Epidemiology of delirium in hospitalized patients in Latin America: A systematic review.

BACKGROUND: Accurate epidemiological data are essential for the planning of policies aimed at the identification, prevention, and management of delirium. The reported occurrence of delirium in hospitalized patients varies widely among studies, ranging between 5% to more than 80% in the international literature. The exact occurrence in Latin America is not well described. OBJECTIVE: The aim of this study is to conduct a systematic analysis of the published data on the epidemiology of delirium in hospitalized patients in Latin America. METHODS: We conducted a systematic review following PRISMA guidelines. Both MEDLINE and LILACS databases were searched for original research articles reporting the occurrence of delirium among adult hospitalized patients in Latin American countries. Studies including pediatric populations were excluded from this analysis. Two authors independently applied eligibility criteria, assessed quality, and extracted data. The corresponding authors of the original articles were contacted to obtain relevant information about the study when this was not present in the published manuscripts. RESULTS: Seven hundred and eighteen original articles were identified. After screening titles and abstracts, 149 studies were included in the final analysis. The occurrence of delirium varied depending on the clinical scenario: (1) in the general medico-surgical wards, it ranged from 2.1% to 60.4%, (2) in the Intensive Care Units (ICUs), from 9.6% to 94.8%, (3) in the post-operatory population, from 5.45% and 52.3%, and (4) it was found to be between 10.7% and 62% in the emergency department setting. The most used delirium assessment tools were the "Confusion Assessment Method" (CAM; in the general population), and the "Confusion Assessment Method for the ICU" (CAM-ICU). Fourteen out of 149 studies were conducted in clinical settings who actively implemented some form of non-pharmacological delirium prevention bundles, most of them as part of ICU sedation-analgesia protocols. CONCLUSION: Delirium occurs frequently in hospitalized patients in Latin America throughout a variety of clinical scenarios, including ICU, general wards, post-operatory populations, and among the emergency department setting. The CAM and the CAM-ICU are the most used delirium assessment tools. Bundles of non-pharmacological interventions to prevent delirium are not universally implemented.

[X-linked adrenoleukodystrophy: A case of acute childhood cerebral presentation]. / Adrenoleucodistrofia ligada a X: Un caso de presentación aguda cerebral infantil.

INTRODUCTION: X-linked adrenoleukodystrophy (X-ALD) is a peroxisomal disease due to a mutation in the ABCD1 gene that leads to the accumulation of very-long-chain fatty acids in tissues. OBJECTIVE: To describe one patient with severe childhood cerebral X-ALD and to analyze his diagnostic process and the rapeutic possibilities. CLINICAL CASE: 7-year-old male child, with a six-month history of decreased visual acuity, learning difficulties due to lack of attention, reading and writing impairment, and social isolation. On physical examination, he presented bilateral decrease in visual acuity, hypoprosexia, hyperpigmented lesions on the hands, and gait abnormality. Brain MRI showed bilateral white mat ter signal alteration in parieto-occipital regions, with 12 points on the Loes' scale. He also presented adrenal insufficiency, meeting clinical criteria for X-ALD. Very-long-chain fatty acid was elevated, confirming the diagnosis. Three months later, the patient progressed to vision loss and inability to walk. MRI was repeated showing 15 points in the Loes' scale due to extensive structural involvement of the central nervous system, with rapidly progressive deterioration. Therefore, he was not consi dered a candidate for bone marrow transplantation. CONCLUSION: This case of X-ALD was of severe childhood cerebral presentation, with rapid progression. The clinical evaluation and classification of radiological findings according to the Loes' scale should guide the choice of management.

Encefalomielitis aguda diseminada: simulando enfermedad cerebrovascular en un adolescente / Acute disseminated encephalomyelitis: simulating cerebrovascular disease in an adolescent

RESUMEN La encefalomielitis aguda diseminada (ADEM) es una enfermedad desmielinizante del sistema nervioso central (SNQ, de baja prevalencia, con predominio de presentación en población pediátrica. Describir y revisar la presentación clínica de un paciente con ADEM, su proceso diagnóstico y el manejo terapéutico, de acuerdo con la evidencia disponible. Adolescente masculino de 17 años, sin antecedentes de importancia, con cuadro de cefalea hemicraneal derecha, tipo punzada, de alta intensidad, dos semanas de evolución y posterior compromiso agudo neurológico multifocal con encefalopatía, hemiparesia y diplopía. Se realiza estudio con resonancia de cerebro contrastada que pone en evidencia lesiones hiperintensas a nivel de tallo, cerebelo y ganglios basales. Estas lesiones son asimétricas, unilaterales y agudas y siguen el trayecto vascular de la arteria cerebelosa posteroinferior (PICA), sin restricción a la difusión o cambios en mapa ADC. Inicialmente se sospecha evento cerebrovascular (ECV) y se estudia con angiorresonancia normal, ayudas diagnósticas para causas cardioembólicas y trombofilias negativas. Al considerar lesiones no se sugieren cambios de origen isquémico, pero si desmielinizantes. Se inicia manejo con pulsos de metilprednisolona con resolución de hemiparesia y encefalopatía. En seguimiento a 18 meses, el paciente no ha presentado nuevos eventos clínicos o radiológicos. La ADEM es una patología infrecuente en la edad pediátrica, con un diagnóstico basado en la clínica y hallazgos imagenológicos en resonancia magnética. Su presentación clínica puede ser inespecífica y como en este caso simular enfermedad cerebrovascular, y el tratamiento se basa en inmunomoduladores, principalmente corticoides, con una tasa de recuperación favorable en las series previamente reportadas.

SUMMARY Acute disseminated encephalomyelitis (ADEM) is a low-prevalence demyelinating disease of the central nervous system (CNS) with a predominance of presentation in the pediatric population. To describe and review the clinical presentation of a patient with ADEM, its diagnostic process and therapeutic management according to the available evidence. A 17-year-old male adolescent, with a 2-week history of high-intensity right-sided headache, stitching type, subsequent acute multifocal neurological compromise with encephalopathy, hemiparesis, and diplopia. A contrast-enhanced brain resonance study with evidence of hyperintense lesions at the level of the stem, cerebellum, and basal ganglia, asymmetric, unilateral, acute, following the vascular path of the posteroinferior cerebellar artery (PICA), but without restriction to diffusion or changes on the ADC map, so that an initial suspicion of cerebrovascular event (CVD) is made, studying with normal angioresonance, diagnostic aids for negative cardioembolic causes and thrombophilias. Considering that lesions do not suggest changes of ischemic origin, but if they are demyelinating, management with methylprednisolone pulses with resolution of hemiparesis and encephalopathy is initiated. In the 18-month follow-up, the patient has not presented new clinical or radiological events. ADEM, is an infrequent pathology in pediatric age, with a diagnosis based on the clinic and magnetic resonance imaging findings, its clinical presentation may be nonspecific and as in this case simulate cerebrovascular disease, the treatment is based on immunomodulatory treatment, mainly corticosteroids, with a favorable recovery rate in the previously reported series.

Probióticos en diarrea aguda, asociada a antibióticos y nosocomial: evidencia en pediatría / Probiotics in Acute, Antibiotic-associated and Nosocomial Diarrhea: Evidence in Pediatrics

Resumen Introducción: los probióticos son microorganismos vivos que, administrados en cantidades adecuadas, proveen una acción benéfica en el ser humano. Existen numerosos estudios acerca de su uso en enfermedad diarreica en pediatría, por lo que se hace necesario evaluar la evidencia. Métodos: se realizó una revisión de la literatura incluyendo solo metaanálisis y revisiones sistemáticas en los últimos 10 años acerca del uso de probióticos en diarrea aguda, diarrea asociada a antibióticos y Clostridium difficile, y diarrea nosocomial. Resultados: en diarrea aguda, los metaanálisis muestran disminución de la duración en un día (intervalo de confianza [IC] 95%; 15,9 a 33,6 horas) y disminución del riesgo de prolongación en los siguientes 4 y 7 días, con recomendaciones fuertes y evidencia moderada para Lactobacillus rhamnosus GG y Saccharomyces boulardii. En diarrea asociada a antibióticos y a C. difficile, los metaanálisis mostraron reducción del riesgo entre el 50% y 60%, con recomendación fuerte para L. rhamnosus GG y S. boulardii con un número necesario a tratar (NNT) de 10 (IC 95%; 7-12). En diarrea nosocomial, se encontró evidencia moderada con el uso de L. rhamnosus GG, principalmente en reducción del riesgo de gastroenteritis sintomática por rotavirus. Sin evidencia suficiente para dar recomendación para las cepas Streptococcus thermophilus y Bifidobacterium bifidum. Conclusión: solo existe evidencia con los probióticos L. rhamnosus GG y S. boulardii en reducción de la duración y disminución del riesgo de prolongación de diarrea aguda, así como reducción del riesgo entre 50% y 60% de diarrea asociada a antibióticos. Existe evidencia moderada con L. rhamnosus GG, en la reducción de riesgo de diarrea nosocomial.

Abstract Introduction: Probiotics are live microorganisms which, when administered in adequate amounts, provide beneficial action in humans. There are numerous studies about their use to treat diarrhea in pediatrics, so it is necessary to evaluate the evidence. Methods: We reviewed metaanalyses and systematic reviews in the last ten years about the use of probiotics to treat acute diarrhea, diarrhea associated with antibiotics and Clostridium difficile and nosocomial diarrhea. Results: Metaanalyses show that treatment of acute diarrhea with probiotics decreases duration by one day (95% CI: 15.9 to 33.6 hours) and reduces a risk of prolongation in the following four to seven days. They provide strong recommendations with moderate evidence for Lactobacillus rhamnosus GG and Saccharomyces boulardii. For diarrhea associated with antibiotics and Clostridium difficile, meta-analyses show risk reduction of between 50% and 60%, with strong recommendations for Lactobacillus rhamnosus GG and Saccharomyces boulardii with an NNT of 10 (95% CI: 7 to 12). For nosocomial diarrhea, moderate evidence was found for the use of Lactobacillus rhamnosus GG, mainly in reducing the risk of symptomatic gastroenteritis due to rotavirus. Currently, sufficient evidence does not exist to give recommendation for strains S. thermophiles and B. bifidum. Conclusion: For reducing the duration and reducing the risk of prolongation of acute diarrhea, evidence exists only for Lactobacillus rhamnosus GG and Saccharomyces boulardii. In addition, they reduce the risk of diarrhea associated with antibiotics by 50% to 60%. There is moderate evidence that Lactobacillus rhamnosus GG reduces the risk of nosocomial diarrhea.

Prevalencia de prescripción inapropiada de terapia supresora de ácido en adultos hospitalizados en un hospital general de Bogotá / Prevalence of Inappropriate Prescription of Acid Suppression Therapy among Adults Hospitalized at a General Hospital in Bogotá

Resumen Objetivo: determinar la prevalencia de prescripción de terapia supresora de ácido (TSA) conformada por los inhibidores de la bomba de protones (IBP) y los antagonistas de los receptores H2 (AR-H2) en pacientes adultos hospitalizados en el Hospital Universitario Fundación Santa Fe de Bogotá (HU-FSFB) que no corresponda con las indicaciones de las guías de práctica clínica (GPC). Métodos: estudio observacional descriptivo de corte transversal que incluyó pacientes adultos hospitalizados en el HU-FSFB con prescripción de TSA de novo, determinando las indicaciones de la TSA y comparándolas con las indicaciones validadas. Se excluyeron los pacientes con prescripción o consumo previo de TSA durante 2 semanas y pacientes internados en la unidad de cuidados intensivos (UCI) o con hospitalización menor de un día. Resultados: entre enero y julio de 2015 se incluyeron 306 pacientes con un promedio de edad de 56,6 (+38) años, con una prevalencia de prescripción de TSA sin indicación basada en la evidencia del 59,5%. Las indicaciones no basadas en la evidencia más comunes fueron profilaxis de sangrado por úlcera gastrointestinal en pacientes de bajo riesgo (64,9%) y causa no establecida (13,7%). Se encontró una asociación estadísticamente significativa entre el tiempo de hospitalización menor de 7 días (odds ratio [OR]: 2,39; intervalo de confianza [IC] 95%: 1,4-3,9) y edad menor de 60 años (OR: 1,9; IC 95%: 1,2-3,03) con prescripción inapropiada de TSA. Conclusión: existe una alta prevalencia (59,5%) de prescripción inapropiada de TSA en pacientes adultos hospitalizados con asociación positiva en menores de 60 años y corta hospitalización en el HU-FSFB.

Abstract Objective: This study's objective was to determine the prevalence of prescriptions of acid suppression therapy consisting of proton pump inhibitors (PPIs) or H2 receptor antagonists (H2RA) in adult patients hospitalized in the Hospital Universitario - Fundación Santa Fe de Bogotá (HU-FSFB - Santa Fe de Bogotá Foundation University Hospital) that are not in accordance with clinical practice guidelines (CPG). Methods: This is a cross-sectional descriptive observational study that included adult patients hospitalized in the HU-FSFB who were treated with acid suppressors for the first time. We determined the indications for prescriptions used and compared them with validated indications. We excluded patients who had previously taken acid suppressants for two weeks, patients admitted to the intensive care unit, and patients who stayed in the hospital for less than one day. Results: Between January and July 2015, 306 patients with an average age of 56.6 years were included in this study. The prevalence of acid suppression prescriptions without indications based on the evidence was 59.5%. The most common indications were prophylaxis of bleeding due to gastrointestinal ulcers in low risk patients (64.9%) and cause not established (13.7%). Statistically significant associations were found between inappropriate prescription of acid suppression and hospitalization times of less than seven days (OR: 2.39 95% CI 1.4-3.9) and ages of less than 60 years (OR: 1.9 95% CI 1.2-3.03). Conclusion: The prevalence of inappropriate prescriptions of acid suppression for adult patients hospitalized in the HU-FSFB was (59.5%). There were positive associations with ages under 60 years and short hospital stays.

The dynamics of nestedness predicts the evolution of industrial ecosystems.

In economic systems, the mix of products that countries make or export has been shown to be a strong leading indicator of economic growth. Hence, methods to characterize and predict the structure of the network connecting countries to the products that they export are relevant for understanding the dynamics of economic development. Here we study the presence and absence of industries in international and domestic economies and show that these networks are significantly nested. This means that the less filled rows and columns of these networks' adjacency matrices tend to be subsets of the fuller rows and columns. Moreover, we show that their nestedness remains constant over time and that it is sustained by both, a bias for industries that deviate from the networks' nestedness to disappear, and a bias for the industries that are missing according to nestedness to appear. This makes the appearance and disappearance of individual industries in each location predictable. We interpret the high level of nestedness observed in these networks in the context of the neutral model of development introduced by Hidalgo and Hausmann (2009). We show that the model can reproduce the high level of nestedness observed in these networks only when we assume a high level of heterogeneity in the distribution of capabilities available in countries and required by products. In the context of the neutral model, this implies that the high level of nestedness observed in these economic networks emerges as a combination of both, the complementarity of inputs and heterogeneity in the number of capabilities available in countries and required by products. The stability of nestedness in industrial ecosystems, and the predictability implied by it, demonstrates the importance of the study of network properties in the evolution of economic networks.