evaluate changes in KDQoL-SF36 scores; severity scoring was used to assess DSI changes over time; Cochran's Q test was used to evaluate changes in frequency of diagnostic criteria of RLS. RESULTS: During 12 months of follow-up, 3 of 5 KDQoL-SF36 domains improved compared with baseline: symptoms (p < 0.0001), effects of kidney disease (p < 0.0001), and burden of kidney disease (p < 0.001). The proportion of patients diagnosed with RLS significantly decreased from 22.1% at baseline to 10% at 12 months (p < 0.0001). No significant differences in the number of symptoms (DSI, p = 0.1) were observed, although their severity decreased (p = 0.009). CONCLUSIONS: In conventional HD patients, the expanded clearance of large middle molecules with MCO-HD membranes was associated with higher health-related quality of life scores and a decrease in the prevalence of RLS.

Pulmonary Thromboembolism in Pregnancy: A Case Report and Literature Review.

Data on the optimal diagnostic management of pregnant women with suspected pulmonary embolism are limited. Despite a lack of compelling evidence in some practices, clinical practice guidelines focus on the management of these patients. We present the case of a 24-year-old patient at 36 weeks of pregnancy in whom pulmonary thromboembolism (PTE) was diagnosed in a timely manner also with hemodynamic instability and echocardiographic images with clear involvement of the right cavities. She received thrombolytic therapy with alteplase 100 mg intravenously over 2 hours, which resulted in excellent outcomes for both the pregnant woman and fetus. Understanding the acute approach and management of these patients will improve our clinical practice; therefore, we reviewed a case report of a pregnant patient with high-risk PTE and compared it with current evidence. In conclusion, PE is a common disease with a high mortality rate during pregnancy. Therefore, having made a timely diagnosis using the relevant diagnostic aids and performing thrombolysis with rtPA increase the probability of survival in our patient, leading to successful results for both her and the fetus.

Invasive and antiplatelet treatment of patients with non-ST-segment elevation myocardial infarction: Understanding and addressing the global risk-treatment paradox.

Clinical guidelines for the treatment of patients with non-ST-segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long-term mortality risk than patients with ST-segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the "treatment-risk paradox"). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four "P" factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long-term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.

Acid-Base Status Disturbances in Patients on Chronic Hemodialysis at High Altitudes.

BACKGROUND: Acid-base disorders have been previously described in patients with chronic hemodialysis, with metabolic acidosis being the most important of them; however, little is known about the potential changes in acid-base status of patients on dialysis living at high altitudes. METHODS: Cross-sectional study including 93 patients receiving chronic hemodialysis on alternate days and living in Bogotá, Colombia, at an elevation of 2,640 meters (8,661 feet) over sea level (m.o.s.l.). Measurements of pH, PaCO2, HCO3, PO2, and base excess were made on blood samples taken from the arteriovenous fistula (AVF) during the pre- and postdialysis periods in the midweek hemodialysis session. Normal values for the altitude of Bogotá were taken into consideration for the interpretation of the arterial blood gases. RESULTS: 43% (n= 40) of patients showed predialysis normal acid-base status. The most common acid-base disorder in predialysis period was metabolic alkalosis with chronic hydrogen ion deficiency in 19,3% (n=18). Only 9,7% (n=9) had predialysis metabolic acidosis. When comparing pre- and postdialysis blood gas analysis, higher postdialysis levels of pH (7,41 versus 7,50, p<0,01), bicarbonate (21,7mmol/L versus 25,4mmol/L, p<0,01), and base excess (-2,8 versus 2,4, p<0,01) were reported, with lower levels of partial pressure of carbon dioxide (34,9 mmHg versus 32,5 mmHg, p<0,01). CONCLUSION: At an elevation of 2,640 m.o.s.l., a large percentage of patients are in normal acid-base status prior to the dialysis session ("predialysis period"). Metabolic alkalosis is more common than metabolic acidosis in the predialysis period when compared to previous studies. Paradoxically, despite postdialysis metabolic alkalosis, PaCO2 levels are lower than those found in the predialysis period.

Use of ticagrelor alongside fibrinolytic therapy in patients with ST-segment elevation myocardial infarction: Practical perspectives based on data from the TREAT study.

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion method in patients with ST-segment elevation myocardial infarction (STEMI). In patients with STEMI who cannot undergo timely primary PCI, pharmacoinvasive treatment is recommended, comprising immediate fibrinolytic therapy with subsequent coronary angiography and rescue PCI if needed. Improving clinical outcomes following fibrinolysis remains of great importance for the many patients globally for whom rapid treatment with primary PCI is not possible. For patients with acute coronary syndrome who underwent primary PCI, the PLATO trial demonstrated superior efficacy of ticagrelor relative to clopidogrel. Results in the predefined subgroup of patients with STEMI were consistent with the overall PLATO trial. Patients who received fibrinolytic therapy in the 24 hours before randomization were excluded from PLATO, and there is thus a lack of data on the safety of using ticagrelor in conjunction with fibrinolytic therapy in the first 24 hours after STEMI. The TREAT study addresses this knowledge gap; patients with STEMI who had symptom onset within the previous 24 hours and had received fibrinolytic therapy (of whom 89.4% had also received clopidogrel) were randomized to treatment with ticagrelor or clopidogrel (median time between fibrinolysis and randomization: 11.5 hours). At 30 days, ticagrelor was found to be non-inferior to clopidogrel for the primary safety outcome of Thrombolysis in Myocardial Infarction (TIMI)-defined first major bleeding. Considering together the results of the PLATO and TREAT studies, initiating or switching to treatment with ticagrelor within the first 24 hours after STEMI in patients receiving fibrinolysis is reasonable.

The products of the reaction between 6-amine-1,3-dimethyl uracil and bis-chalcones induce cytotoxicity with massive vacuolation in HeLa cervical cancer cell line.

As a part of our research in the chemistry of chalcones we have prepared four pyrimidine monoadducts of bis-chalcones through the reaction with 6-amino-1,3-dimethyl uracil. These compounds displayed cytotoxicity with a massive vacuolation in different human cell lines in vitro. Compound 6 was the most cytotoxic inducer of vacuoles, this compound induced G1 phase cell cycle arrest, and their cytotoxicity went without morphological and biochemical evidence of apoptotic cell death in HeLa cells. In addition, our results showed that this vacuole formation does not require de novo protein synthesis and the content vacuolar is acidic. Compound 6 induce necrotic cell death with excessive vacuolation, similar to a process of autophagy. Spautin-1 an inhibitor of autophagy, decreased the transformation of microtubule-associated protein 1 light chain 3 (LC3B-I) to LC3B-II and the vacuolation induced by compound 6 in HeLa cells, both autophagy processes. These compounds could be of pivotal importance in the study of non-apoptotic cell death with vacuole formation and could be useful in research into new autophagy inhibitors agents.

Prinzmetal's angina.

This syndrome is due to focal spasm of an epicardial coronary artery, leading to severe myocardial ischemia. Although it is frequently thought that the spasm occurs in arteries without stenosis, many Prinzmetal patients have spasm adjacent to atheromatous plaques. The exact cause of the spasm has not been well defined, but it may be related to the hypercontractility of the vascular smooth muscle due to vasoconstrictor mitogens, leukotrienes, or serotonin. In some patients, it is a manifestation of a vasospastic disorder and it is associated with migraine, Raynaud's phenomenon, or aspirin-induced asthma. We present a case associated with transient ST-segment depression.

Quiste pericárdico en un paciente con trasplante cardíaco: Descripción de un caso clínico / Pericardial Cyst in a Heart Transplant Patient: A Case Report

El quiste pericárdico es una entidad rara, de origen congénito, que acontece en el 7% de los casos de masas mediastínicas, localizado habitualmente en el lado derecho del pericardio y el mediastino anterior. En general, los pacientes evolucionan en forma asintomática, a excepción de los casos en los que el quiste presenta una localización fuera de los sitios mencionados o en los que por su tamaño condiciona síntomas. En los sintomáticos, las manifestaciones dependen del sitio, la localización del quiste y los órganos involucrados. En esta presentación se describe el caso clínico de un paciente a quien se le realizó un trasplante cardíaco y posteriormente desarrolló un quiste pericárdico.

Pericardial cysts are an uncommon congenital anomaly which represents 7% of mediastinal masses. Cysts frequently occur in the right cardiophrenic angle and in the anterior mediastinum. Although most pericardial cysts are asymptomatic, symptoms may develop in unusually located or large cysts. The clinical manifestations depend on the site of location and on the organs involved. We describe the case of a heart transplant patient who developed a pericardial cyst after transplantation.

Endocarditis bacteriana en el cable de resincronizador. Descripción de un caso clínico y revisión de la literatura / Endocardite bacteriana no cabo-eletrodo do ressincronizador: Descrição de um caso clínico e revisão da literatura / Bacterial endocarditis in a resynchronization wire: Case report and review of the literature

La endocarditis, relacionada con la infección del cable del resincronizador cardíaco, es una complicación rara asociada a los marcapasos endocavitarios. La incidencia de endocarditis que aparece tras el implante de un marcapasos endocavitario permanente oscila entre el 0,13% y el 7,9%. La historia natural de la infección en algunos casos es sombría, con un porcentaje de mortalidad alto, entre un 30-35%, según diferentes estudios. A continuación se presenta el caso de una paciente con endocarditis en el cable de un resincronizador implantable en la que no fue necesaria la extracción del mismo.

Endocarditis related to infection of the endocavitary wire is a rare complication associated with pacemakers endocavitaries. The incidence of endocarditis that appears after the implantation of a permanent endocardial pacemaker ranges between 0.13% and 7.9%. The natural history of infection in some cases is grim, with a high mortality rate, between 30-35%, according to various studies. We present a patient with endocarditis associated to a resynchronization wire in which it was not necessary its removal.

A endocardite relacionada com a infecção do cabo-eletrodo do ressincronizador cardíaco é uma complicação rara associada aos marcapassos endocavitários. A incidência da endocardite que aparece após o implante de um marcapasso endocavitário permanente oscila entre 0,13% e 7,9%. A história natural da infecção em alguns casos é sombria, com uma alta porcentagem de mortalidade, entre um 30-35%, segundo diferentes estudos. A seguir apresenta-se o caso de uma paciente com endocardite no cabo-eletrodo de um ressincronizador implantável em que não foi necessária a extração do mesmo.

Quemadura de vía aérea / Airway burn

La mayoría de las muertes tempranas por accidentes con fuego son provocadas por la inhalación de gases más que por las lesiones causadas por llamas, debido principalmente al compromiso ventilatorio que esto produce. Por lo anterior debe existir un alto grado de sospecha de compromiso de vía aérea en aquellos pacientes que presenten quemaduras faciales, en espacios cerrados, vibrisas chamuscadas, compromiso respiratorio progresivo, esputo carbonáceo o que se encuentren en estado de inconciencia. Sin embargo, la presencia de estos hallazgos no es patognomónica de daño en el árbol bronquial ni su ausencia lo descarta. El principal método de diagnóstico es la fibrobroncoscopía, que permite observar directamente las lesiones y además lavar y remover restos que puedan encontrarse en la vía aérea, pero lamentablemente no se encuentra disponible en todos los servicios de urgencia.

Most of the early deaths from accidents with are fire mainly caused by compromise of the ventilation due to gas inhalation rather thand by injuries caused by flames. Therefore there must be a high degree of suspicion of air compromise for patients presenting facial burns indoors, burnt hair of the nasal cavity, progressive respiratory compromise, carbonaceous sputum or unconsciousness. However, neither is the presence of these findings pathognomonic of damage to the bronchial tree nor does their discharge it. The main method is the fibrobroncoscopy diagnosis, which allows direct observation of the injuries and also the washing and removal of debris that can be found in the airways. Unfortunately, this is method is not available in all amergency services.

Taquicardia de Coumel: descripción de un caso clínico / Coumel´s tachycardia: a clinical case

Se presenta el caso de un hombre de 17 años, con taquicardia reciprocante permanente de la unión atrioventricular, que es una forma especial de taquicardia paroxística supraventricular, que se presenta en forma incesante y en la cual participa una vía accesoria de conducción lenta retrógada. El paciente fue tratado con ablación por catéter con éxito.

Niveles séricos de procalcitonina y sepsis en el posoperatorio inmediato de diversos tipos de cirugía / Serum procalcitonin levels and sepsis during the immediate postoperative period in several types of surgery

Introducción: la procalcitonina (PCT) es un marcador que ha demostrado ser útil en el diagnóstico de infecciones bacterianas. Considerando que algunas cirugías como la cardiaca inducen liberación de PCT, se necesitan múltiples estudios que demuestren su utilidad en estas circunstancias.Objetivo: evaluar la capacidad discriminatoria de la PCT ntre el síndrome de respuesta inflamatoria sistémica (SRIS) con sepsis y sin sepsis, en el periodo posoperatorio temprano para un valor de PCT mayor a 2 ng/ml.Material y métodos: evaluamos 119 pacientes con SRIS en las primeras 72 horas de posoperatorio. Se midió los niveles séricos de PCT semicuantitativa y se realizo seguimiento a los pacientes para clasificarlos en SRIS con sepsis y SRIS sin sepsis basados en el protocolo de sepsis de la Fundación Cardio-Infantil de Bogotá.Resultados: la sensibilidad para el diagnóstico de sepsis con procalcitonina de > 2 ng/ml fue de 28 por ciento y especificidad de 68 por ciento. La mortalidad global de la población fue 11,7 por ciento encontrándose asociación con los niveles de procalcitonina dado por un OR 5.20 (IC 95 por ciento limites 1.42 – 19.86).Discusión: las características demográficas de la población son reflejo de las características y estadísticas institucionales. Los resultados difieren de la literatura probablemente por el uso de procalcitonina semicuantitativa y no LUMI-test®, además de los tipos de cirugía incluidos. Estas observaciones deben ser confirmadas por otros estudios.Conclusión: la medición de procalcitonina semicuantitativa no es una herramienta útil en discriminar pacientes sépticos de los no sépticos en posoperatorio temprano.

Angina de Prinzmetal / Angina de Prinzmetal / Prinzmetal's angina

Essa síndrome é causada por um espasmo focal de uma artéria coronária epicárdica, levando a isquemia miocárdica grave. Embora freqüentemente acredite-se que o espasmo ocorra em artérias sem estenose, muitos pacientes com angina de Prinzmetal apresentam espasmo adjacente a placas ateromatosas. A causa exata do espasmo não está bem definida, mas pode estar relacionada à hipercontratilidade do músculo liso vascular devido a mitógenos vasoconstrictores, leucotrienos ou serotonina. Em alguns pacientes, é uma manifestação de distúrbio vasoespástico e está associado à migrânea, fenômeno de Raynaud ou asma induzida por aspirina. Apresentamos um caso associado com depressão transitória do segmento ST.

This syndrome is due to focal spasm of an epicardial coronary artery, leading to severe myocardial ischemia. Although it is frequently thought that the spasm occurs in arteries without stenosis, many Prinzmetal patients have spasm adjacent to atheromatous plaques. The exact cause of the spasm has not been well defined, but it may be related to the hypercontractility of the vascular smooth muscle due to vasoconstrictor mitogens, leukotrienes, or serotonin. In some patients, it is a manifestation of a vasospastic disorder and it is associated with migraine, Raynaud's phenomenon, or aspirin-induced asthma. We present a case associated with transient ST-segment depression.

Este síndrome es causado por un espasmo focal de una arteria coronaria epicárdica, llevando a isquemia miocárdica grave. Aunque frecuentemente se crea que el espasmo ocurra en arterias sin estenosis, muchos pacientes con angina de Prinzmetal presentan espasmo adyacente a placas ateromatosas. La causa exacta del espasmo no está bien definida, pero puede estar relacionada a la hipercontractilidad del músculo liso vascular debido a mitógenos vasoconstrictores, leucotrienos o serotonina. En algunos pacientes, es una manifestación de disturbio vasoespástico y está asociado a la migraña, fenómeno de Raynaud o asma inducida por aspirina. Presentamos un caso asociado con depresión transitoria del segmento ST.

Diseccion aórtica: estado actual / Aortic dissection: state of the art

La disección aguda es la afección más común de la aórtica y es dos o tres veces más frecuente que la ruptura del aneurisma aórtico abdominal; de no tratarse, tiene una mortalidad del 90 por ciento a tres meses. En los últimos años, se han dado grandes avances en su diagnóstico oportuno y tratamiento adecuado, tanto médico como quirúrgico, con significativa disminución de la mortalidad. Su incidencia está aumentando en los países industrializados, quizá incluso esté infravalorada, debida al grupo de pacientes que fallecen antes de que se llegue a un diagnóstico definitivo.

Síndrome de Sheehan: descripción de un caso clínico y revisión de la literatura / Sheehan’s syndrome: a case report and literature review

Introducción: la necrosis hipofisaria posparto o síndrome de Sheehan se presenta secundaria a una hemorragia obstétrica, ocasionando un colapso circulatorio intenso el cual, a su vez, predispone a la isquemia de la hipófisis aumentada de tamaño. Objetivo: presentar un caso clínico de una paciente quien consultó por manifestaciones tardías de este síndrome y hacer una revisión de la literatura. Metodología: se buscó información en la bases de datos de PubMed/MEDLINE, Cochrane y SciELO; así como en referencias de artículos de revista y textos principalmente de los últimos cinco años. Seguidamente, se tomaron los siete artículos más relevantes según la calificación de la revista en donde fueron publicados. Resultados: la característica clínica del síndrome de Sheehan que se manifiesta con mayor frecuencia es la incapacidad para lactar debido a una producción insuficiente de prolactina. Otras manifestaciones tardías incluyen: secreción inadecuada de la hormona antidiurética y deficiencias en la secreción de cortisol, de hormona tiroidea y de gonadotrofinas. Es importante que el obstetra y el médico general sepan reconocer este síndrome, ya que la pérdida aguda del funcionamiento de la adenohipófisis puede ser de mal pronóstico si no se realiza un reemplazo hormonal adecuado. Además, el buen control hormonal evita o disminuye las complicaciones metabólicas y cardiovasculares. Conclusión: el síndrome de Sheehan es una enfermedad poco frecuente, la cual es difícil de diagnosticar tempranamente. Asimismo, requiere una terapia de reemplazo hormonal con controles permanentes clínicos y paraclínicos.

Introduction: postpartum pituitary necrosis, or Sheehan’s syndrome, occurs following obstetric haemorrhage which causes intense circulatory collapse, thereby predisposing pituitary ischemia leading to this organ becoming enlarged (the posterior pituitary is generally affected). This document presents a clinical case of a patient who consulted due to late manifestations of this syndrome. A literature review is also made. Objective: presenting the case of a patient who consulted for late manifestations of Sheehan’s syndrome and reviewing the pertinent literature. Methodology: information was sought in the PubMed / Medline, Cochrane, SciELO databases and references from articles in journals and texts (mainly from the last five years) were also taken into account. The seven most relevant articles were taken according to the impact of the journal in which they were published. Results: the most frequently found clinical characteristic was an inability to lactate due to insufficient prolactin production. The most common clinical feature found was an inability to breastfeed due to insufficient prolactin production. Other manifestations included inappropriate antidiuretic hormone secretion and cortisol, thyroid hormone and gonadotropin secretion deficiencies. Obstetricians and GPs should be able to recognise this syndrome and know about its management as the acute loss of adenohypophysis functioning may have a poor prognosis without timely and suitable hormone replacement. Good hormone control prevents or decreases metabolic and cardiovascular complications. Conclusion: this is a rare syndrome in which early diagnosis is difficult and requires hormone replacement therapy with ongoing clinical and laboratory controls.

Envenenamiento por múltiples picaduras de abejas y choque anafiláctico secundario: descripción de un caso clínico y revisión de la literatura / Multiple bees stings poisoning and secondary anaphylactic shock: a case report and literature review

Menos del 5% de las 20.000 especies estimadas de abejas son sociales y, por lo tanto, pueden producirse ataques masivos o generarse situaciones de riesgo al enjambrar o construir panalescerca o en el interior de domicilios. El veneno de abejas está constituido por una mezcla de substancias con proteínas, siendo las principales enzimas, péptidos y aminas biogénicas. Estas proteínas poseen acciones farmacológicas y alergénicas capaces de provocar cuadros de envenenamiento en el humano y en animales. Se describe el caso clínico de un agricultor que sufrió picaduras por más de 500 abejas con desenlace fatal. Además, se realiza una breve revisión de la literatura sobre el tema.

Less than 5% of the estimated 20,000 species of bees are social, and therefore massive attacks might occur or situations of risk could be generated when swarming to build hives near or inside homes. Bee venom consists of a mixture of substances, mainly protein enzymes, peptides and biogenic amines, these proteins have pharmacological actions and allergens can induce boxes poisoning in humans and animals. We describe the case of a farmer who suffered more than 500 stings by bees with a fatal outcome. In addition, a brief review of the literature is presented.

Intoxicación por Paraquat: descripción de un caso clínico / Paraquat poisoning: a case report

El paraquat es el herbicida más vendido en todo el mundo. Se absorbe por las vías digestiva e inhalatoria. Si llega a los pulmones, produce congestión, edema alveolar con aumento de macrófagos que progresa a fibrosis y edema pulmonar, los cuales se presentan hasta 14 días después de la exposición si el afectado no recibió tratamiento oportuno y correcto. El paraquat se dirige fundamentalmente a los pulmones y genera allí radicales libres oxidantes; por eso, en los casos de intoxicación aguda está totalmente contraindicado usar oxígeno excepto cuando la presión parcial de oxigeno en sangre arterial sea inferior a 50 mmHg. Se presenta un caso clínico de un paciente quien desarrolló un síndrome de distress respiratorio del adulto (SDRA) secundario a ingesta intencional de paraquat. El manejo inicial se realizó con lavado gástrico y tierra de Fuller en solución acuosa al 30%. Posteriormente, el paciente desarrolló compromiso pulmonar y renal, los cuales fueron manejados con pulso de ciclofosfamida a 15 mg/kg/día por 2 días, metilprednisolona 1g/día por 3 días y posteriormente dexametasona 5 mg IV cada 6 horas por 5 días con una evolución clínica satisfactoria.

Paraquat is the best-selling herbicide throughout the world. It is absorbed by the digestive and inhalatory routes. If it reaches the lungs, congestion with swelling is developed, increased alveolar macrophages that progresses to fibrosis and pulmonary edema, which occur until 14 days after exposure if not treated timely and correct. Paraquat is directed primarily to the lungs and therefore generates free radicals oxidants, which is why, in cases of acute poisoning is absolutely forbidden to use oxygen except where arterial blood partial pressure of oxygen in is less than 50 mm Hg. A patient who developed an adult respiratory distress syndrome (ARDS) secondary to deliberate ingestion of paraquat is presented. Initial patient management was performed with gastric lavage and land Fuller in aqueous solution at 30%. Subsequently developing pulmonary and renal failure were handled with cyclophosphamide pulse of 15 mg/kg/day for 2 days, methylprednisolone 1g/día for 3 days, then dexamethasone 5 mg IV every 6 hours for 5 days, with favourable outcome.

Necrólisis epidérmica tóxica por olanzapina: reporte de un caso clínico / Toxic Epidermic Necrolysis Secondary to the Use of Olanzapine: Case Report

Introducción: En 1956, Alan Lyell llamó necrólisis epidérmica tóxica (NTE) a los cuadros caracterizados histológicamente por necrosis de la epidermis y clínicamente por una epidermólisis difusa, con exfoliación o formación de lesiones bulosas, además de manifestaciones no cutáneas, lo que provoca trastornos hidroelectrolíticos, de termorregulación e hipercatabolismo. Objetivo: Describir un caso clínico con una reacción mayor y poco frecuente, secundaria al uso de olanzapina. Métodos: Se buscó información en la bases de datos de PubMed/Medline, Cochrane, SciELO, al igual que en referencias en artículos de revista y textos de los últimos cinco años. Se revisaron 16 artículos y se seleccionaron 10 de ellos para la discusión. Resultados: Las reacciones secundarias en la piel debido al uso Olanzapina se presentan en menos del 0,5% de los pacientes que la consumen; sin embargo, estas reacciones van desde exantema generalizado hasta NET, con un riesgo elevado de muerte. Conclusión: La piel es el órgano más frecuentemente afectado por las reacciones adversas a los medicamentos; pero sólo un pequeño porcentaje de las reacciones cutáneas supone un riesgo vital o conduce a secuelas importantes. La baja frecuencia de estas reacciones hace poco probable que se detecten en los ensayos clínicos previos a la comercialización de los medicamentos. El consumo de diferentes fármacos ha sido descrito como responsable de la aparición de reacciones cutáneas graves...

Introduction: In 1956, Alan Lyell used the term toxic epidermal necrolysis (TEN) to describe a histological and clinical pattern characterized by necrosis of the epidermis, diffuse epidermolysis with exfoliation and/or training bulosas injuries, as well as non-cutaneous manifestations such as hydro electrolytic, thermoregulatory and catabolic impairment. Objective: To describe a clinical case with a larger and unusual reaction, secondary to the use of olanzapine. Methods: Search for information in the databases: PubMed/Medline, Cochrane, SciELO, as well as in references from journals articles and textbooks, mainly in the last fi ve years. 16 articles were reviewed, 10 of which were included in the discussion. Results: The secondary reactions in the skin due to the use Olanzapine are present in <0,5% of patients who consumed it; however these reactions vary from a rash to TEN with a high risk of death. Conclusion: The skin is the organ most frequently affected by adverse reactions to medicines. However, only a small percentage of skin reactions are serious and life threatening. The low incidence of these reactions are unlikely to be detected in clinical trials prior to the marketing of medicines. The use of various drugs has been described as responsible for the occurrence of serious skin reactions...