Design and application of model for training ultrasound-guided vascular cannulation in pediatric patients.

UNLABELLED: Central vascular cannulation is not a risk-free procedure, especially in pediatric patients. Newborn and infants are small and low-weighted, their vascular structures have high mobility because of tissue laxity and their vessels are superficial and with small diameter. These characteristics, together with the natural anatomical variability and poor collaboration of small children, make this technique more difficult to apply. Therefore, ultrasound imaging is increasingly being used to locate vessels and guide vascular access in this population. OBJECTIVE: (a) To present a model that simulates the vascular system for training ultrasound-guided vascular access in pediatrics patients; (b) to ultrasound-guided vascular cannulation in the model. RESULTS: The model consisted of two components: (a) muscular component: avian muscle, (b) vascular component: elastic tube-like structure filled with fluid. 864 ecoguided punctures was realized in the model at different vessel depth and gauge measures were simulated, for two medical operators with different degree of experience. The average depth and diameter of vessel cannulated were 1.16 (0.42)cm and 0.43 (0.1)cm, respectively. The average number of attempts was of 1.22 (0.62). The percentage of visualization of the needle was 74%. The most frequent maneuver used for the correct location, was the modification of the angle of the needle and the relocation of the guidewire in 24% of the cases. The average time for the correct cannulations was 41 (35.8)s. The more frequent complications were the vascular perforation (11.9%) and the correct vascular puncture without possibility of introducing the guidewire (1.2%). The rate of success was 96%. CONCLUSIONS: The model simulates the anatomy (vascular and muscular structures) of a pediatric patient. It is cheap models, easily reproducible and a useful tool for training in ultrasound-guided puncture and cannulation.

Usefulness of cardiac biomarker screening to detect dilated cardiomyopathy in Dobermanns.

OBJECTIVES: To assess the diagnostic accuracy of two cardiac biomarker assays (N-terminal pro-BNP , Troponin I) in detecting dilated cardiomyopathy in Dobermanns. MATERIALS AND METHODS: Dobermanns undergoing cardiac biomarker testing were screened by echocardiography and Holter monitoring, then assigned to a group: normal, equivocal, arrhythmia form of dilated cardiomyopathy, echocardiographic form of dilated cardiomyopathy or both. Some were reassessed to identify final status. Initial cardiac biomarker results were compared to final status. Receiver operating characteristic curves were used to identify area under the curve and corresponding sensitivity (Se), specificity (Sp) for different cut-offs (CO) for each cardiac biomarker. RESULTS: A total of 118 Dobermanns with cardiac biomarker data had echocardiography/Holter assessment. Repeat assessment was carried out in 47 Dobermanns after 394.5 ±151.0 days. Seventeen dogs changed group between initial and final status. The final status of 59 was normal, nine were equivocal and 50 had dilated cardiomyopathy (prevalence 42.4%). Of the dilated cardiomyopathy group, 25 had dilated cardiomyopathy-both, 13 dilated cardiomyopathy-echocardiography and 12 dilated cardiomyopathy-Holter. Receiver operating characteristic area under the curve=0.807 for N-terminal proBNP (Se 0.69 and Sp 0.81) and 0.873 for high-sensitivity cardiac Troponin I (Se 0.77 and Sp 0.86). When both Se and Sp were optimised for all forms of dilated cardiomyopathy, N-terminal proBNP cut-off was 626 pmol/L (Se and Sp 0.79) and high-sensitivity cardiac Troponin I cut-off was 0.056 ng/mL (Se and Sp 0.84). Receiver operating characteristic area under the curve was higher for dilated cardiomyopathy-echocardiography (NT-proBNP 0.883; high-sensitivity cardiac Troponin I 0.907) than dilated cardiomyopathy-Holter. CLINICAL SIGNIFICANCE: Cardiac biomarker screening may be useful to select Dobermanns which would benefit from further assessment by echocardiography and Holter.

[Severe pediatric head injuries (II): factors associated to morbidity-mortality]. / Traumatismo craneoencefálico pediátrico grave (II): factores relacionados con la morbilidad y mortalidad.

OBJECTIVE: To describe the factors associated to morbidity-mortality in pediatric patients with severe head injury (SHI). MATERIAL AND METHOD: A review was made of the patients admitted to the Pediatric Intensive Care Unit (PICU) with SHI between July 1983 and December 2009. RESULTS: Of the 389 patients with head injuries, 174 (45%) presented SHI. The mean age of these subjects was 67 (9) months, with a Glasgow Coma Score (GCS) of 5.5 (1.8) and a PRISM score of 10.6 (6.7). Thirty-nine percent of the patients showed diffuse encephalic injury (DEI) in the computed tomography (CT) study. Seventy-nine percent of the patients subjected to intracranial pressure monitoring (ICP) presented intracranial hypertension. These patients had a greater incidence of serious sequelae (66.7 vs. 23.1%; p=0.01). Sequelae of clinical relevance were recorded in 59 patients (34%), and proved serious in 64% of the cases. The mortality rate among the patients with SHI was 24.7%, and mortality was significantly associated with a lower GCS score, hyperglycemia, intracranial hypertension and the presence of mydriasis or shock. The mortality rate associated to severe DEI was significantly higher than in the case of mild-moderate DEI (87.5 vs. 7.2%; p<0.001). The independent mortality risk factors in the pediatric patients with SHI were found to be the presence of mydriasis (OR: 31.27), intracranial hypertension (OR: 13.23) and hyperglycemia (OR: 3.10). CONCLUSIONS: a) SHI in pediatric patients was associated with high morbidity-mortality; b) intracranial hypertension was associated to the development of serious sequelae; c) independent mortality risk factors were the existence of mydriasis, intracranial hypertension and hyperglycemia.

[Severe pediatric head injuries (I). Epidemiology, clinical manifestations and course]. / Traumatismo craneoencefálico pediátrico grave (I). Epidemiología, clínica y evolución.

OBJECTIVE: To describe the epidemiology, clinical manifestations and evolutive characteristics of pediatric patients with severe head injury (SHI). MATERIAL AND METHOD: A review was made of the patients admitted to the pediatric intensive care unit (PICU) with SHI between July 1983 and December 2009. RESULTS: Of the 389 patients with head injuries admitted to the PICU during the study period, 174 (45%) presented SHI. The mean age in this group was of 67±9 months, with a Glasgow Coma Score (GCS) of 5.5±1.8 and a PRISM score of 10.7±6.7. The most frequent etiology of SHI was traffic accidents (56%), though these have decreased significantly in the last decade (58.5% vs 45.3%; P<.001). Twenty-one percent of the patients required evacuation of the lesions detected by computed tomography (CT), and 39% presented severe diffuse encephalic injury (DEI). Seventy-nine percent of the patients in whom intracranial pressure (ICP) was monitored presented intracranial hypertension. Sequelae of clinical relevance were recorded in 59 patients (39%), and proved serious in 64% of the cases. The mortality rate in this patient series was 24.7%. Intracranial hypertension decreased significantly in the last decade (88% vs 54%; P<.05), and clinical recovery has improved (23.3% vs 63.1%; P<.001). CONCLUSIONS: a) The incidence of traffic accidents has decreased in the last decade in the studied population; b) patients with SHI in which ICP was monitored showed a high incidence of intracranial hypertension; c) morbidity-mortality among pediatric patients with SHI has decreased over the course of the study period.

Balloon valvuloplasty for treatment of pulmonic stenosis in English Bulldogs with an aberrant coronary artery.

BACKGROUND: English Bulldogs (EB) with pulmonic stenosis (PS) sometimes have an aberrant coronary artery (CA) type R2A encircling the pulmonary artery (PA). Balloon valvuloplasty (BV) is treatment of choice for severe PS, but is considered to be contraindicated in dogs with aberrant CA. HYPOTHESIS: Conservative BV in EB with aberrant CA is safe and improves clinical signs and quality of life. ANIMALS: Four client-owned EB with severe PS were retrospectively reviewed/analysed. METHODS: Retrospective study: Case records, echocardiography, BV, and follow-up investigations of EB diagnosed with severe PS and treated with BV were reviewed. The ratios of PA to aortic (Ao) velocity time integral (VTI) were calculated to assess progression/improvement of PS. RESULTS: An aberrant CA was confirmed on angiography in all EB. Conservative BV was performed, using a balloon of the size of the PA annulus or smaller (0.6-1 x PA annulus size). All dogs survived the procedure, but only a mild reduction in pressure gradient was achieved. There was an improvement in PA to Ao VTI in 3 of 4 dogs (P < or = .017), which were free of evidence of congestive heart failure (CHF) 5, 10, and 15 months after BV. One dog that had right-sided CHF when BV was performed died due to progressive right-sided CHF within 3 months. CONCLUSIONS: Conservative BV in EB might be safe and might improve quality and quantity of life.

[Posterior reversible leukoencephalopathy syndrome in a patient with Parkinson's disease and initial psychiatric symptoms: a complex clinical presentation]. / Sindrome de leucoencefalopatia posterior reversible en un paciente con enfermedad de Parkinson y sintomatologia inicial psiquiatrica: una presentacion clinica compleja.

INTRODUCTION: The relevance of the immunosuppressive drug tacrolimus in the prevention of rejection and graft-versus-host disease in transplanted patients is beyond all doubt. However, tacrolimus often has neurotoxic effects, including severe conditions such as posterior reversible leukoencephalopathy syndrome. CASE REPORT: A 75-year-old male who had undergone a kidney transplantation five years earlier, for which he was receiving treatment with tacrolimus and mycophenolate. He also had advanced Parkinson's disease, treated with several dopamine agonists. The patient visited the emergency department after a week-long history of visual hallucinations, delirium, expansive mood, confusion and headache. The focal psychogeriatric examination revealed psychosis secondary to dopaminergic agonists as the first diagnostic option, without excluding other possible iatrogenic causes despite the tacrolimus being within the therapeutic range (8.3 ng/mL). Both cranial computed tomography, which did not show any significant findings, and a magnetic resonance scan, in which a bilateral parietooccipital oedema was observed, were performed, this latter finding being compatible with posterior reversible leukoencephalopathy syndrome. While the patient was in hospital, tacrolimus was replaced by everolimus, and the dopaminergic medication was adjusted, resulting in a swift and full remission of the clinical signs and symptoms. CONCLUSIONS: The diagnosis of posterior reversible leukoencephalopathy syndrome should be considered in patients with a history of organ transplantation treated with immunosuppressive drugs who have an acute onset condition with neurological or psychiatric symptoms.

TITLE: Sindrome de leucoencefalopatia posterior reversible en un paciente con enfermedad de Parkinson y sintomatologia inicial psiquiatrica: una presentacion clinica compleja.Introduccion. La relevancia del farmaco inmunosupresor tacrolimus en la prevencion del rechazo y la enfermedad de injerto contra huesped en pacientes trasplantados es indiscutible. Sin embargo, con frecuencia, el tacrolimus presenta efectos neurotoxicos, incluyendo cuadros graves, como el sindrome de leucoencefalopatia posterior reversible. Caso clinico. Varon de 75 años, con antecedentes de trasplante renal hace cinco años, en tratamiento con tacrolimus y micofenolato, y de enfermedad de Parkinson avanzada, en tratamiento con varios agonistas dopaminergicos. Acudio a urgencias por un cuadro de una semana de evolucion consistente en alucinaciones visuales, delirios, animo expansivo, confusion y cefalea. La exploracion psicogeriatrica por focos mostro como primera opcion diagnostica una psicosis secundaria a agonistas dopaminergicos, sin excluir otras causas yatrogenas a pesar de encontrarse el tacrolimus en el rango terapeutico (8,3 ng/mL). Se realizaron una tomografia computarizada craneal, que no mostro hallazgos significativos, y una resonancia magnetica, en la que se visualizo un edema parietooccipital bilateral, hallazgo compatible con un sindrome de leucoencefalopatia posterior reversible. Durante el ingreso se sustituyo el tacrolimus por everolimus y se ajusto la medicacion dopaminergica, con lo que se produjo de forma rapida una remision completa del cuadro. Conclusiones. El diagnostico de sindrome de leucoencefalopatia posterior reversible debe considerarse en los pacientes con antecedentes de trasplante de organo en tratamiento con farmacos inmunosupresores que presentan un cuadro de instauracion aguda con sintomas neurologicos o psiquiatricos.

Optimizing the collection of used paper from small businesses through GIS techniques: the Leganés case (Madrid, Spain).

This article deals with a methodology for the design of routes for the "bin to bin" (BTB) collection of paper and cardboard waste (PCB) from small businesses, as well as with the new location and calculation of the number of containers needed in the streets for both commercial and non-commercial use due to the large amount of PCB deposited in them. This study was carried out in five shopping areas of the city of Leganés (Community of Madrid, Spain). One of the characteristics of the area is a high density of population and urban traffic. The tool used is the Geographical Information System (GIS-Arc-View). With it we can generate PCB points of high population density in commercial streets based on territorial analysis. We placed the special routes and the new container locations within a distance of 60 m of these collection points (CPT). The system calculates and optimizes six routes according to different urban restrictions. Finally, we provided service to 59% of the shops, which generate almost 82% of the PCB waste, using 160 min per day to collect 1027 kg of high quality PCB. If we compare the system with the system in place previously, we can conclude that the "bin to bin" (BTB) system improves the quality of the PCB in the containers, avoiding overflow and reducing the percentage of rejected material.

An update on canine cardiomyopathies - is it all in the genes?

Dilated cardiomyopathy is the second most common cardiac disease in dogs and causes considerable morbidity and mortality. Primary dilated cardiomyopathy is suspected to be familial, and genetic loci have been associated with the disease in a number of breeds. Because it is an adult-onset disease, usually with late onset, testing breeding dogs and bitches before breeding for a genetic mutation that could lead to dilated cardiomyopathy would be helpful to prevent disease. There is growing evidence that the genetic basis may be multigenic rather than monogenic in the majority of studied breeds. This review article describes the known genetic aspects of canine dilated cardiomyopathy and the implications of genetic tests on heart testing and the future of veterinary cardiology.

Treatment of dogs with compensated myxomatous mitral valve disease with spironolactone-a pilot study.

OBJECTIVES: Spironolactone improves outcome in dogs with advanced myxomatous mitral valve disease (MMVD). Its efficacy in preclinical MMVD is unknown. The hypothesis was the administration of spironolactone to dogs with compensated MMVD demonstrating risk factors for poorer prognosis will decrease the rate of disease progression. The aim was to provide pilot data to evaluate preliminary effects and sample size calculation for a definitive clinical trial. ANIMALS: Twenty-five client-owned dogs with MMVD with at least one of the following; left atrial to aortic ratio (LA:Ao) ≥ 1.5, normalized left ventricular internal diameter in diastole ≥ 1.6), N-terminal pro-B-type natriuretic peptide (NT-proBNP) > 550 pmol/L, cardiac troponin I > 0.025 ng/mL. METHODS: Prospective, single-center, equally randomized, placebo-controlled, double-blinded, parallel grouped pilot study. No dogs were receiving medications for cardiac disease before the enrollment. RESULTS: Twelve dogs received placebo; 13 received spironolactone. One dog in the spironolactone group died suddenly, 1 developed congestive heart failure, and 2 received suboptimal spironolactone doses. At enrollment, NT-proBNP was significantly higher in the spironolactone group (p=0.005). Left atrial to aortic ratio (p=0.002) and left ventricular internal diameter in diastole (p=0.005) increased over time in the placebo group, but not the spironolactone group; the change did not differ significantly between groups. The change in biomarker concentrations did not differ significantly between groups; there was a tendency toward an increase in NT-proBNP over time in the placebo group. Enrollment of 76 dogs would be necessary to demonstrate a difference in the change in LA:Ao over 6 months between the groups. CONCLUSIONS: Preliminary results support undertaking a larger clinical trial of treatment of dogs with preclinical MMVD with spironolactone.

[Mild behavioural impairment as an antecedent of dementia: presentation of the diagnostic criteria and the Spanish version of the MBI-C scale for its evaluation]. / Deterioro comportamental leve como antecedente de la demencia: presentacion de los criterios diagnosticos y de la version española de la escala MBI-C para su valoracion.

INTRODUCTION: Neuropsychiatric symptoms are common in dementia and also in previous stages such as mild cognitive impairment. Their presence is related to greater conversion to dementia in cognitively healthy people or with mild cognitive impairment compared to those who do not suffer them. AIM: An international working group pertaining to the Alzheimer Association has proposed the concept of 'mild behavioral impairment' (MBI) to identify patients with mild neuropsychiatric symptoms and normal cognition or mild cognitive impairment and to study the further risk of developing dementia from any cause. A new scale, the Mild Behavioral Impairment-Checklist (MBI-C), has been developed for the assessment of MBI in clinical and research settings. DEVELOPMENT: Data on the greater risk of dementia in the presence of neuropsychiatric symptoms are shown to justify the development of the new concept of MBI, improving the previous attempts of categorization of these states. Diagnostic criteria of MBI and the process of creation of the MBI-C scale are described. The Spanish version is presented in this article. Finally, the next steps in the investigation of the concept and measurement of MBI and its future prospects are suggested. CONCLUSIONS: The new MBI criteria and their measurement using the MBI-C scale are promising for a better and earlier identification of patients at risk of developing dementia and as an aid to investigate the underlying neurodegenerative processes.

TITLE: Deterioro comportamental leve como antecedente de la demencia: presentacion de los criterios diagnosticos y de la version española de la escala MBI-C para su valoracion.Introduccion. Los sintomas neuropsiquiatricos son frecuentes en la demencia y tambien en estadios previos, como el deterioro cognitivo leve. Su aparicion se relaciona con mayor conversion a demencia en personas cognitivamente sanas o con deterioro cognitivo leve, en comparacion con las personas que no los presentan. Objetivo. Dar a conocer la importancia en las fases previas a la demencia del concepto 'deterioro comportamental leve' (DCoL) y mostrar los criterios consensuados de DCoL de la International Society to Advance Alzheimer's Research and Treatment. Estos criterios permitiran identificar a pacientes con sintomas neuropsiquiatricos leves y cognicion normal o deterioro cognitivo leve, y estudiar el riesgo ulterior de desarrollar demencia por cualquier causa. A su vez, se presenta una nueva escala, la Mild Behavioral Impairment-Checklist (MBI-C), para la valoracion clinica y en investigacion del DCoL. Desarrollo. Se muestran datos del mayor riesgo de demencia en presencia de sintomas neuropsiquiatricos para justificar el desarrollo del nuevo concepto de DCoL, que perfecciona los intentos previos de categorizacion de estos estados. Se describen los criterios diagnosticos de DCoL y el proceso de creacion de la MBI-C, y se presenta su version española. Finalmente, se plantean los proximos pasos en la investigacion del concepto y medicion del DCoL y sus perspectivas de futuro. Conclusiones. Los nuevos criterios de DCoL y su medicion mediante la MBI-C resultan prometedores de cara a una mejor y mas temprana identificacion de los pacientes con riesgo de desarrollar demencia y una ayuda para la investigacion de los procesos neurodegenerativos subyacentes.

Vascular ultrasound in pediatrics: estimation of depth and diameter of jugular and femoral vessels.

OBJECTIVES: To estimate, on the basis of anthropometric and demographic variables, the depth (Dp) and diameter (Dm) of femoral and jugular vessels, which have been located and measured by ultrasound, in pediatric patients. METHOD: 750 measurements of Dp and Dm of the femoral vein (FV), femoral artery (FA) and internal jugular vein (IJV) were made in 125 pediatric patients. The values were correlated with patients' sex, weight, age, size and body surface area (BSA). RESULTS: Mean Dp values were 0.72 (0.34) cm for FA, 0.79 (0.35) cm for FV and 0.77 (0.24) cm for IJV. Mean antero-posterior Dm values were 0.37 (0.17) cm for FA, 0.42 (0.22) cm for FV and 0.59 (0.23) cm for IJV. In the studied pediatric patients, femoral and jugular vessels depth correlated with age, size, weight and BSA (R = 0.46-0.60); vascular depth could be estimated from patients' weight and size (FA-Dp: R = 0.71; FV-Dp: R = 0.72; IJV-Dp: R = 0.53). Correlation with diameter was better for FA and FV (R = 0.81-0.89) than for IJV (R = 0.42-0.51); vascular diameter could be estimated from patient's size (FA-Dm: R = 0.89; FV-Dm: R = 0.86; IJV-Dm: R = 0.52). CONCLUSIONS: FV, FA and IJV depth and diameter correlated with weight, size, age and body surface area in the studied pediatric patients. Correlation was better for femoral than for jugular vessels. Depth could be estimated from patients' weight and size, while diameter could be estimated from the size. Such estimations may facilitate the choice of vessels to be cannulated, length and diameter of cannulation needles and the diameter of catheters to be used in pediatric patients.

[Effects of pleural effusion]. / Consecuencias del derrame pleural.

Pleural effusion (PE) can change the equilibrium between volume of thoracic cavity and volume of intrathoracic structures, and it can disturb the function of respiratory system, heart, and diaphragm. PE alters scanty the pulmonary gas exchange, but it provokes restrictive changes in pulmonary function proportionally to fluid volume, increase thoracic diameters, and decrease lung compliance. PE can originate a syndrome similar to cardiac tamponade. Elevate intrapleural pressure increase intrapericardic pressure and this disturb the cardiac chambers filling, specially right chambers, and decrease cardiac output. Large PE can invert the diaphragm inducing paradoxical movement that origin a reduction of alveolar ventilation. All these alterations improve with drainage of the PE. We think that PE must always be drained, specially if respiratory failure is present.

Prevalence of and risk factors for degenerative mitral valve disease in dogs attending primary-care veterinary practices in England.

BACKGROUND: To date, epidemiological studies on degenerative mitral valve disease (DMVD) in dogs have largely reported referral caseloads or been limited to predisposed breeds. Analysis of primary-care data to identify factors associated with DMVD would help clinicians identify high-risk individuals and improve understanding. OBJECTIVES: To estimate the prevalence of and identify risk factors for DMVD in dogs attending primary-care veterinary practices in England. ANIMALS: Cases were identified within the electronic patient records of 111,967 dogs attending 93 practices. Four hundred and 5 dogs were diagnosed with DMVD (diagnosed cases) and a further 3,557 dogs had a heart murmur (HM) consistent with DMVD (possible cases). METHODS: Retrospective cross-sectional study design. Prevalence was adjusted for the sampling approach. Mixed effects logistic regression models identified factors associated with DMVD. RESULTS: Prevalence estimates of diagnosed DMVD and HMs consistent with DMVD (both diagnosed and possible cases) were 0.36% (95% confidence interval [CI]: 0.29-0.45) and 3.54% (95% CI: 3.26-3.84) respectively. In the multivariable analysis, males had higher odds of diagnosed DMVD than did females (odds ratio [OR] 1.40, 95% CI: 1.12-1.74). Insured dogs had increased odds of DMVD compared with noninsured dogs (OR 3.56, 95% CI: 2.79-4.55) and dogs ≥20 kg had approximately half the odds of DMVD diagnosis compared with dogs <20 kg (OR 0.51, 95% CI: 0.36-0.74). Strong associations between a DMVD diagnosis and individual breeds and age were identified. CONCLUSIONS AND CLINICAL IMPORTANCE: Degenerative mitral valve disease was a common disorder in practice-attending dogs. Knowledge of identified risk factors for DMVD could improve clinical diagnosis and direct future research.

Clinical severity score system in dogs with degenerative mitral valve disease.

BACKGROUND: Several risk factors already have been determined for dogs with degenerative mitral valve disease (DMVD). Risk factors often have been considered in isolation and have not always taken into account additional information provided by the history and physical examination (PE). HYPOTHESIS/OBJECTIVES: Data obtained from history and PE of dogs with DMVD provide prognostic information and can be used for risk stratification. ANIMALS: Client-owned dogs (n = 244) with DMVD recruited from first opinion practice. METHODS: Prospective longitudinal follow-up of dogs with DMVD. History and PE data were obtained at 6-month intervals and analyzed with time-dependent Cox models to derive relative risk of cardiac death. Independent hazard ratios were used to derive a clinical severity score (CSS), the prognostic value of which was evaluated by analyzing the median survival times for different risk groups and ROC analysis. Analysis of the progression of CSS over time also was undertaken. RESULTS: History of cough, exercise intolerance, decreased appetite, breathlessness (difficulty breathing) and syncope with PE findings of heart murmur intensity louder than III/VI and absence of respiratory sinus arrhythmia were independently associated with outcome and allowed development of the CSS. Clinical severity score distinguished groups of dogs with significantly different outcomes. CONCLUSIONS AND CLINICAL IMPORTANCE: Routinely obtained clinical findings allow risk stratification of dogs with DMVD. Results of ancillary diagnostic tests may be complementary to history and PE findings and always should be interpreted in conjunction with these findings.

[Differential features of DRG 541 readmitting patients]. / Características diferenciales de los pacientes del Grupo Relacionado con el Diagnóstico (GRD) 541 que reingresan.

OBJECTIVE: Hospital readmission is considered an adverse outcome, and the hospital readmission ratio is an indicator of health care quality. Published studies show a wide variability and heterogeneity, with large groups of patients with different diagnoses and prognoses. The aim of the study was to analyse the differences between patients readmitted and those who were not, in patients grouped into the diagnosis related group (DRG) 541. MATERIAL AND METHOD: A retrospective observational study was conducted on DRG 541 patients discharged in 2010. Readmission is defined as any admission into any hospital department, and for any reason at ≤30 days from discharge. An analysis was performed that included age, sex, day of discharge, month of discharge, number of diagnoses and drugs at discharge, respiratory depressant drugs, length of stay, requests for consultations/referrals, Charlson comorbidity index, feeding method, hospitalisations in the previous 6 months, albumin and haemoglobin levels and medical examinations within 30 days after discharge. RESULTS: Of the 985 patients included in the study, 189 were readmitted. On multivariate analysis, significant variables were: Haemoglobin -0.6g/dl (95% confidence interval [95%CI] -0.9 to -0.3), gastrostomy feeding odds ratio (OR) 5.6 (95%CI: 1.5 to 21.6), hospitalisations in previous 6 months OR 1.9 (95%CI: 1.3 to 2.8), visits to emergency department OR 17.4 (95%CI: 11.3 to 26.8), medical checks after discharge OR 0.4 (95%CI: 0.2 to 0.8). CONCLUSIONS: DRG 541 readmitting patients have some distinctive features that could allow early detection and prevent hospital readmission.

Retroperitoneal fibrosis in a patient with Parkinson's disease treated with pergolide.

We describe a 68-year-old patient with Parkinson's disease who developed retroperitoneal fibrosis during pergolide treatment. Because pergolide is an ergot derivative, it could be related to the development of this complication.

Occurrence of the vir plasmid among animal and human strains of invasive Escherichia coli.

Forty-six isolates of Escherichia coli recovered from systemic diseases in animals and persons were studied to determine which isolates possessed properties attributed to the Vir plasmid. These properties were production (i) of a chick letha toxin and (ii) of a specific surface antigen. Neither toxic activity nor surface antigen production could be detected in nine E coli strains from septicemia in chickens and 11 from human cerebrospinal fluid. Two of 8 strains from human septicemic disease and 3 of 18 isolates from calf septicemia produced the toxin, but lacked the characteristic surface antigen. Two of the 18 bovine strains had both characteristics. Several methods of screening for Vir+ transconjugants were investigated in an attempt to facilitate their recognition after mating a Vir+ donor with a suitable recipient. These methods, which included precipitation in agar plates containing antiserum, immunodiffusion tests, and fluorescent antibody tests, were unsuccessful. It was observed, however, that the pattern of growth in tryptic soy broth of the Vir+ transconjugants was usually different from that of the Vir- clones. Vir+ transconjugants grew as a heavy sediment with a clear supernatant, whereas their Vir- counterparts showed a uniform turbidity. When the Vir plasmid was transferred to an E coli strain which lacked appendages, fimbriae were observed to be associated with the presence of the plasmid. Two types of fimbriae were evident. One type appeared to be sex fimbriae and the other was probably the surface antigen associated with the Vir phenotype.

[Intermittent mandatory ventilation]. / Ventilación mandatoria intermitente.

Intermittent mandatory ventilation (IMV) is a mode of ventilation that allows the patient to make spontaneous breaths during the expiratory phase of mandatory ventilator breaths. There are two types of IMV according to whether respirator breaths are synchronized with the patient's respiratory efforts: Non-synchronized IMV and synchronized IMV (SIMV), and according to whether SIMV is volume- or pressure programmed. The main advantage of SIMV is that the respirator delivers the preset ventilator pressure and rate while allowing the patient to breath spontaneously, thus facilitating progressive weaning from mechanical ventilation. It diminishes the risk of barotrauma, produces less hemodynamic com-promise than control ventilation, reduces atrophy of respiratory muscles and the need for sedation and muscle relaxation and can be associated with pressure support ventilation.

[Eosinophilic fasciitis: its relationship with L-tryptophan ingestion]. / Fascitis eosinofílica: relación con la ingesta de L-triptófano.

The tryptophan ingestion has recently been involved in the etiology of the eosinophilia-myalgia syndrome. The common findings shared by eosinophilic fasciitis (EF) and that syndrome has suggested a possible role of tryptophan consumption in the development of both diseases. We report two cases of EF whose onset was likely attributed to tryptophan ingestion. Healing was achieved in both patients: the first one had a spontaneous remission and the second patient received glucocorticoid treatment. The EF pathogenesis is yet unknown as the tryptophan role involved in its development. It is likely that tryptophan could release some metabolic factor that support the patient propensity to this illness. It is remarkable to search for the possible tryptophan ingestion in every patient who presents a sclerodermiform syndrome, particularly in EF patients.

Longitudinal electrocardiographic evaluation of dogs with degenerative mitral valve disease.

BACKGROUND: Increased heart rate (HR) and decreased heart rate variability (HRV) are evident in some dogs with degenerative mitral valve disease (DMVD). OBJECTIVES: Evaluation of the factors influencing HR and HRV (assessed by the vasovagal tonus index; VVTI) and their change over time in dogs with DMVD. ANIMALS: Client-owned dogs (n = 257) with DMVD recruited from first opinion practice. METHODS: Prospective longitudinal follow-up at six-monthly intervals of dogs with DMVD. Dogs followed up for at least 18 months (n = 102) were grouped according to their outcome as dogs dying/euthanized because of cardiac disease (n = 28; Group 1), noncardiac disease (n = 40; Group 2) and dogs alive (n = 34; Group 3). HR and VVTI were measured on 1-minute ECG recordings. Repeated measures linear models were constructed to investigate the factors that influence HR and VVTI and their changes over time. RESULTS: Heart rate and VVTI were affected by disease severity and were different in Cavaliers compared to other breeds. Group 1 and Group 2 dogs underwent an increase in HR and decrease in VVTI, evident at least 18 months before death. Group 1 had a further decrease in VVTI followed by an increase in HR approximately 1 year and 6 months before death, respectively. CONCLUSIONS AND CLINICAL IMPORTANCE: Dogs with DMVD have an increase in HR and decrease in HRV over a year before death, with greater changes in those dogs dying/euthanized because of cardiac disease. Both HR and VVTI can potentially be regarded as biomarkers for all-cause mortality.