[Analysis of organ failure and mortality in sepsis due to secondary peritonitis]. / Análisis de la insuficiencia de órganos y mortalidad en la sepsis por peritonitis secundaria.

OBJECTIVES: To identify the organs most susceptible to develop multiorgan dysfunction syndrome (MODS) in patients with sepsis due to secondary peritonitis, and to determine the outcome and mortality predicting utility of the SOFA (Sequential Organ Failure Assessment) system. DESIGN: A prospective, observational cohort study was made. SETTING: The resuscitation unit of a third-level university hospital. PATIENTS: A prospective, observational cohort study was made of 102 patients with sepsis of abdominal origin and failure of at least one organ related to the infection. The demographic characteristics were documented, along with the abdominal origin of sepsis, mortality after 28 days, and the daily SOFA score. RESULTS: The mortality rate after 28 days was 55%. A total of 53% of the patients presented failure of two or more organs on the first day of admission. The mean daily SOFA score was significantly higher among the patients that died after day 4 of admission. The variables showing a statistically significant correlation to increased mortality were: MODS (P=.000), central nervous system failure (P=.000) and SOFA score on day 4 of admission (P=.012). The area under the ROC curve showed the mortality predicting capacity of the SOFA score on day 4 of admission to be 0.703 (95%CI 0.538-0.853; P=.026). The maximum discriminating capacity was recorded for MODS, with an area under the ROC curve of 0.776 (95%CI 0.678-0.874; P=.000). CONCLUSIONS: Organ failure outcome as predicted by the SOFA score showed high precision - the mean SOFA score on day 4 of admission being a good mortality predictor. MODS was the main cause of death, while central nervous system, renal and respiratory failure were identified as the mortality risk factors.

[Anesthesia in the patient with impaired liver function]. / Anestesia en el paciente con alteración de la función hepática.

We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures.

Reply to the comment on 'Monte Carlo calculated microdosimetric spread for cell nucleus-sized targets exposed to brachytherapy 125I and 192Ir sources and 60Co cell irradiation'.

A discrepancy between the Monte Carlo derived relative standard deviation [Formula: see text] (microdosimetric spread) and experimental data was reported by Villegas et al (2013 Phys. Med. Biol. 58 6149-62) suggesting wall effects as a plausible explanation. The comment by Lindborg et al (2015 Phys. Med. Biol. 60 8621-4) concludes that this is not a likely explanation. A thorough investigation of the Monte Carlo (MC) transport code used for track simulation revealed a critical bug. The corrected MC version yielded [Formula: see text] values that are now within experimental uncertainty. Other microdosimetric findings are hereby communicated.

Microdosimetric spread for cell-sized targets exposed to 6°Co, ¹9²Ir and ¹²5I sources.

The magnitude of the spread in specific energy deposition per cell may be a confounding factor in dose-response analysis motivating derivation of explicit data for the most common brachytherapy isotopes (125)I and (192)Ir, and for (60)Co radiation frequently used as reference in RBE studies. The aim of this study is to analyse the microdosimetric spread as given by the frequency distribution of specific energy for a range of doses imparted by (125)I, (192)Ir and (60)Co sources. An upgraded version of the Monte Carlo code PENELOPE was used for scoring energy deposition distributions in liquid water for each of the radiation qualities. Frequency distributions of specific energy were calculated according to the formalism of Kellerer and Chmelevsky. Results indicate that the magnitude of the microdosimetric spread increases with decreasing target size and decreasing energy of the radiation quality. Within the clinical relevant dose range (1 to 100 Gy), the spread does not exceed 4 % for (60)Co, 5 % for (192)Ir and 6 % for (125)I. The frequency distributions can be accurately approximated with symmetrical normal distributions at doses down to 0.2 Gy for (60)Co, 0.1 Gy for (192)Ir and 0.08 Gy for (125)I.

Formation of fatty acid ethyl esters during chronic ethanol treatment in mice.

Ethyl esters of long-chain fatty acids are formed in the liver and brain of mice after 1-6 days of ethanol intoxication. This observation extends the reports of Lange and co-workers who detected these compounds as unusual metabolites of ethanol in human tissues [E. A. Laposata and L. G. Lange, Science 231, 497 (1986)]. Ethyl esters of oleic and linoleic acids, and, in smaller amounts, ethyl esters of palmitic and stearic acids were found in the livers of mice that had been treated with ethanol by inhalation. In the brain, only the esters of unsaturated fatty acids were found, in lower amounts than in liver. All the fatty acid ethyl esters seemed to have reached steady-state levels in the tissues after 3 or 4 days of alcohol treatment. When incorporated into synaptosomal plasma membranes in vitro, in intramembrane concentrations estimated to resemble those observed in the mice, these esters reduced the fluorescence anisotropy, i.e. they disordered the membranes.

Use of alternative therapies by patients with rheumatic disease in Guadalajara, Mexico: prevalence, beliefs, and expectations.

OBJECTIVE: To assess the prevalence, practices, beliefs, and expectations of patients with rheumatic diseases in relation to the use of alternative therapies. METHODS: We conducted a cross-sectional survey of 300 consecutive patients with rheumatic diseases at 3 outpatient rheumatic disease clinics in Guadalajara, Mexico to evaluate the use of alternative therapies. A face-to-face structured interview was administered by a trained assistant to evaluate the prevalence of use and patient beliefs, perceptions, and expectations in relation to alternative therapies. RESULTS: Two hundred fifty patients (83%) had used a total of 1,386 alternative therapies (range 1-19); 203 (68%) patients had used alternative therapy in the previous 12 months. Sixty-one percent received at least one alternative treatment before the first rheumatology consultation, but an additional 18% initiated these therapies after their initial contact with a rheumatologist at our clinics. Only 66 (26%) of the patients using alternative therapy notified their rheumatologist about their use. Thirty-six patients (14%) discontinued formal treatment at least on one occasion in order to receive alternative therapies, and only 8 (22%) notified their rheumatologist. Alternative therapy practitioners recommended discontinuation of conventional therapy on 57% of the occasions when formal treatments were discontinued. Mean expenditures per patient for fees to alternative therapy providers were equivalent to 28 days of the official minimum daily wage, and per patient costs for the remedies themselves were equivalent to 13 days of the official minimum daily wage. Patients who used alternative therapy in the past 12 months had lower education (7 versus 10 years, P < 0.001) and were slightly more disabled (1.7 versus 1.5, modified Health Assessment Questionnaire, P < 0.01). CONCLUSIONS: In this survey most patients used alternative therapies for the treatment of their rheumatic disease. Alternative therapies were costly and appeared to decrease adherence to conventional therapy. Health care providers should openly discuss the use of alternative therapy in patients with rheumatic diseases.

The effect of rapid eye movement sleep deprivation on cortical beta-adrenergic receptors.

The relationship between rapid eye movement sleep deprivation (REMD) and rat beta-adrenergic receptors was evaluated. REMD was achieved using the platform method and verified by EEG and EMG recordings. Although the amount of REM sleep was diminished 90%, there was no alteration in either the number of binding sites or their affinity for [3H]-dihydroalprenolol. Periods of stress as well as recovery periods after REMD were also without effect on the cortical beta-adrenergic receptors. Thus no support is garnered for the interaction of REMD and the cortical beta-adrenergic receptor binding parameters, although REMD is sometimes used as a mode of therapy for depression and other antidepressives do in fact affect the beta-adrenergic system. The mechanism of REMD as a potential antidepressive therapy is yet to be elucidated.

Kinetic effects of trimethoprim-sulfamethoxazole in children with biliary atresia: a new dosing regimen.

Pharmacokinetics for combination trimethoprim/ sulfamethoxazole (TMP/SMX) was studied in only four patients with biliary atresia (BA): three girls, 6.2,8.0 and 8.2 years of age and one boy 8.4 years of age, as this is an uncommon obstructive anomaly of the extrahepatic biliary system and has been described as having a poor prognosis. These four patients are the survivors of 27 initial children who were operated on previously. They have been receiving 2.3 +/- 0.5 mg/kg TMP, and 11.5 +/- 2.6 mg/kg SMX every 12 h since 2 weeks after surgical treatment for biliary atresia performed at 2-2.5 months of age. The patients have suffered some episodes of cholangitis during their short lives, most of them after interrupting temporally the chemotherapy. Nevertheless, they have achieved a favorable quality of life. TMP/SMX disposition was well characterized by a one compartment open pharmacokinetic model. Wide interpatient variability was observed for all pharmacokinetic parameters with coefficients of variation for t1/2 el, ClT, and Vd of 33.2, 49.6, and 26.3%, respectively, for SMX and 108.9, 52.1, and 71.0%, respectively, for TMP. A marked difference in the pharmacokinetics of TMP and SMX was observed, for example; (ClT: mean +/- SD; 90.3 +/- 47.0 ml/kg/g for TMP and 13.7 +/- 6.8 ml/kg/h for SMX), (t1/2 el with 7.93 +/- 8.64 h for TMP and 10.51 +/- 3.49 h for SMX). In order to develop dosage schedules that would reliably achieve peak serum concentrations of TMP/SMX in the therapeutic range, we found that established dose leads to high fluctuations at steady state between C(max), ss and C(min), ss, without maintaining therapeutic levels. Recommended maintenance dose varied from 8 to 30 mg/kg for SMX with a mean of 21.9 +/- 10.89 mg/kg/12 h, and from 0.8 to 4.5 mg/kg/12 h with a mean of 3.2 +/- 1.7 mg/kg/12 h. The present study illustrates the need for pharmacokinetic studies for the individualization of drug dosing in patients with BA.

[Fulminant hepatic failure and liver transplantation. Experience of the Hospital Virgen de la Arrixaca]. / Fracaso hepático fulminante y trasplante hepático. Experiencia del Hospital Virgen de la Arrixaca.

INTRODUCTION: Medical treatment for fulminat hepatic failure seeks spontaneous recovery of the liver function, but the results are very discouraging (50-80% mortality). Liver transplantation is an option in patients with a poor evolution despite medical treatment, with survival rates of > 50%. The ideal moment for performing the transplant is controversial, as it should not be done too soon, when the liver disease is still reversible, or tool late, when the patient is in an irreversible clinical situation. PATIENTS AND METHOD: A retrospective review was made of the clinical histories of 34 patients admitted to our hospital with a diagnosis of fulminant hepatic failure, of whom 26 underwent transplantation. The most frequent cause was viral, with 10 cases (38%); no aetiology at all could be established in 11 cases (42%). Thirteen patients had preoperative complications, the most frequent being renal insufficiency. As for degree of ABO/DR compatibility, 13 cases were identical (40%), 17 compatible (51%) and the other 3 incompatible (9%). RESULTS: Thirty-three transplants were performed in 26 patients: 4 were retransplants due to chronic rejection, 2 for primary graft failure and 1 for hyperacute rejection. The overall mortality rate was 46% (12 patients), the most frequent cause of death being infection (50%). The overall actuarial survival rate was 68% at 1 year, 63% at 3 years and 59% at 5 years. The factors of poor prognosis were renal and respiratory insufficiency, a grade D electroencephalogram, and encephalopathy grades III and IV, the latter being the only prognostic factor identified in the multivariate analysis. The prognostic factors for mortality were a grade D electroencephalogram, encephalopathy grades III and IV and respiratory insufficiency, the latter being the only prognostic factor identified in the multivariate analysis. CONCLUSIONS: The achievement of good results with the use of transplantation in the management of fulminant hepatic failure depends on an optimum selection of transplant candidates, which means identifying them early, i.e. early indication for transplant, reduction in mean waiting time and exclusion of factors of poor prognosis.

[Severe cardiac failure in Kearns-Sayre syndrome]. / Insuficiencia cardíaca grave en el síndrome de Kearns-Sayre.

Mitochondrial disorders are a group of diseases that can affect virtually all organ systems. A 19 year old man was seen in 1993 with neurologic abnormalities consisting of impaired function of muscles, diplopia, progressive loss of vision, impaired phonation and swallowing, during the last 10 years. Physical examination disclosed moderate wasting of the four limb muscles, mild motor weakness of neck muscles, symmetrical hyporeflexia, cerebellar dysfunction, severe external ophtalmoplegia and ptosis. Fundii oculi examination showed retinitis pigmentosa. The electromyogram demonstrated myopathic changes with normal nerve conduction velocities. The cerebrospinal fluid was normal, except for a mild increase in lactic acid. Histochemical study of a muscle biopsy specimen demonstrated ragged red fibers and increase of the subsarcolemal oxidative activity of mitochondriae. The diagnosis of Kearns-Sayre disease was confirmed and he was discharged advising physical therapy. On February 1995, he was again admitted, this time with right cardiac failure and worsening of all his previous symptoms and signs. He complained of myalgias and his muscle weakness was more striking on clinical examination. Echocardiography showed biventricular dilatation and left ventricular hypertrophy with preserved systolic function. A new muscle biopsy revealed an heteroplasmic deletion of 5 Kb with 80% of mutant mitochondrial DNA. In brief, we report a patient with the clinical phenotype of Kearns-Sayre syndrome who presented an acute congestive cardiac failure due to cardiomyopathy, an association which has seldom been, reported in the literature.

Observation on a human intentional poisoning case by the organophosphorus insecticide fenthion.

A case of acute poisoning by oral ingestion of fenthion is reported. Plasma cholinesterase activity and fenthion whole blood concentration were thoroughly evaluated during the therapeutic intervention that consisted in administration of atropine, toxogonine and fresh plasma. Correlation studies between clinical signs, cholinesterase activity and fenthion levels revealed that pChE activity was not as helpful as the patient's clinical status in determining when the atropine infusion could be stopped. Moreover pChE was also useless in signaling sudden relapses. It is concluded, based on this case, that supportive care combined with antidotal therapy remains the cornerstone of treatment specially in severe acute poisoning cases.

[Giant scrotal lymphangioma: a 57 kg tumor]. / Linfangioma gigante de escroto: un tumor de 57 kg.

OBJECTIVE: To a giant lymphangioma of the scrotum that took place at the Hospital de Especialidades, Centro Médico Nacional Siglo XXI, lMSS, Mexico City. CASE REPORT: A 45-year-old-man operated on for an abdominal lipoma 2 years previously develops a progressive growth of the scrotum, which reached a weight of 57 kilograms. This mass disturbed adequate erection and urination. Resection of the mass and of the abdominal wall and scrotum was made. Three years later, the patient died without recurrence of the tumor. DISCUSSION: Scrotal lymphangioma is rare. It is a benign tumor that needs a complete resection to avoid re-currence.

Descripción anatómica de los segmentos óseos que componen el cráneo de la especie Pudu puda / Anatomical description of the bone segments that make up the skull of the Pudu puda species

RESUMEN: El Pudú (Pudu puda), uno de los ciervos más pequeños del mundo y autóctono de Chile, es considerado como vulnerable (VU) en todo el territorio nacional, hay escasa información específica de los sistemas orgánicos que lo componen y cada vez es más común encontrarlos en zonas urbanas. Estas problemáticas hacen despertar la necesidad de fortalecer la investigación y el estudio de esta especie. En consecuencia, en el presente estudio se realizó una descripción anatómica del esqueleto craneal de dos ejemplares de Pudu puda, donde se destacaron sus principales características óseas comparándolas con especies domesticas ya estudiadas (ovino y caprino). Así se logró determinar diferencias entre las especies estudiadas y la necesidad de profundizar el análisis a través de mediciones de las piezas óseas.

SUMMARY: The Pudú (Pudu puda), one of the smallest deer in the world and indigenous to Chile, is considered vulnerable (VU) throughout the national territory, there is little specific information on the organic systems that compose it, and it is becoming more common find them in urban areas. These problems awaken the need to strengthen research and study of this species. Consequently, in the present study an anatomical description of the cranial skeleton of two specimens of Pudú puda was made, where their main bony characteristics were highlighted by comparing them with domestic species already studied (sheep and goats). Thus, it was possible to determine differences between the species studied and the need to deepen the analysis through measurements of the bone pieces.