Research progress of IDO1-mediated tryptophan metabolism in sepsis / 药学学报

Sepsis is a condition characterized by organ dysfunction resulting from the systemic inflammatory response triggered by an infection. Excessive inflammation and immunosuppression are intertwined, and severe cases may even develop into multiple organ failure. Studies have shown that indoleamine 2,3-dioxygenase 1-mediated tryptophan metabolism is involved in the occurrence and development of sepsis, and elevated plasma kynurenine levels and Kyn/Trp ratios are early indicators of sepsis development. In this paper, we provide a comprehensive summary of the role of IDO1 in the acute inflammatory phase of sepsis, late immunosuppression, and organ damage. This includes its regulation of inflammatory state, immune cell function, blood pressure, and other aspects. Additionally, we analyze preclinical studies on targeted IDO1 drugs. An in-depth understanding and study of IDO may help to understand the pathogenesis and clinical significance of sepsis and multiple organ damage from a new perspective and provide new research ideas for exploring its prevention and treatment methods.

Hipotensión intracraneal espontánea. Una puesta al día

Introducción: La hipotensión intracraneal espontánea es un síndrome causado por la disminución del volumen de líquido cefalorraquídeo consecuencia de su fuga al espacio extradural. Aunque la ICHD-3 proporciona un alto nivel de especificidad diagnóstica, esta enfermedad puede manifestarse de forma atípica. Hasta en un 30% no es posible establecer el punto de escape, pero con el refinamiento de los exámenes de imágenes este porcentaje se ha reducido a un 15%-20%. Actualmente, su manejo no se encuentra estandarizado y las recomendaciones se basan en evidencia de limitada calidad metodológica, además de la variabilidad de protocolos entre distintos centros. Desarrollo En esta revisión actualizamos los procedimientos diagnósticos y terapéuticos. Por un lado, analizamos el rol de la resonancia nuclear magnética de encéfalo y médula espinal completa como primer paso diagnóstico y, por otro lado, señalamos los exámenes destinados a determinar la fuga de líquido cefalorraquídeo. Tal es el caso de la mielo-resonancia, la mielo-tomografía computarizada, tanto estándar, dinámica y por sustracción digital, además de la cisternografía con 111-Indium-DPTA. Sin embargo, determinar cuál de estos exámenes es el óptimo es objeto de debate. Lo mismo ocurre con el tratamiento: reposo; parche sanguíneo epidural a ciegas, parche guiado por fluoroscopia o tomografía computarizada, parche de fibrina; o cirugía. Conclusiones Se requiere de una mayor investigación, especialmente con trabajos multicéntricos controlados, para una mejor comprensión de la fisiopatología, el diagnóstico por imágenes, los enfoques terapéuticos y evaluación objetiva de los resultados clínicos. Solo así se establecerán pautas diagnósticas y de tratamiento validadas.

Introducction: Spontaneous intracranial hypotension is a syndrome caused by decreased CSF volume secondary to its leakage into the extradural space Although ICHD-3 provides a high level of diagnostic specificity, manifestations may be atypical, making diagnosis challenging. The site of leakage may be undetermined in point Up to 30% of cases, although with recent refinement of imaging, this percentage has been reduced to 15-20%. Currently, management is not standardized and recommendations are based on inconclusive evidence, with variability of protocols between centres. Development. In this review, we update diagnostic and therapeutic procedures. We analyse the role of whole brain and spinal cord MRI as a first investigation and review tests aimed at determining cerebrospinal fluid leakage, such as MRI myelography, conventional CT myelography, dynamic CT myelography, and digital subtraction CT myelography, as well as 111-Indium-DPTA cisternography. Determining optimal use of these investigations remains a matter of debate. The same is true for treatment: rest, blind epidural blood patch, fluoroscopy or CT-guided epidural blood patch, fibrin patch and surgery are discussed. Conclusión: Further research, especially multicentre controlled studies, is required to improve understanding of pathophysiology, diagnostic imaging, therapeutic approaches and to objectively assess clinical outcomes. Only then will diagnostic and treatment guidelines be evidence-based.

Platypnea-orthodeoxia syndrome: an intriguing perioperative hypoxemia case report

Abstract Platypnea-orthodeoxia syndrome (POS) is a rare condition of positional hypoxemia and dyspnea. The following is a case of hypoxemia for no obvious reason in the perioperative scenario. A 70-year-old male patient was submitted to a radical prostatectomy. On several occasions after anesthetic induction, peripheral oxygen saturation decreased without any understandable cause. In the postanesthesia care unit, severe hypoxemia occurred in the upright position, oddly correcting with recumbency. An echocardiography showed a right-to-left intracardiac shunt through a patent foramen ovale with no pulmonary hypertension, establishing POS. Achieving this diagnosis required a broad workup with a high degree of suspicion.

Relationship between prehospital clinical status intracranial pressure and outcomes in pediatric patients with severe head trauma

Introduction: The prehospital phase of the management of pediatric severe traumatic brain injury may have a direct influence on the results. Objective: To evaluate the influence of prehospital variables on intracranial pressure and the results in pediatric patients with severe TBI. Method: A descriptive study of 41 pediatric patients who were admitted to the medical emergency department and later admitted to the pediatric intensive care unit due to severe head trauma was carried out between January 2003 and December 2018. Results: children aged 5-17 years predominate, and the highest number of cases were received between 0-3h at the neurotrauma center. Of the 41 cases, 27 arrived with a non-expedited airway and hypoxia was verified upon arrival by pulse oximetry. A correlation was observed between arterial hypotension on admission and elevated intracranial pressure in 9 of 15 children (60%) and in the deceased (40%). Discussion: Clinical conditions, oxygenation, arterial hypotension, and treatment in the prehospital phase may influence the state of intracranial pressure and other intracranial variables in pediatric patients with severe head injury.

Introducción: La fase prehospitalaria del manejo del traumatismo craneoencefálico grave pediátrico puede tener una influencia directa en los resultados. Objetivo: Evaluar la influencia de variables prehospitalarias sobre la presión intracraneal y los resultados en pacientes pediátricos con TCE grave. Metodología: Se realizó un estudio descriptivo de 41 pacientes pediátricos que ingresaron al servicio de urgencias médicas y posteriormente ingresaron a la unidad de cuidados intensivos pediátricos por traumatismo craneoencefálico severo entre enero de 2003 y diciembre de 2018. Resultados: predominan los niños de 5 a 17 años, y el mayor número de casos se recibieron entre las 0-3h en el centro de neurotrauma. De los 41 casos, 27 llegaron con vía aérea no acelerada y se verificó hipoxia al llegar mediante oximetría de pulso. Se observó correlación entre hipotensión arterial al ingreso y presión intracraneal elevada en 9 de 15 niños (60%) y en los fallecidos (40%). Discusión: Las condiciones clínicas, la oxigenación, la hipotensión arterial y el tratamiento en la fase prehospitalaria pueden influir en el estado de la presión intracraneal y otras variables intracraneales en pacientes pediátricos con traumatismo craneoencefálico grave.

Competencia clínica del personal de enfermería para el manejo de la hipotensión arterial intradialítica en el servicio de hemodiálisis del Centro Médico Naval / Clinical competence of nursing staff for the management of intradialytic hypotension in the hemodialysis service of the Naval Medical Center

Introducción: el correcto manejo de la hipotensión arterial durante la hemodiálisis es fundamental en la formación y trabajo del personal de enfermería nefrológica del Centro Médico Naval. El personal debe tener conocimientos suficientes sobre la hipotensión y sus factores asociados que le ayuden a predecirla y actuar de manera preventiva, así como con habilidades instrumentales para llevar a cabo medidas en la práctica. Objetivo: analizar la competencia clínica del personal de enfermería en el servicio de hemodiálisis del Centro Médico Naval con respecto a su formación académica y experiencia profesional en el manejo de la hipotensión arterial intradialítica. Metodología: estudio prospectivo, descriptivo y observacional. Se emplearon dos instrumentos: una adaptación del Cuestionario de conocimientos para el manejo de hemodiálisis de Miller y la Guía de observación de habilidades instrumentales en el personal de enfermería de Murillo. Resultados: se contó con una muestra de doce enfermeros pertenecientes al servicio de hemodiálisis. El 33.3% mostró un nivel regular de competencia clínica y 66.7% un nivel bueno. En promedio, la competencia clínica se ubicó en 78%. Discusión: los resultados obtenidos difieren de los reportados en otras investigaciones, tanto por el año de aplicación como de los sujetos evaluados. Limitaciones: se contó con una muestra baja debido a que el personal del servicio no es numeroso. Conclusiones: es necesario reforzar los conocimientos del personal sobre el tema. Sin embargo, se observó que las habilidades instrumentales fueron excelentes en todos los casos. No se observa relación con el nivel de estudios o la experiencia profesional.

Introduction: the correct management of arterial hypotension during hemodialysis is fundamental in the training and work of the nephrological nursing staff at the Naval Medical Center. The staff must have sufficient knowledge about hypotension and its associated factors to help them predict it and act preventively, as well as instrumental skills to carry out measures in practice. Objective: to analyze the clinical competence of the nursing staff in the hemodialysis service of the Naval Medical Center concerning their academic training and profesional experience in the management of intradialytic arterial hypotension. Methodology: a prospective, descriptive, and observational study. Two instruments were used: an adaptation of Miller's Hemodialysis Management Knowledge Questionnaire and Murillo's Guide to Observation of Instrumental Skills in Nursing Personnel. Results: There was a sample of twelve nurses belonging to the hemodialysis service. 33.3% percent showed a fair level of clinical competence and 66.7% a good level. On average, clinical competence was 78%. Discussion: the results obtained differ from those reported in other studies, in terms of both the year of application and the subjects evaluated. Limitations: there was a low sample size due to the small number of service personnel. Conclusions: it is necessary to reinforce the knowledge of the personnel on the subject. However, it was observed that instrumental skills were excellent in all cases. No relationship was observed with the level of studies or professional experience.

Intensive care management of Gitelman syndrome: A rare case

Gitelman syndrome (GS) is an autosomal-recessive disorder distinguished by hypokalemia, hypomagnesemia, and hypocalciuria. Elderly people and women of childbearing age are highly affected by GC. Not much evidence is known about its effects on maternal and fetal outcomes. GS is caused by mutations in the thiazide-sensitive Na-Cl cotransporter gene. Due to its rarity and lack of knowledge, it is susceptible to misdiagnosis or being overlooked. In our case, the patient suffered from recurrent hypokalemia, hypomagnesemia, hypochloraemia, and hypocalciuria with hypotension. After taking proper medication, the patient recovered slowly, and during counseling, the patient was provided a diet chart by nutritionists to avoid recurrent electrolyte imbalances.

Correlation of Serum Lactate Levels, Perfusion Index and Plethysmography Variability Index With Invasive Blood Pressure in Late Preterm and Term Infants With Shock

Objective: To study the correlation of objective parameters for diagnosing shock viz., perfusion index (PI), plethysmography variability index (PVI) and serum lactate (SL) with invasive blood pressure in late preterm and term infants with shock. Methods: Prospective observational study (diagnostic test) conducted at the neonatal intensive care unit of Kanchi Kamakoti CHILDS Trust Hospital, Chennai between June, 2018 and May, 2020. Term and late preterm neonates with shock were included in the study. PI, PVI, SL, SpO2 and heart rate were monitored. PI, PVI and SLL were recorded at 0,12, 24 and 72 hours of onset of shock. All the babies were followed up till discharge or death. Results: Total 78 neonates were enrolled in the study. At 0 hour, SL and PVI had negative correlation (P =0.002 and P=0.003) while PI had a weak-to-moderate positive correlation (P=0.002) with invasive blood pressure. SL ?4.65 had a sensitivity of 75% and specificity of 75.8%, and PI <0.455 had a sensitivity of 65%, and specificity of 58.6% for predicting invasive hypotension. PVI ?23.5 had a sensitivity of 90% and specificity of 63.8% in predicting invasive hypotension. Conclusion: PI has moderate positive correlation while SL and PVI have moderate negative correlation with invasive blood pressure. The cutoff values of SL ?4.65, PI <0.45 and PVI ?23.5 can predict invasive hypotension with good sensitivity and negative predictive value.

Nivel de conocimiento de los estudiantes del tercer curso en Odontología de la UNAN-León, sobre trastornos de presión arterial y manejo odontológico / Level of knowledge third year dentistry students UNAN-León about blood pressure disorders and dental management

Las patologías cardiovasculares constituyen la causa más frecuente de muerte en el mundo, las más comunes son hipertensión e hipotensión. En la consulta odontológica, los pacientes con trastornos de presión arterial requieren diferentes protocolos de atención. En el tercer curso de odontología se tiene el primer contacto con pacientes, al haber estudiado y aprobado la parte teórica del manejo odontológico. Según los antecedentes encontrados, no existen investigaciones que abarquen ambos trastornos de la presión arterial, por lo que se realizó un estudio descriptivo de corte transversal para determinar el nivel de conocimiento en estudiantes del tercer curso Odontología UNAN-León, sobre trastornos de la presión arterial y su manejo odontológico en el segundo semestre del año 2021, por una encuesta tipo examen a estudiantes inscritos en cirugía bucal I, 55 estudiantes fueron encuestados. Se determinó que 50.9% tienen un nivel de conocimiento regular, seguido por 27.3% con nivel bueno, 12.7% deficiente y 9.1% obtuvo nivel de conocimiento excelente sobre los trastornos de presión arterial. Según investigaciones previas en odontología, la mayoría de los estudiantes presentaba un nivel de conocimiento deficiente sobre hipertensión arterial. Por lo que es importante evaluar periódicamente los niveles de conocimiento sobre éstos y otros trastornos que pueden presentarse en la consulta dental (AU)

Cardiovascular diseases are the most common cause of death world, hypertension and hypotension are very common nowadays. In the dental office, patients with blood pressure disorders require different care protocols. Students of the third year of dentistry have their first contact with patients, having studied and approved the theoretical part of dental management. According to antecedents researched, there are no investigations that cover both blood pressure disorders. So a descriptive cross-sectional study was made to determine the knowledge of third-year dentistry students UNAN-León, about blood pressure disorders and their dental management in the second semester of the year 2021, by an exam-type survey of students registered in oral surgery I, with 55 students surveyed. It determined that 50.9% have a regular level of knowledge, followed by 27.3% with a good level, 12.7% poor and 9.1% has an excellent level of knowledge about blood pressure disorders. According to previous research in dentistry faculty, the majority of students have a poor level of knowledge about high blood pressure. Therefore, it's important to evaluate periodically the levels of knowledge about these and other disorders that may occur in the dental office (AU)

Establishment of a Rat Model of Hypotension Induced by Reserpine / 中国医学科学院学报

Objective To determine the optimal dosage and intervention duration of reserpine to establish a rat model of hypotension.Methods According to the body weight and systolic blood pressure (SBP),60 male Wistar rats were assigned to six groups (n=10),including a control group and five observation groups with different doses.The control group was administrated with 10 ml/kg 0.5% sodium carboxymethyl cellulose solution,and the observation groups with 0.016,0.032,0.064,0.128,and 0.160 mg/kg reserpine suspensions,respectively.All the groups were administrated by gavage twice a day,and the body weights of rats were monitored daily.SBP and heart rate (HR) were measured before modeling and 1-6 weeks after administration.After 6 weeks of administration,the blood samples of inner canthus were collected.The levels of lactate dehydrogenase (LDH),creatine kinase MB isoenzyme (CK-MB),alanine aminotransferase,aspartate aminotransferase (AST),serum creatinine,and blood urea nitrogen (BUN) were measured by an autoanalyzer.Three rats in each group were randomly selected for observation of the changes in SBP after drug withdrawal and the rest rats were sacrificed for measurement of the levels of norepinephrine and dopamine in the brain.Results Compared with the control group,different doses of reserpine lowered the SBP of rats (F=28.492,P<0.001).The decline in SBP increased in a concentration-dependent manner.SBP reached the lowest value after 1 week,rose slightly later,and was stable after 3 weeks of administration.There was no significant difference in SBP between 0.016 mg/kg reserpine group and the control group after the 5th week (P>0.05).The SBP levels of rats in 0.032,0.064,0.128,and 0.160 mg/kg reserpine groups showed no significant difference between each other (P=0.204) and were lower than that in the control group (all P<0.001).One week after drug withdrawal,the SBP of rats in the observation groups rose to the baseline level and remained stable.HR showed similar changes among groups,first increasing and then decreasing.There was no significant difference in HR among different groups at the same time point (F=0.922,P=0.475).Compared with the control group,reserpine of different doses reduced the norepinephrine content in the hippocampus (all P<0.001),and 0.128 mg/kg (P=0.045) and 0.160 mg/kg (P=0.042) reserpine lowered the dopamine level in the striatum,which showed no significant differences between different reserpine groups(P=0.343,P=0.301).The levels of LDH,CK-MB,and BUN in the serum increased with the increase in reserpine concentration,and the levels of LDH (P=0.001),CK-MB (P=0.020),AST (P=0.007),and BUN (P=0.001) in the 0.160 mg/kg reserpine group were significantly different from those in the control group.Conclusions The rat model of hypotension can be induced by gavage with reserpine.The gavage with reserpine at a dose of 0.032 mg/kg,twice a day for three consecutive weeks is the optimal scheme for the modeling.After the model establishment,continuous administration is essential to maintain the hypotension.

Risk factors and prognosis of hypotension within 72 hours after birth in extremely preterm infants / 中国当代儿科杂志

OBJECTIVES@#To investigate the risk factors and prognosis of hypotension within 72 hours after birth in extremely preterm infants.@*METHODS@#A retrospective analysis was conducted on clinical data of extremely preterm infants admitted to the Children's Hospital of Zhejiang University School of Medicine from January 2019 to April 2022. Based on the presence of hypotension within 72 hours after birth, the eligible infants were divided into a hypotension group (41 cases) and a normotension group (82 cases). The clinical characteristics, echocardiographic parameters within 72 hours after birth, and early complications were compared between the two groups. Multivariate logistic regression analysis was used to explore the risk factors for hypotension within 72 hours after birth, and receiver operating characteristic curve analysis was performed to evaluate the predictive value of relevant indicators for the occurrence of hypotension within 72 hours after birth in the preterm infants.@*RESULTS@#The proportion of infants who required medication or surgical closure of patent ductus arteriosus (PDA), the proportions of infants with intraventricular hemorrhage ≥ grade III and severe pulmonary hemorrhage, and the mortality rate within 7 days in the hypotension group were significantly higher than those in the normotension group (P<0.05). Multivariate logistic regression analysis showed that lower birth weight, larger PDA diameter, and hemodynamically significant PDA were risk factors for the occurrence of hypotension within 72 hours after birth in extremely preterm infants (P<0.05). The receiver operating characteristic curve analysis showed that the combination of birth weight, PDA diameter, and hemodynamically significant PDA had an area under the curve of 0.873 (95%CI: 0.802-0.944, P<0.05) for predicting hypotension within 72 hours after birth, with a sensitivity of 73.2% and specificity of 91.5%.@*CONCLUSIONS@#Hypotension within 72 hours after birth is closely related to birth weight and PDA, and increases the risk of early severe complications and mortality in extremely preterm infants.

Headache attributed to spontaneous intracranial hypotension and associated possible causes / Cefaleia atribuída à hipotensão intracraniana espontânea e possíveis causas associadas

Bem Junior and coworkers published a very interesting and opportunely case report on spontaneous intracranial hypotension, associated with cerebrospinal fluid (CSF) fistula in this issue. In recent decades, many publications have been addressing the subject. Spontaneous intracranial hypotension is little known among physicians, and the diagnosis is difficult even considering neurologists. Many patients progress without the correct diagnosis for weeks or even months. The clinical expression is classically similar to that found in post-dural puncture headache syndrome, an entity prevalent after spinal anesthesia. The most frequent symptom presentation is orthostatic headache, which worsens in the upright position and subsides after lying down.

Bem Junior e colaboradores publicaram nesta edição um relato de caso muito interessante e oportuno sobre hipotensão intracraniana espontânea, associada à fístula do líquido cefalorraquidiano (LCR). Nas últimas décadas, muitas publicações têm abordado o assunto. A hipotensão intracraniana espontânea é pouco conhecida entre os médicos e o diagnóstico é difícil mesmo entre neurologistas. Muitos pacientes evoluem sem o diagnóstico correto por semanas ou até meses. A expressão clínica é classicamente semelhante à encontrada na síndrome da cefaleia pós-punção dural, entidade prevalente após raquianestesia. O sintoma mais frequente é a cefaleia ortostática, que piora na posição ortostática e cede após deitar.

Needle caliber and design are associated with the risk of post-dural puncture headache after diagnostic lumbar puncture / O calibre e o design da agulha estão associados ao risco de cefaleia pós-punção dural após punção lombar diagnóstica

Introduction:Post-dural puncture headache (PDPH) is defined as an orthostatic headache that develops within the first few days after performing a spinal tap and it is related to extravasation of cerebrospinal fluid (CSF) into the epidural space, resulting in CSF hypovolemia and hypotension. The risk factors for PDPH are not yet fully understood. Objective:To evaluate the risk of spontaneously reported PDPH according to the size and type of spinal tap needle. Methods:A total of 4589 patients undergoing outpatient lumbar puncture (LP) were included. All CSF collections were performed at Senne Liquor Diagnostico, a laboratory specialized in CSF collection and analysis. Patients were instructed to report by telephone if they had orthostatic headache during the first 7 days after LP to the medical team of the laboratory. Patients with previous headache were instructed to report any change in the headache pattern during the same period. Needle gauge was classified into two groups: 1) 25 G or less and 2) greater than 25 G. Two types of needles were used and compared: 1) Pencil point and 2) Quincke. Comparisons of the percentages of spontaneous reports of PDPH were made using the chi-square test. Results:141 patients (3.07%) reported PDPH to the laboratory's medical team. Needles of 25G gauge or less were used in 31.8% of cases. The percentage of patients reporting PHD in the group of 25G or less needles was 1.9% versus 3.6% in the group of larger than 25G needles (p=0.003). Pencil point needles were used in 10.6% of cases. The percentage of PHD among pencil point group was 1.4% versus 3.2% in Quincke group (p=0.026). Conclusion:25 G or finer gauge needles as well as pencil point type needles significantly reduced the risk of spontaneously reported PHD.

Introdução: A cefaleia pós-punção dural (CPPD) é definida como uma cefaleia ortostática que se desenvolve nos primeiros dias após a realização de uma punção lombar e está relacionada ao extravasamento de líquido cefalorraquidiano (LCR) para o espaço peridural, resultando em hipovolemia do LCR e hipotensão. Os fatores de risco para CPPD ainda não são totalmente compreendidos. Objetivo:Avaliar o risco de CPPD relatada espontaneamente de acordo com o tamanho e tipo de agulha de punção lombar. Métodos: Foram incluídos 4.589 pacientes submetidos à punção lombar (PL) ambulatorial. Todas as coletas de LCR foram realizadas no Senne Liquor Diagnostico, laboratório especializado em coleta e análise de LCR. Os pacientes foram orientados a relatar por telefone à equipe médica do laboratório se apresentassem cefaleia ortostática nos primeiros 7 dias após a PL. Pacientes com cefaleia prévia foram orientados a relatar qualquer alteração no padrão de cefaleia durante o mesmo período. O calibre da agulha foi classificado em dois grupos: 1) 25 G ou menos e 2) maior que 25 G. Dois tipos de agulhas foram utilizados e comparados: 1) ponta de lápis e 2) Quincke. As comparações dos percentuais de notificações espontâneas de CPPD foram feitas por meio do teste do qui-quadrado. Resultados:141 pacientes (3,07%) relataram CPPD à equipe médica do laboratório. Agulhas de calibre 25G ou menos foram utilizadas em 31,8% dos casos. A porcentagem de pacientes que relataram HDP no grupo de agulhas 25G ou menos foi de 1,9% versus 3,6% no grupo de agulhas maiores que 25G (p=0,003). Agulhas com ponta de lápis foram utilizadas em 10,6% dos casos. O percentual de DPH no grupo ponta de lápis foi de 1,4% versus 3,2% no grupo Quincke (p=0,026). Conclusão: Agulhas de calibre 25 G ou mais fino, bem como agulhas tipo ponta de lápis reduziram significativamente o risco de HP relatado espontaneamente.

Síndrome de hipotensión endocraneana espontánea: reporte de un caso clínico / Spontaneous intracranial hypotension syndrome: clinic case report

La hipotensión intracraneal espontánea (SIH) es una patología con una incidencia anual aproximada de 5 por cada 100.000 personas al año, caracterizada clásicamente por cefalea ortostática comúnmente secundaria a una fuga espontánea de líquido cefalorraquídeo (LCR), pudiendo existir a su vez una amplia gama de síntomas asociados. El diagnóstico se centra en la clínica y en hallazgos típicos en la resonancia nuclear magnética (RM), sin embargo, según diversos estudios, puede corresponder a una patología subdiagnosticada por la dificultad que ha existido en definir criterios diagnósticos universales y un manejo terapéutico estandarizado, el cual varía inicialmente entre manejo médico conservador y/o parches de sangre epidural (PHE). Reportamos el caso de una paciente femenina de 51 años quien fue atendida en el Hospital Herminda Martin de Chillán donde se realizó el diagnóstico y tratamiento sintomático con PHE.

Spontaneous intracranial hypotension (SIH) is a pathology with an annual incidence of approximately 5 per 100,000 people per year, classically characterized by orthostatic headache commonly secondary to a spontaneous cerebrospinal fluid (CSF) leak, and there may also be a wide range of of associated symptoms. The diagnosis is centered on the clinic and on typical findings in magnetic resonance imaging (MRI), however, according to various studies, it may correspond to an underdiagnosed pathology due to the difficulty that has existed in defining universal diagnostic criteria and standardized therapeutic management. which initially varies between conservative medical management and/or epidural blood patches (PHE). We report the case of a 51-year-old female patient who was treated at the Herminda Martin de Chillán Hospital where the diagnosis and symptomatic treatment with PHE were made.

Preoperative assessment of inferior vena cava collapsibility index by ultrasound is not a reliable predictor of post-spinal anesthesia hypotension

Abstract Background Post-spinal anesthesia hypotension is of common occurrence, and it hampers tissue perfusion. Several preoperative factors determine patient susceptibility to hypotension. This study aimed to assess the effectiveness of the Inferior Vena Cava Collapsibility Index (IVCCI) for predicting intraoperative hypotension. Methods One hundred twenty-nine adult patients who were scheduled for elective surgical procedures after administration of spinal (intrathecal) anesthesia were included in the study. Ultrasound evaluation of the Inferior Vena Cava (IVC) was done in the preoperative area, and the patients were shifted to the Operating Room (OR) for spinal anesthesia. An independent observer recorded the change in blood pressure after spinal anesthesia inside the OR. Results Twenty-five patients developed hypotension (19.37%). Baseline systolic blood pressure and mean blood pressures were statistically higher in those patients who developed hypotension (p= 0.001). The logistic regression analysis for IVCCI and the incidence of hypotension showed r2 of 0.025. Receiver Operating Characteristic (ROC) curve analysis demonstrated the Area Under the Curve (AUC) of 0.467 (95% Confidence Interval, 0.338 to 0.597; p= 0.615). Conclusions Preoperative evaluation of IVCCI is not a good predictor for the occurrence of hypotension after spinal anesthesia.

Spontaneous intracranial hypotension: a case report in the context of differential diagnosis of chronic headaches / Hipotensão intracraniana espontânea: relato de caso no contexto do diagnóstico diferencial de cefaleias crônicas

Spontaneous intracranial hypotension (SIH) is a rare and debilitating condition caused by decreased intracranial pressure, which occurs more frequently in females. SIH can have several causes, among them the spontaneous formation of cerebrospinal fluid venous fistula (CSF-venous fistula), which is primarily responsible for the appearance of postural headache. Orthostatic headache is diagnosed by CSF pressure < 6 mmHg associated with specific imaging findings. Other specific symptoms such as dizziness, reduced muscle strength, blurred vision and syncope and other more systemic symptoms such as fatigue, mental confusion and difficulty concentrating are commonly observed. Etiological investigation through imaging studies such as magnetic resonance imaging and dynamic tomography of myelography is necessary for diagnosis. Due to the debilitating condition, several therapeutic approaches have been developed, ranging from more conservative approaches, with observation and use of analgesics, to more invasive interventions such as surgical ligation, transvenous embolization and blood tamponade.

A hipotensão intracraniana espontânea (HIH) é uma condição rara e debilitante causada pela diminuição da pressão intracraniana, que ocorre com mais frequência em mulheres. A HIE pode ter diversas causas, entre elas a formação espontânea de fístula venosa do líquido cefalorraquidiano (fístula liquórica-venosa), principal responsável pelo aparecimento da cefaleia postural. A cefaleia ortostática é diagnosticada pela pressão liquórica < 6 mmHg associada a achados de imagem específicos. Outros sintomas específicos como tontura, redução da força muscular, visão turva e síncope e outros sintomas mais sistêmicos como fadiga, confusão mental e dificuldade de concentração são comumente observados. A investigação etiológica por meio de exames de imagem como ressonância magnética e tomografia dinâmica da mielografia é necessária para o diagnóstico. Devido ao quadro debilitante, diversas abordagens terapêuticas têm sido desenvolvidas, desde abordagens mais conservadoras, com observação e uso de analgésicos, até intervenções mais invasivas como ligadura cirúrgica, embolização transvenosa e tamponamento sanguíneo.

Association between intraoperative hypotension and postoperative nausea and vomiting: a retrospective analysis of 247 thyroidectomy cases

Abstract Background: Postoperative nausea and vomiting (PONV) are major complications after general anesthesia. Although various pathways are involved in triggering PONV, hypotension plays an important role. We hypothesized that intraoperative hypotension during general anesthesia might be responsible for the incidence of PONV. Methods: We retrospectively investigated patients who underwent thyroidectomy. The initial blood pressure measured before induction of anesthesia was used as the baseline value. The systolic blood pressure measured during the operation from the start to the end of anesthesia was extracted from anesthetic records. The time integral value when the measured systolic blood pressure fell below the baseline value was calculated as area under the curve (AUC) of s100%. Results: There were 247 eligible cases. Eighty-eight patients (35.6%) had PONV. There was no difference in patient background between the patients with or without PONV. Univariate analysis showed that the total intravenous anesthesia (TIVA) (p = 0.02), smoking history (p = 0.02), and AUC-s100% (p = 0.006) were significantly associated with PONV. Multiple logistic regression analysis revealed that TIVA (OR: 0.54, 95% CI: 0.29-0.99), smoking history (OR: 0.60, 95% CI: 0.37-0.96), and AUC-s100% (OR: 1.006, 95% CI: 1.0-1.01) were significantly associated with PONV. Conclusion: Intraoperative hypotension evaluated by AUC-s100% was related to PONV in thyroidectomy.

Hemodynamic course during ablation and selective hepatic artery embolization for metastatic liver carcinoid: a retrospective observational study

Abstract Background: Manipulation of carcinoid tumors during ablation or selective hepatic artery embolization (transarterial embolization, TAE) can release vasoactive mediators inducing hemodynamic instability. The main aim of our study was to review hemodynamics and complications related to minimally invasive treatments of liver carcinoids with TAE or ablation. Methods: Electronic medical records of all patients with metastatic liver carcinoid undergoing ablation or TAE from 2003 to 2019 were abstracted. Noted were severe hypotension (mean arterial pressure [MAP] ≤ 55 mmHg), severe hypertension (systolic blood pressure ≥ 180 mmHg), and perioperative complications. Associations of procedure type and pre-procedure octreotide use with intraprocedural hemodynamics were assessed using linear regression. A robust covariance approach using generalized estimating equation method was used to account for multiple observations. Results: A total of 161 patients underwent 98 ablations and 207 TAEs. Severe hypertension was observed in 24 (24.5%) vs. 15 (7.3%), severe hypotension in 56 (57.1%) vs. 6 (2.9%), and cutaneous flushing observed in 2 (2.0%) vs. 48 (23.2%) ablations and TAEs, respectively. After adjusting for preprocedural MAP, ablation was associated with lower intraprocedural MAP compared to TAE (estimate −27 mmHg, 95%CI −30 to −24 mmHg, p < 0.001). Intraprocedural declines in MAP were not affected by preprocedural use of octreotide (p = 0.7 for TAE and p = 0.4 for ablation). Conclusions: Ablation of liver carcinoids was associated with substantial hemodynamic instability, especially hypotension. In contrast, a higher number of TAE patients had cutaneous flushing. Preprocedural use of octreotide was not associated with attenuation of intraprocedural hypotension.

Spontaneous intracranial hypotension: from cerebral venous thrombosis to neurosurgical treatment: a case series experience from a Brazilian tertiary health care center / Hipotensão intracraniana espontânea: de trombose venosa cerebral ao tratamento cirúrgico: uma série de casos de um centro terciário de saúde brasileiro

Abstract Background Spontaneous intracranial hypotension (SIH) is a secondary cause of headache and an underdiagnosed disease. The clinical presentation can be highly variable. It typically presents with isolated classic orthostatic headache complaints, but patients can develop significant complications such as cerebral venous thrombosis (CVT). Objective To report 3 cases of SIH diagnosis admitted and treated in a tertiary-level neurology ward. Methods Review of the medical files of three patients and description of clinical and surgical outcomes. Results Three female patients with SIH with a mean age of 25.6 ± 10.0 years old. The patients had orthostatic headache, and one of them presented with somnolence and diplopia because of a CVT. Brain magnetic resonance imaging (MRI) ranges from normal findings to classic findings of SIH as pachymeningeal enhancement and downward displacement of the cerebellar tonsils. Spine MRI showed abnormal epidural fluid collections in all cases, and computed tomography (CT) myelography could determine an identifiable cerebrospinal fluid (CSF) leak in only one patient. One patient received a conservative approach, and the other two were submitted to open surgery with lamino-plasty. Both of them had uneventful recovery and remission in surgery follow-up. Conclusion The diagnosis and management of SIH are still a challenge in neurology practice. We highlight in the present study severe cases of incapacitating SIH, complication with CVT, and good outcomes with neurosurgical treatment.

Resumo Antecedentes Hipotensão intracraniana espontânea (HIE) é uma causa secundária de cefaleia e uma doença subdiagnosticada. A apresentação clínica pode ser muito variável. Tipicamente, se apresenta com queixas isoladas de cefaleia ortostática clássica, porém pode evoluir com complicações significativas como trombose venosa cerebral (TVC). Objetivo Relatar 3 casos de diagnóstico de hipotensão intracraniana espontânea manejados em uma enfermaria de neurologia de nível terciário. Métodos Revisão dos prontuários de três pacientes e descrição dos resultados clínicos e cirúrgicos. Resultados Três pacientes do sexo feminino com média de idade de 25.6 ± 10.0 anos. As pacientes apresentavam cefaleia ortostática e uma delas apresentou sonolência e diplopia devido a TVC. A ressonância magnética (RM) do encéfalo varia de achados normais até achados clássicos de HIE como realce paquimeníngeo e deslocamento inferior das tonsilas cerebelares. A RM da coluna mostrou coleções anormais de líquido epidural em todos os casos e a mielografia por tomografia computadorizada (TC) foi capaz de determinar fístula liquórica identificável em apenas uma paciente. Uma paciente recebeu abordagem conservadora e as outras duas foram submetidas a cirurgia aberta com laminoplastia. Ambas tiveram recuperação e remissão sem intercorrências no seguimento cirúrgico. Conclusão O diagnóstico e manejo da hipotensão intracraniana ainda são desafios na prática neurológica. Destacamos no presente estudo casos graves, complicação com TVC e bons resultados com tratamento neurocirúrgico.

High-intensity interval training poses no risk to hypertensive women / El entrenamiento de intervalos de alta intensidad no presenta riesgo para mujeres hipertensas / Treinamento intervalado de alta intensidade não apresenta risco para mulheres hipertensas

ABSTRACT Introduction: The aim of this study was to evaluate whether a single session of high-intensity interval training (HIIT) would promote a hypotensive effect and cardiovascular risk in hypertensive women, in addition to increasing the bioavailability of nitric oxide. Methods: The sample consisted of 10 hypertensive women (63.7 ± 10.34 years; 66 ± 7.67 kg and 153.7 ± 9.08 cm) and the training load was established at 60% of the maximum aerobic speed. Results: We observed a very high hypotensive effect between the interaction moments during the intervention (Int. Pre: 122.40 ± 18.58; Int. Post: 143.00 ± 24.90; Int. Post 60min: 121.40 ± 13.87; p<0.001, η2P = 0.569). No cardiovascular risk was observed during the intervention (DP = Int. Pre: 9138.20 ± 1805.34; Int. Post: 14849.70 ± 3387.94; Int. Post 60min: 9615.90 ± 1124.41, p< 0.001, η2P = 0.739) and there was no increase in the bioavailability of nitric oxide. Conclusion: In conclusion, this work reveals that an HIIT session is capable of generating a hypotensive effect while not posing cardiovascular risk in hypertensive women. Level of evidence I; High-quality randomized clinical trial with or without statistically significant difference, but with narrow confidence intervals .

RESUMEN Introducción: El objetivo de este estudio fue evaluar si una única sesión de entrenamiento de intervalos de alta intensidad (HIIT) podría promover un efecto hipotensor y riesgo cardiovascular en mujeres hipertensas, así como aumentar la biodisponibilidad del óxido nítrico. Métodos: La muestra fue compuesta por 10 mujeres hipertensas (63,7 ± 10,34 años; 66 ± 7,67 kg y 153,7 ± 9,08 cm) y la carga de entrenamiento se estableció en el 60% de la velocidad aeróbica máxima. Resultados: Se observó un efecto hipotensor muy elevado entre los momentos de interacción durante la intervención (Int. Pre: 122,40 ± 18,58; Int. Post: 143,00 ± 24,90; Int. Post 60 min: 121,40 ± 13,87; p <0,001, η2P = 0,569). No se observó ningún riesgo cardiovascular durante la intervención (DP = Int. Pre: 9138,20 ± 1805,34; Int. Post: 14849,70 ± 3387,94; Int. Post 60 min: 9615,90 ± 1124,41, p <0,001, η2P = 0,739) y no hubo aumento de la biodisponibilidad de óxido nítrico. Conclusiones: En conclusión, este trabajo revela que una sesión de HIIT es capaz de generar efecto hipotensor sin presentar riesgo cardiovascular en mujeres hipertensas. Nivel de evidencia I; Estudio clínico aleatorizado de alta calidad con o sin diferencia estadísticamente significativa, pero con intervalos de confianza estrechos.

RESUMO Introdução: O objetivo deste estudo foi avaliar se uma única sessão de treinamento intervalado de alta intensidade (HIIT) promoveria efeito hipotensor e risco cardiovascular em mulheres hipertensas, bem como aumentar a biodisponibilidade de óxido nítrico. Métodos: A amostra foi composta por 10 mulheres hipertensas (63,7 ± 10,34 anos; 66, ± 7,67 kg e 153,7 ± 9,08 cm) e a carga de treinamento foi estabelecida em 60% da velocidade aeróbica máxima. Resultados: Observamos um efeito hipotensor muito alto entre os momentos de interação durante a intervenção (Int. Pré: 122,40 ± 18,58; Int. Pós: 143,00 ± 24,90; Int. Pós 60 min.: 121,40 ± 13,87; p < 0,001, η2P = 0,569). Nenhum risco cardiovascular foi observado durante a intervenção (DP = Int. Pré: 9138,20 ± 1805,34; Int. Pós: 14849,70 ± 3387,94; Int. Pós: 60 min.: 9615,90 ± 1124,41, p < 0,001, η2P = 0,739) e não houve aumento da biodisponibilidade de óxido nítrico. Conclusões: Em conclusão, este trabalho revela que uma sessão de HIIT é capaz de gerar efeito hipotensor sem apresentar risco cardiovascular em mulheres hipertensas. Nível de evidência I; Estudo clínico randomizado de alta qualidade com ou sem diferença estatisticamente significativa, mas com intervalos de confiança estreitos .

Dialysis prescription: Determinants and relationship with intradialytic complications and the dialysis dose. A prospective study

Introduction: Dialysis still remains the most common modality for the treatment of end stage kidney disease and it could be maneuvered to augment its dose, minimize complications and improve outcome. Dialysis prescription is a brief of how dialysis is to be given and involves adjustments in patients' characteristics, disease or dialytic procedure. This study aimed to assess the determinants of the prescribed dialysis and its relationship with intradialytic complications and the dialysis dose. Methods: A prospective study in which 1248 sessions for 232 consented participants with end stage kidney disease on maintenance hemodialysis were studied from 2017-2020. Biodata was taken, participants were examined and blood samples were taken to determine electrolytes, urea/creatinine and hematocrit. Pearson's correlation was used to determine the strength of association between dialysis dose and some variables. Results: Determinants of the prescribed dose were dialysis frequency (P<0.001), and predialysis systolic blood pressure (P<0.001) and packed cell volume (P<0.001). Dialysis sessions without significant intradialytic blood pressure changes were most likely to be completed, as sessions with intra-dialysis hypotension were most likely to be terminated. Participants dialyzed with high flux dialyzers, via an arterovenous fistula, higher blood flow and ultrafiltration rates had higher dialysis doses (P<0.001 in all instances). Conclusion: Higher dialysis doses were achieved with higher blood flow and ultrafiltration rates. Intradialytic hypotension was common with dialysis termination, higher blood flow and ultrafiltration rates. Intradialytic hypertension was common with low flux dialyzers. An optimized dialysis prescription is needed to deliver an adequate dialysis dose and minimize complications