Angiotensin II Use in Treatment of Refractory Shock Due to Benazepril and Amlodipine Toxic Ingestion.

INTRODUCTION: Calcium channel blockers (CCB) are a leading cause of ingestion-associated fatality. Angiotensin-converting enzyme inhibitor (ACEi) overdose as part of co-ingestion is common and associated with refractory shock. Treatment options to manage this profound vasoplegia are limited. We describe the first case of use of newly formulated Angiotensin II for treatment of severe ACEi and CCB poisoning. CASE REPORT: A 57-year-old man presented after suicide attempt by ingesting 20 tablets each of amlodipine 10 mg and benazepril 20 mg. His hypotension was initially managed with 35 mL/kg of crystalloid, norepinephrine, and hyperinsulinemic euglycemic therapy (HIET). His hemodynamics further deteriorated, and he developed lactic acidosis, electrolyte derangements, and renal dysfunction. Further complications of his ingestion included cardiac arrest, subsequent requirement for emergency cricothyrotomy, and renal replacement therapy. Maximal hemodynamic support with HIET therapy insulin drip 4.4 units/kg/hour, norepinephrine 2 mcg/kg/min, epinephrine 1 mcg/kg/min, vasopressin .06 units/hour, and intravenous lipid emulsion was unsuccessful. Ang II was started and titrated to maximal doses with dramatic improvement in hemodynamics. Within hours of starting Ang II, epinephrine was stopped and norepinephrine decreased by 50%. He was downgraded from the intensive care unit without any ongoing end-organ dysfunction. DISCUSSION: Isolated CCB overdoses have high complication rates and well-established treatments. Therefore, management of CCB and ACEi co-ingestion is typically driven by CCB poisoning algorithm. There are multiple reports of CCB and ACEi co-ingestions causing treatment-refractory shock. Therapeutic options are limited by toxicities and availability of salvage therapies. Ang II is a safe and highly effective option to manage these patients.

ACTH-secreting parotid acinic cell carcinoma unusually reported as a paraneoplastic syndrome.

Paraneoplastic syndromes, induced by an immunological cross-reaction or hormone/peptide secretion, are an atypical presentation of tumors. Some tumors, such as small cell lung cancer and bronchial carcinoid, can be adrenocorticotropic hormone (ACTH) secreting tumors. Less commonly, parotid acinic cell carcinoma can be ACTH-secreting tumor leading to Cushing's syndrome. Few literature cases have described ACTH related paraneoplastic syndrome of parotid adenocarcinoma. Because of the rarity of the condition, little is known about the management and prognosis of this phenomenon. In this report, we highlighted the case of a 59-year-old male with a past medical history of parotid adenocarcinoma treated with surgery, chemotherapy, and radiation therapy presented with clinical and biochemical signs of hyperaldosteronism. Abdominal ultra-sound, computed tomography, and magnetic resonance imaging showed hepatic mass. Liver biopsy with immunohistochemistry confirmed the presence of parotid adenocarcinoma secreting ACTH. He is on paclitaxel and carboplatin medication with good clinical response.

Cardiomyocytes disrupt pyrimidine biosynthesis in nonmyocytes to regulate heart repair.

Various populations of cells are recruited to the heart after cardiac injury, but little is known about whether cardiomyocytes directly regulate heart repair. Using a murine model of ischemic cardiac injury, we demonstrate that cardiomyocytes play a pivotal role in heart repair by regulating nucleotide metabolism and fates of nonmyocytes. Cardiac injury induced the expression of the ectonucleotidase ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1), which hydrolyzes extracellular ATP to form AMP. In response to AMP, cardiomyocytes released adenine and specific ribonucleosides that disrupted pyrimidine biosynthesis at the orotidine monophosphate (OMP) synthesis step and induced genotoxic stress and p53-mediated cell death of cycling nonmyocytes. As nonmyocytes are critical for heart repair, we showed that rescue of pyrimidine biosynthesis by administration of uridine or by genetic targeting of the ENPP1/AMP pathway enhanced repair after cardiac injury. We identified ENPP1 inhibitors using small molecule screening and showed that systemic administration of an ENPP1 inhibitor after heart injury rescued pyrimidine biosynthesis in nonmyocyte cells and augmented cardiac repair and postinfarct heart function. These observations demonstrate that the cardiac muscle cell regulates pyrimidine metabolism in nonmuscle cells by releasing adenine and specific nucleosides after heart injury and provide insight into how intercellular regulation of pyrimidine biosynthesis can be targeted and monitored for augmenting tissue repair.

Evolución del grado de control de una cohorte de pacientes anticoagulados de Atención Primaria / Evolution of the degree of control in a cohort of anticoagulated patients in Primary Care

Introducción: Solo el 60 por ciento de los pacientes en tratamiento con antagonistas de la vitamina K (AVK) están controlados. Objetivos: A nalizar una cohorte de pacientes anticoagulados para valorar su grado de control y su evolución a los 2 años, tras una intervención formativa breve. Métodos: Estudio longitudinal, observacional, retrospectivo de 157 anticoagulados con AVK. Se recogieron datos sociodemográficos, comorbilidades, motivo de prescripción del AVK y grado de control basal y tras 2 años de seguimiento. Utilizamos 2 métodos de valoración diferentes: Rosendaal y método directo (porcentaje de INR-Razón Normalizada Internacional- en rango). Asimismo, establecimos correlaciones temporales intramétodo. Resultados: El grado de control pasó del 47,3 por ciento al 53,5 por ciento a los 2 años, según Rosendaal (p= 0,52), y del 39,5 por ciento al 53,5 por ciento según el método directo (p< 0,05). El tiempo en rango terapéutico fue del 63,1 ±19,9 por ciento al inicio y 65 ±19,2 por ciento al final del seguimiento. La correlación entre los 2 controles fue positiva para ambos métodos (Rosendaal: 0,23; método directo: 0,33). El análisis multivariante fue significativo para el sexo masculino y para un objetivo diferente de 2,5-3,5 (odds ratio: 2,22 y 2,73, respectivamente). Conclusiones: El control del INR mejoró a los 2 años de seguimiento tras la actividad formativa. La evolución del grado de control de cada paciente es parcialmente predecible. El peor control se asoció al sexo femenino y al objetivo de INR de 2,5-3,5. El control mejora 2,22 veces en los varones y 2,73 veces en quienes no tienen un INR objetivo de 2,5-3,5(AU)

Introduction: Only 60 percent of patients on treatment with vitamin K antagonists (AVK) are controlled. Objectives: We proposed to analyze a cohort of anticoagulated patients to assess their degree of control and their evolution at 2 years, after a brief training intervention. Methods: Longitudinal, observational, retrospective study of 157 anticoagulated with AVK. Sociodemographic data, comorbidities, reason for VKA prescription and degree of baseline control were collected and after 2 years of follow-up. We use 2 different valuation methods: Rosendaal and direct method (INR percentage -International Normalized Ratio- in range). Likewise, we established intra-method temporal correlations. Results: The degree of control went from 47.3 percent to 53.5 percent at 2 years, according to Rosendaal (p = 0.52), and from 39.5 percent to 53.5 percent according to the direct method (p<0.05). The time in the therapeutic range was 63.1±19.9 percent at the start and 65±19.2 percent at the end of the follow-up. The correlation between the 2 controls was positive for both methods (Rosendaal: 0.23; direct method:0.33). The multivariate analysis was significant for males and for a target other than 2.5-3.5(odds ratio: 2.22 and 2.73, respectively). Conclusions: INR control improved after 2 years of follow-up after training activity. The evolution of the degree of control of each patient is partially predictable. The worst control was associated with female sex and the INR goal of 2.5-3.5. Control improves 2.22 times in males and 2.73 times in those without a target INR of 2.5-3.5(AU)

Candidiasis y Candida albicans / Candidiasis and Candida albicans

La candidiasis es una enfermedad micótica debida a levaduras pertenecientes al género Candida. Dentro del gran conjunto de microorganismos que colonizan al ser humano, Candida albicans es el agente etiológico más comúnmente detectado ya que habita como comensal en las superficies mucosas y la piel. C. albicans participa en procesos de fermentación de azúcares y asimilación de nutrientes, pero, en algunas ocasiones se relaciona con procesos patológicos. En los últimos años los avances tecnológicos y médicos; así como el aumento en la incidencia de infecciones por el virus de la inmunodeficiencia humana, el auge creciente de la terapia inmunomoduladora y el uso de antibióticos de amplio espectro durante largos períodos de tiempo se han convertido en los factores de riesgo más importantes para la creciente incidencia de infecciones por microorganismos del género Candida. Debido a esto, resulta imperativo el conocimiento de esta enfermedad y sus formas clínicas más importantes, así como el abordaje diagnóstico y el tratamiento actual; información que recolectamos en este documento para brindar una visión general sobre esta patología(AU)

Candidiasis is a fungal disease caused by yeasts belonging to the genus Candida. Within the large group of microorganisms that colonize humans, candida albicans is the most commonly detected etiological agent since it inhabits mucosal surfaces and skin as a commensal. C. albicans participates in sugar fermentation processes and assimilation of nutrients but, on some occasions, it is related to pathological processes. In recent years, technological and medical advances; As well as the increase in the incidence of human immunodeficiency virus infections, the growing boom in immunomodulatory therapy and the use of broad-spectrum antibiotics for long periods of time have become the most important risk factors for the increasing incidence of infections by microorganisms of the genus Candida. Due to this, knowledge of this disease and its most important clinical forms, as well as the current diagnostic approach and treatment, is imperative; information that we collect in this document to provide an overview of this condition(AU)

Expansión de la medicina familiar en América Latina: desafíos y líneas de acción / Expansion of family medicine in Latin America: challenges and lines of action / Expansão da medicina familiar na América Latina: desafios e linhas de ação

RESUMEN Este documento tiene por objetivos resumir los desafíos actuales de la medicina familiar en América Latina y proponer posibles líneas de acción para consolidar su desarrollo. En los últimos 40 años, los sistemas de salud de la Región de las Américas han encarado reformas cuyos resultados fueron negativos en términos de equidad, y la atención primaria de la salud, lejos de ser aquella estrategia destinada a reducirla, se restringió a una política focal y selectiva. En este contexto, las propuestas técnicas de expansión de las plazas de formación en medicina familiar y su inserción en las carreras de Medicina, han carecido de coherencia y de una dirección política clara, por lo que su falta de eficacia puede leerse como un síntoma de estas reformas incompletas. Al respecto, la Confederación Iberoamericana de Medicina Familiar realizó recomendaciones sobre el compromiso político de los gobiernos para asegurar la estructura y el financiamiento necesarios, consolidar el modelo de medicina familiar como mecanismo de instrumentación de la atención primaria de la salud, la jerarquización de los programas de formación, las condiciones laborales de los médicos de familia y la certificación profesional, entre otras. Estas recomendaciones técnicas, sin acción política coherente y oportuna, no serán más exitosas que los intentos previos.

ABSTRACT This article summarizes the current challenges of family medicine in Latin America and proposes possible lines of action to consolidate its development. In the last 40 years, the health systems of the Region of the Americas have faced reforms whose results were negative in terms of equity, and primary health care, far from being a strategy designed to reduce it, was restricted to a selective and focal policy. In this context, the technical proposals for expansion of training positions in family medicine and their insertion in medical careers have lacked consistency and a clear political direction, and thus their lack of effectiveness can be considered a symptom of these incomplete reforms. In this regard, the Ibero-American Confederation of Family Medicine made recommendations on the political commitment of governments to ensure the necessary structure and funding, consolidate the model of family medicine as a mechanism for the implementation of primary health care, the hierarchy of programs of training, the working conditions of family doctors and professional certification, among others. These technical recommendations, without a consistent and timely political action, will not be more successful than previous attempts.

RESUMO Este documento tem como objetivo resumir os desafios atuais da medicina familiar na América Latina e propor possíveis linhas de ação para consolidar seu desenvolvimento. Nos últimos 40 anos, os sistemas de saúde da Região das Américas encararam reformas cujos resultados foram negativos em termos de igualdade, e a atenção primária à saúde, longe de sê-la aquela estratégia destinada a reducir-la, restringiu-se a uma política focal e seletiva. Neste contexto, as propostas técnicas de expansão das praças de formação em medicina familiar e sua inserção nas carreiras de Medicina, não dispuseram de coerência e de uma direção política clara, razão pela qual sua falta de eficácia se pode ler como um sintoma destas reformas incompletas. Neste sentido, a Confederação Ibero-americana de Medicina Familiar realizou recomendações sobre o compromisso político dos governos a fim de assegurar a estrutura e o financiamento necessários, consolidar o modelo de medicina familiar como mecanismo de instrumentação da atenção primária à saúde, a hierarquização dos programas de formação, as condições laborais dos médicos de família e a certificação profissional, entre outras. Estas recomendações técnicas, sem ação política coerente e oportuna, não serão mais exitosos que as tentativas prévias.

Clear cell "sugar" tumor of the lung: benign or malignant?

Clear cell "sugar" tumors of the lung are rare pulmonary tumors. This case study illustrates a patient who was found to have a persistent nodule in the left-upper lobe of the lung. Positron emission tomographic scanning showed mild-moderate 18-fluorodeoxyglucose uptake. Based on these findings, a video-assisted resection of the tumor was undertaken. The mass was identified histologically, as a clear cell "sugar" tumor of the lung. This case report discusses the benign versus malignant nature of this rare tumor.

Current state-of-the-art and future perspectives of robotic technology in neurosurgery.

Neurosurgery is one of the most demanding surgical specialties in terms of precision requirements and surgical field limitations. Recent advancements in robotic technology have generated the possibility of incorporating advanced technological tools to the neurosurgical operating room. Although previous studies have addressed the specific details of new robotic systems, there is very little literature on the strengths and drawbacks of past attempts, currently available platforms and prototypes in development. In this review, the authors present a critical historical analysis of the development of robotic technology in neurosurgery as well as a comprehensive summary of the currently available systems that can be expected to be incorporated to the neurosurgical armamentarium in the near future. Finally, the authors present a critical analysis of the main technical challenges in robotic technology development at the present time (such as the design of improved systems for haptic feedback and the necessity of incorporating intraoperative imaging data) as well as the benefits which robotic technology is expected to bring to specific neurosurgical subspecialties in the near future.