Management of cirrhotic ascites in children. Review and recommendations. Part 1: Pathophysiology, diagnostic evaluation, hospitalization criteria, treatment, nutritional management. / Manejo de la ascitis secundaria a cirrosis en el paciente pediátrico. Revisión y recomendaciones. Parte 1: Fisiopatología, evaluación diagnóstica, criterios de hospitalización, tratamiento, manejo nutricional.

Ascites is a major complication of cirrhosis. There are several evidence-based articles and guidelines for the management of adults, but few data have been published in relation to children. In the case of pediatric patients with cirrhotic ascites (PPCA), the following questions are raised: How are the clinical assessment and ancillary tests performed? When is ascites considered refractory? How is it treated? Should fresh plasma and platelets be infused before abdominal paracentesis to prevent bleeding? What are the hospitalization criteria? What are the indicated treatments? What complications can patients develop? When and how should hyponatremia be treated? What are the diagnostic criteria for spontaneous bacterial peritonitis? How is it treated? What is hepatorenal syndrome? How is it treated? When should albumin be infused? When should fluid intake be restricted? The recommendations made here are based on pathophysiology and suggest the preferred approach to its diagnostic and therapeutic aspects, and preventive care.

La ascitis es una complicación grave de la cirrosis. Existen numerosos artículos y guías basadas en la evidencia para adultos, pero poco se ha publicado para niños. Ante un paciente pediátrico con ascitis secundaria a cirrosis (PPAC), se plantean las siguientes preguntas: ¿Cómo se realiza la evaluación clínica y los exámenes complementarios? ¿Cuándo se considera que la ascitis es refractaria; cómo se trata? ¿Debe infundirse plasma fresco y plaquetas antes de la paracentesis abdominal para evitar el sangrado? ¿Cuáles son los criterios de hospitalización? ¿Cuáles son los tratamientos indicados? ¿Qué complicaciones puede presentar? ¿Cuándo y cómo debe tratarse la hiponatremia? ¿Qué criterios diagnósticos tiene la peritonitis bacteriana espontánea; cómo se trata? ¿Qué es el síndrome hepatorrenal; cómo se trata? ¿Cuándo debe infundirse albúmina? ¿Cuándo debe restringirse el aporte líquido? Las recomendaciones que efectuamos, basadas en la fisiopatología, sugieren el enfoque preferido para encarar sus aspectos diagnósticos, terapéuticos y los cuidados preventivos.

Structural evidence for ammonia tunneling across the (beta alpha)(8) barrel of the imidazole glycerol phosphate synthase bienzyme complex.

Since reactive ammonia is not available under physiological conditions, glutamine is used as a source for the incorporation of nitrogen in a number of metabolic pathway intermediates. The heterodimeric ImGP synthase that links histidine and purine biosynthesis belongs to the family of glutamine amidotransferases in which the glutaminase activity is coupled with a subsequent synthase activity specific for each member of the enzyme family. Its X-ray structure from the hyperthermophile Thermotoga maritima shows that the glutaminase subunit is associated with the N-terminal face of the (beta alpha)(8) barrel cyclase subunit. The complex reveals a putative tunnel for the transfer of ammonia over a distance of 25 A. Although ammonia tunneling has been reported for glutamine amidotransferases, the ImGP synthase has evolved a novel mechanism, which extends the known functional properties of the versatile (beta alpha)(8) barrel fold.

[Providing information to patient's families on the end of life process in the intensive care unit. Nursing evaluation]. / Información a familiares de pacientes en proceso final de vida en unidades de cuidados intensivos. Evaluación por parte de las enfermeras.

INTRODUCTION: Informing is a process that includes many aspects and when it involves a family member at the end of life it becomes a complicated matter, not only for giving the information, but also for the mood of family members. Thus, the information should be adapted to the language and education of the patient and family. That information must be proper and suitable to the moment. OBJECTIVE: To describe the aspects of information offered to relatives of patients in the end of life process in Intensive Care Units (ICU), and to determine the nursing evaluation in this process. To evaluate the professionals' attitude on this subject. MATERIAL AND METHOD: An observational study conducted on nurses in pediatric and adult ICU nurses of a large public health hospital complexes in the city of Madrid. The data was collected using a questionnaire on the evaluation of care of children who died in pediatric ICU. RESULTS: The majority of the nurses, 71% (159), said that the information was given in a place alone with the doctor. More than half (52.4%, 118) considered that the information was sufficient/insufficient depending on the day. Significant differences were found as regards the behavior of the staff at the time of a death in (P<.01), with pediatric ICU professionals being more empathetic. CONCLUSIONS: ICU nurses believe that the information is appropriate for the prognosis and adapted to the patient situation. They also consider the place where the information is given and the attitude of the professionals in the end of life process are adequate.

Bone remodelling is reduced by recovery from iron-deficiency anaemia in premenopausal women.

Iron-deficiency anaemia (IDA), one of the most common and widespread health disorders worldwide, affects fundamental metabolic functions and has been associated with deleterious effects on bone. Our aim was to know whether there are differences in bone remodelling between a group of premenopausal IDA women and a healthy group, and whether recovery of iron status has an effect on bone turnover markers. Thirty-five IDA women and 38 healthy women (control group) were recruited throughout the year. IDA women received pharmacological iron treatment. Iron biomarkers, aminoterminal telopeptide of collagen I (NTx), procollagen type 1 N-terminal propeptide (P1NP), 25-hydroxyvitamin D, and parathormone (PTH) were determined at baseline for both groups and after treatment with pharmacological iron for the IDA group. IDA subjects were classified as recovered (R) or non-recovered (nR) from IDA after treatment. NTx levels were significantly higher (p <0.001), and P1NP levels tended to be lower in IDA women than controls after adjusting for age and body mass index (BMI), with no differences in 25-hydroxyvitamin D or PTH. After treatment, the R group had significantly lower NTx and P1NP levels compared to baseline (p <0.05 and p <0.001 respectively), whilst no significant changes were seen in the nR group. No changes were seen in 25-hydroxyvitamin D or PTH for either group. IDA is related to higher bone resorption independent of age and BMI. Recovery from IDA has a concomitant beneficial effect on bone remodelling in premenopausal women, decreasing both bone resorption and formation.

Infecciones nosocomiales en pacientes críticos: incidencia en el período 1988 - 1989 en el CTI del Hospital de Clínicas / Nosocomial infections in critically ill patients: incidence during the period 1988-1989 at the ICU of Hospital de Clinicas

Durante un período de nueve meses (1988-1989) realizamos en forma diaria y prospectiva, una encuesta de incidencia de infecciones nosocomiales (INOS) en todos los ingresos correlativos al Centro de Tratamiento Intensivo (CTI) del Hospital de Clínicas de Montevideo (HC). Seguimos en lo fundamental las pautas del CDC de Atlanta, USA. Encontramos que 68,6 por ciento de 205 ingresos eran portadores de una o más infecciones (nosocomial, comunitaria o ambas). Veintiocho pacientes (13,6 por ciento) ingresaron por infecciones de la comunidad, en tanto que 121 adquirieron 251 INOS. Es destacable que 95 enfermos iniciaron INOS antes de su ingreso al CTI, mientras que 69 de 205 encuestados (33,6 por ciento) desarrollaron INOS durante su estadía en el CTI. Las INOS más frecuentes fueron las bronquitis purulentas. Las neumonías constituyeron 22 por ciento de todas las INOS y 26 por ciento de las iniciadas en CTI. El riesgo mayor para adquirir neumonía nosocomial durante la ventilación mecánica (NNV) ocurrió entre los días 3 y 11 a partir del momento de la intubación. Los pacientes asistidos más de cinco días tuvieron 12 veces más INOS que sus opuestos. Los gérmenes más frecuentes en INOS de CTI fueron Pseudomas aeruginosa (28 por ciento), Enterobacter (21 por ciento) y Staphilococcus aureus MS (18 por ciento). Acinetobacter y SAMAR estuvieron presentes en muy pocas infecciones, mientras Enterococo y Cándida no ocasionaron ningún problema importante. En 38 por ciento de los 84 fallecidos una o más INOS fue causa única o asociada de fallecimiento