Caso clínico: Síndrome de Ogilvie / Clinical Case: Ogilvie Syndrome

Introducción: El síndrome de Ogilvie es una patología rara que se puede encontrar en pacientes que han sido sometidos a cirugías extensas dando un cuadro clínico de obstrucción intestinal, llegando a ser letal de no ser diagnosticada a tiempo. Existen varios tratamientos tanto farmacológicos, endoscópicos y quirúrgicos para descomprimir el colon. Caso clínico: Se presenta el caso de un paciente de 35 años intervenido quirúrgicamente de un meningioma que sufre de un cuadro de obstrucción intestinal posterior a la intervención catalogándose como un Síndrome de Ogilvie.

Introduction: Ogilvie syndrome is a rare condition that can be found in patients who have undergone extensive surgery giving a clinical picture of intestinal obstruction, becoming lethal if not diagnosed in time. There are several pharmacological, endoscopic and surgical treatments to decompress the colon. Clinical case: We present the case of a 35 year-old patient surgically operated on a meningioma suffering from a picture of intestinal obstruction following the intervention, being classified as an Ogilvie Syndrome. The case is presented by the low incidence of the same.

Predictive value of fetal hepatic biometry for birth weight and cord blood markers in gestational diabetes.

OBJECTIVE: The objective of this study is to evaluate third-trimester fetal liver biometry, to predict birth weight and cord markers at birth in diabetic pregnancies. STUDY DESIGN: Fetal liver biometry (liver diameters, area and volume) was obtained between 32 and 34 weeks. A blood sample was obtained from cord after birth. Receiver operating characteristic (ROC) curve models were evaluated for 75th and 90th birth weight percentile. Univariate and multivariate models were used. RESULT: All the hepatic diameters, area and sectional volume demonstrated significant differences in both birth weight percentile ⩾75 and ⩾90. All ROC curves showed significant values. A significant association was observed for all measurements with birth weight. In multivariate model, liver area volume gave significant values for predicting birth weight. Cord leptin, c-peptide and ferritin were related to fetal hepatic size. CONCLUSION: The hepatic changes in gestational diabetes were valid to predict birth weight and metabolic changes at birth.

[Impact of Lean methodology to improve care processes and levels of satisfaction in patient care in a clinical laboratory]. / Impacto de la metodología Lean en la mejora de procesos asistenciales y niveles de satisfacción en la atención de pacientes en un laboratorio clínico.

INTRODUCTION: The application of the Lean methodology in health institutions is an effective tool to improve the capacity and workflow, as well as to increase the level of satisfaction of patients and employees. OBJECTIVE: To optimise the time of outpatient care in a clinical laboratory, by implementing a methodology based on the organisation of operational procedures to improve user satisfaction and reduce the number of complaints for delays in care. MATERIAL AND METHODS: A quasi-experimental before and after study was conducted between October 2011 to September 2012. XBar and S charts were used to observe the mean service times and standard deviation. The user satisfaction was assessed using service questionnaires. RESULTS: A reduction of 17 minutes was observed in the time of patient care from arrival to leaving the laboratory, and a decrease of 60% in complaints of delay in care. Despite the high staff turnover and 38% increase in the number of patients seen, a culture of empowerment and continuous improvement was acquired, as well as greater efficiency and productivity in the care process, which was reflected by maintaining standards 12 months after implementation. CONCLUSION: Lean is a viable methodology for clinical laboratory procedures, improving their efficiency and effectiveness.

Glutathione S-transferase, glutathione peroxidase and acetylcholinesterase activities in mussels transplanted to harbour areas.

As part of an integrative monitoring campaign involving water and sediment chemistry, in situ bioassays, and mussel bioaccumulation and biomarkers, Mytilus galloprovincialis mussels of standard size were transplanted from a clean location to five sites in two important harbours from the Atlantic coast of Spain (Vigo and Pasaia). After a 30-day field exposure, the concentrations of major contaminants (trace metals, polychlorinated biphenyls and polycyclic aromatic hydrocarbons) accumulated in mussel tissues were measured at each site, and a mussel bioaccumulation index (MBI) was calculated. The enzymatic activity levels of glutathione S-transferase (GST), glutathione peroxidase (GPx) and acetylcholinesterase (AChE) were quantified in the gills of transplanted mussels (n=12). Mussels from the most polluted sites consistently exhibited significantly higher GST and GPx activities compared to the control site, whereas AChE activity was significantly inhibited. The responses of the GST and GPx activities were related to MBI, trace metals and PAH concentrations in mussels, whereas AChE activity was related to the trace metals concentrations in mussels. The above results suggest that GST and AChE activities can be used as potential biomarkers for active monitoring in marine coastal ecosystems. However, at this moment, GPx activity is not robust enough to be applicable to harbour areas.

[Incidental aneurysms and perimesencephalic subarachnoid haemorrhages]. / Aneurismas incidentales en el contexto de hemorragias subaracnoideas perimesencefálicas.

A perimesencephalic subarachnoid hemorrhage refers to the presence of bleeding around the midbrain with a normal angiography, meeting the well established clinical criteria and radiological criteria. Unlike the aneurysmal subarachnoid hemorrhage, it has a good prognosis, the recovery in most cases being complete and satisfactory. On the other hand, between 2 and 5% of the population will develop an intracranial aneurysm in the course of their life, most of them asymptomatic, with the likelihood of finding an incidental aneurysm in patients who have suffered a perimesencephalic hemorrhage. The importance of a proper diagnosis governs the course to follow, being a challenge for vascular treatment teams who must analyse the findings in detail and individualize treatment decisions.

Improving the use of sputum cultures in lower respiratory tract infection.

BACKGROUND: The clinical value of sputum culture in suspected lower respiratory tract infection (LRTI) remains contentious. The quality of samples submitted significantly impacts their clinical usefulness. METHODS: Using pre-defined criteria we prospectively analysed the appropriateness of sputum samples submitted from consecutive patients with suspected LRTI attending two acute hospital units over ten weeks. We then provided an education package for staff on when and how to collect appropriate sputum samples, and repeated the evaluation. RESULTS: Our intervention reduced sample numbers from 347 to 133, simultaneously increasing the proportion of appropriately sent samples from 40.5 to 60.2% (p=0.001) and reducing cost. Appropriate sampling was associated with a higher yield of pathogens (relative risk 1.51, 95% confidence intervals 1.03-2.21, p=0.03). The rate at which sputum samples appeared to alter clinicians' management remained low and constant at 18% pre- and post-intervention. CONCLUSION: A simple educational intervention can significantly increase appropriateness of sputum sampling, reducing workload and cost.

Application of Toxicity Identification Evaluation (TIE) procedures for the characterization and management of dredged harbor sediments.

This study refers to the performance of Phase I Toxicity Identification Evaluation (TIE) procedures to identify the contaminants (i.e. organic compounds, metals and ammonia) exerting toxicity in marine sediments from the Pasaia harbor (Oiartzun estuary, northern Spain). The effectiveness of the manipulations to reduce toxicity was proved with the marine amphipod survival test (whole-sediment) and the sea urchin embryo-larval assay (elutriates). By means of TIEs it was concluded that organic compounds were the major contaminants exerting toxicity, although toxic effects by metals was also demonstrated. Additionally, the combination of Phase I treatments allowed to investigate the toxicity changes associated to the mobility of contaminants during dredging activities. Therefore, the performance of TIE procedures as another line of evidence in the decision-making process is recommended. They show a great potential to be implemented at different steps of the characterization and management of dredged harbor sediments.

Integrative sediment assessment at Atlantic Spanish harbours by means of chemical and ecotoxicological tools.

This study refers to the integrative assessment of sediment quality in three harbour areas at the Spanish Atlantic Coast: Vigo (Northwestern Spain), Bilbao and Pasajes (Northern Spain). At each site, two lines of evidence have been considered: chemical analyses (metal, PAH and PCB concentrations in sediments and ammonia concentration in bioassays) and toxicity tests (Microtox®, Corophium sp. marine amphipod and Paracentrotus lividus sea urchin larvae). Chemical and ecotoxicological results have been integrated by means of a tabular matrix and a multivariate factorial analysis (FA). Highly toxic samples have been characterised in Vigo and Pasajes harbours while Bilbao samples present toxicity levels ranging from non-toxic to moderately toxic. High toxicity is associated with high levels of contaminants whereas confounding factors (ammonia, organic matter and mud) have been identified to be the main cause of low to moderate toxicity. Based on the obtained results, it can be concluded that deriving potential toxicity of sediments based on comparison with Sediment Quality Guidelines (SQGs) is in agreement to toxicity results in areas presenting high levels of contaminants. However, at lower levels of toxicity (low to moderate), the mismatch between the potential toxicity (SQG approach) and the toxicity measured by bioassays is greater, as the former only accounts for chemical concentrations, without considering the interaction between contaminants and the effect of confounding factors. Contrarily, the multivariate analysis seems to be a robust tool for the integration and interpretation of different lines of evidence in areas affected by different sources of contamination.

Extracellular matrix, biotensegrity and tumor microenvironment. An update and overview.

The extracellular matrix (ECM) constitutes a three-dimensional network that surrounds all cells, organs and tissues in the body. It forms a biophysical filter for protection, nutrition and cell innervation, as well as the medium for facilitating immune response, angiogenesis, fibrosis and tissue regeneration. It is the mechanism by which mechanical forces are transmitted to the basement membrane which, through the integrins, supports the tensegrity system and activates the epigenetic mechanisms of the cell. A review and update on current knowledge on this topic reveals how disturbance of the ECM leads to a loss of efficient filtering, nutrition, elimination, and cell denervation functions, in addition to loss of regeneration capacity and disorders in mechanotransduction. Furthermore, such disturbance results in a loss of substrate, and with it the ability to provide a proper immune response against tumor, toxic and infectious agents. Reciprocal communication between ECM stromal and parenchymatous cells directs gene expression. The oncogenic capacity of the stroma derives from the associated cells as well as from the tumor cells, the angiogenic microenvironment and from an alteration in tensegrity; all of which are dependent on the ECM. It has been shown that the malignant phenotype is reversible by correction of the altered cues of the ECM.

Necesidades de cuidado de enfermería en soldados amputados por minas antipersona / Necessities of nursing care in soldiers amputated by antipersonal mine

En el mundo existen más de 500 millones de personas con una u otra forma de discapacidad[1]; la Organización Mundial de la Salud (OMS) sostiene que la proporción oscila entre el 10% y el 12%, del total de la población; la Organización Internacional del Trabajo (OIT) señala que de estos, 400 millones se encuentran en países en desarrollo. El Departamento Administrativo Nacional de Estadísticas (DANE) reconoce que de cada cien colombianos, seis presentan algún tipo de discapacidad permanente y que se presenta una tendencia creciente, de esta situación como consecuencia del conflicto armado. El uso de minas antipersona se constituye en una de las situaciones que además de un gran número de víctimas, genera una amplia gama de problemática social, que evidencia la necesidad de plantear estrategias para el abordaje de una situación de salud que afecta un amplio grupo poblacional, en el que los militares y sus familias son los más afectados, en respuesta a esta situación se plantea la investigación que da origen a este articulo y responde al interrogante asociado a la identificación de necesidades de cuidado de enfermería, vivenciadas por los soldados amputados por minas antipersona durante el proceso de rehabilitación. Se reconoció que en el grupo de necesidades que cobran mayor relevancia son las asociadas a la vinculación de la familia y las redes de apoyo a los procesos de rehabilitación y las que se relacionan con la importancia de incentivar la reconstrucción del proyecto de vida del soldado, que posterior a la amputación manifiesta temores, expectativas e incertidumbre frente al desempeño de los roles previos y a la necesidad de reconstruir o redimensionar, en el marco del proceso de rehabilitación, una nueva forma de relación con el entorno.

Prenatal diagnosis of right aortic arch: associated findings, pregnancy outcome, and clinical significance of vascular rings.

OBJECTIVES: To analyze the characteristics and clinical implications of right aortic arch (RAA) detected in fetal life. METHODS: Retrospective study of all cases of RAA diagnosed prenatally in high-risk patients who underwent fetal echocardiography between 2000 and 2007. RESULTS: There were 48 RAA; 18 had vascular ring (Group 1), including 15 RAA with aberrant left subclavian artery and 3 double aortic arch, and 30 had not vascular ring (Group 2), all RAA with mirror-image branching. The prenatal diagnosis was confirmed in 94%. In Group 1 most fetuses had normal heart (89%), and none had 22q11 deletion. There were 16 live births and all infants but one are asymptomatic (mean follow-up of 31 months). In Group 2 almost all fetuses had congenital heart defects (CHDs) (97%), and five were chromosomally abnormal (17%), including four 22q11 deleted. The 1-year survival rate was 69%, which was significantly higher in Group 1 (89% vs 57%, p < 0.05). CONCLUSIONS: RAA can be accurately diagnosed by fetal echocardiography. The outlook for these patients largely depends on the presence of associated defects, mainly CHDs, and their severity. If isolated, aortic arch anomalies are asymptomatic vascular variants in most cases. This information is important to assist parental counseling in pregnancy.

Conotruncal anomalies in fetal life: accuracy of diagnosis, associated defects and outcome.

OBJECTIVES: To assess the accuracy of prenatal echocardiography, associated anomalies, and outcome of fetuses with conotruncal anomalies (CTA). STUDY DESIGN: We searched our database for CTA prenatally diagnosed between 1990 and 2005. We included tetralogy of Fallot (TOF), transposition of the great arteries (TGA), double-outlet right ventricle (DORV), truncus arteriosus (TA), pulmonary atresia with ventricular septal defect (PA-VSD) and posterior malalignment type VSD with aortic arch obstruction (pmtVSD-AAO). Data of 144 fetuses with complete follow-up were retrieved and analyzed. RESULTS: The main reason for referral was suspected heart defect on a routine obstetric scan (72%). Most cases were detected < or =22 weeks (55%). The presence of a CTA was confirmed postnatally in 143 cases (99%), and the diagnosis of the first fetal echocardiography was correct in 126 (87.5%). Most diagnosis of TOF (33/36, 91.7%), TGA (34/38, 89.5%) and DORV (34/38, 89.5%) were proved correct. Inadequate assessment of the interventricular septum, the distal aortic arch and/or the severity of the right outflow tract obstruction accounted for most errors. The accuracy rate was lower in TA (11/14, 78.6%) and PA-VSD (4/7, 57.1%), with evaluation of the branch pulmonary arteries as the main source of discrepancies. In 7/18 incorrect cases subsequent scans allowed to obtain a correct diagnosis. Most fetuses (64%) had an isolated CTA. Thirty-seven had chromosomal anomalies (26%) but none were found in TGA. 22q11 deletion affected 8.7% of the tested patients. Nuchal translucency (NT) was above 95th centile in 19/104 cases (18%) in which NT were measured. Fifty cases were interrupted. The overall one-year survival rate was 71%, with differences between cases with and without associated defects (9/25, 36% vs. 57/68, 83.8%; p<0.01). The uncomplicated forms of TGA and TOF had the best survival rates (100%). CONCLUSIONS: Most CTA can be diagnosed by fetal echocardiography with a high degree of accuracy. Chromosomal defects should always be ruled out, except for simple TGA. Current survival figures in many isolated CTA, especially simple TGA and TOF, support a change in the "classical" concept that congenital heart defects detected prenatally often have the worst outlook. CONDENSATION: Most CTA can be diagnosed by fetal echocardiography with a high degree of accuracy. Isolated CTA are more common and most of these may have a favourable outcome.

Role of uterine artery Doppler in interpreting low PAPP-A values in first-trimester screening for Down syndrome in pregnancies at high risk of impaired placentation.

OBJECTIVES: Low maternal serum levels of pregnancy-associated plasma protein-A (PAPP-A) are associated with both increased risk of aneuploidies and impaired trophoblastic invasion, while high uterine artery (UtA) resistance is associated with impaired trophoblastic invasion but not with an increased risk of aneuploidies. The aim of this study was to determine whether high UtA resistance plays a role in explaining low PAPP-A levels in the absence of aneuploidies. METHODS: This was a prospective study of 116 singleton pregnancies at high risk for impaired placentation (having at least one major risk factor: prior history of pre-eclampsia, pregestational diabetes mellitus, chronic hypertension, chronic kidney disease, body mass index >30, autoimmune disorder, thrombophilia or recurrent pregnancy loss), booked for routine assessment of risk for aneuploidies by means of the first-trimester combined screening test (nuchal translucency thickness (NT) + PAPP-A + beta-human chorionic gonadotropin (beta-hCG)). Measurement of NT and the mean UtA pulsatility index (PI) were carried out at the 11 to 13 + 6-week scan. All values were calculated in multiples of the median (MoM) adjusted for gestational age. A cut-off risk of 1/270 at time of sampling was adopted to differentiate high- from low-risk groups for trisomy 21. RESULTS: There were 108 patients deemed to be at low risk for trisomy 21 and eight at high risk. None had chromosomal defects, giving a false-positive rate for trisomy 21 of 6.9%. The greatest differences between patients at low risk and those at high risk for trisomy 21 were found in their PAPP-A (0.98 vs. 0.38 MoM, P < 0.01) and beta-hCG (1.09 vs. 1.77 MoM, P = 0.04) values. Greater NT thickness (1.02 vs. 0.90 MoM) and higher mean UtA-PI (1.05 vs. 0.96 MoM) were recorded in the high-risk group, although the differences did not reach statistical significance (P = 0.19 and 0.40, respectively). After log-transformation there were no significant correlations between mean UtA-PI and NT and between mean UtA-PI and beta-hCG. There was a significant negative linear correlation between mean UtA-PI and PAPP-A (r = -0.331; P < 0.01). After adjusting the PAPP-A values by UtA-PI, the false-positive rate for trisomy 21 decreased to 2.6%. CONCLUSION: Mean UtA-PI at the 11 to 13 + 6-week scan may be an effect-modifier variable for PAPP-A that should be taken into account in the first-trimester combined screening for aneuploidies, at least in pregnancies at high risk for impaired placentation.

Hypoplastic left heart syndrome diagnosed in fetal life: associated findings, pregnancy outcome and results of palliative surgery.

OBJECTIVES: To analyze the main prenatal characteristics of hypoplastic left heart syndrome (HLHS), its association with extracardiac anomalies including increased nuchal translucency (NT) and the outcome of affected patients. METHODS: We searched our database for classical forms of HLHS (aortic atresia, mitral and aortic atresia and critical aortic stenosis evolved to a severely hypoplastic left ventricle) prenatally diagnosed between 1998 and 2006. Data on 101 fetuses were retrieved and analyzed. RESULTS: The main reason for referral was suspected heart defect on a routine ultrasound scan (82%). The mean gestational age at diagnosis was 21 weeks. Most cases were detected at < or = 22 weeks (72%), the upper limit for termination of pregnancy (TOP) in our country (Spain). An intact atrial septum was diagnosed in 11 of the 58 fetuses (19%) in which pulmonary vein blood flow was assessed, and this diagnosis was proved to be correct in the six liveborn babies. Most fetuses (68%) had an isolated HLHS. Fourteen fetuses (14%) were chromosomally abnormal and all had associated extracardiac defects. NT was above the 95th centile in 21 of the 74 cases (28%) in which this measurement was available. 79% (58/73) of the cases in which HLHS was detected at < or = 22 weeks were terminated, and no differences in the rate of TOP were found through the study period. Among the 43 continuing pregnancies, seven fetuses died in utero and there were 36 live births; in 12 cases the parents opted for compassionate care and 24 chose to have the infant surgically treated. In the cohort of intention-to-treat cases, the overall survival rate was 36% (9/25). This rate improved from 18% (2/11) in the period 1998-2002 to 50% (7/14) in 2003-2006. There were no survivors in cases with intact atrial septum or when there were associated defects. At follow-up, 2/9 survivors suffered from significant neurological morbidity. CONCLUSIONS: Fetal echocardiography allows an accurate diagnosis of HLHS, which is made in most instances in the first half of pregnancy. Despite the advantage offered by the prenatal detection of HLHS, which provides the opportunity to plan perinatal management, our up-to-date results show that the outlook for these fetuses is still poor, and highlight the importance of presenting these figures when counseling parents with affected fetuses.

Gestational diabetes mellitus in a cohort of HIV-1 infected women.

OBJECTIVES: We undertook a prospective study to estimate the prevalence of gestational diabetes mellitus (GDM) and associated risk factors in a cohort of 669 HIV-1 infected women. METHODS: The O'Sullivan and glucose tolerance tests were performed during regular visits of 609 mothers. RESULTS: The median age of the cohort was 30.7 years (range 16-44), with most women having had heterosexual contact (67%). The majority were in Centers for Disease Control (CDC) category A (71%) and 53% exhibited hepatitis C co-infection. Median viral load and CD4 count at third trimester were 545 cells/microL (range 139-1690 cells/microL) and 1.9 log (range 1.7-5.4), respectively. Seventy-four per cent of the patients were treated with highly active antiretroviral therapy (HAART), of whom 41% received a protease inhibitor (PI). An above-average prevalence of 7% [95% confidence interval (CI) 5.2-9.5] for positive GDM diagnosis was found. Risk factors associated with GDM in univariate analysis included older age, hepatitis C co-infection, stavudine and PI exposure. However, only older age [adjusted odds ratio (AOR) 1.09, 95% CI 1-1.1] and PI exposure (AOR 2.4, 95% CI 1-5.3) remained as independent risk factors for GDM development in multivariate analysis. CONCLUSIONS: In our cohort, the prevalence of GDM appears to be increased, with older age and PI exposure contributing as significant independent risk factors.

Determination of tackiness of chitosan film-coated pellets exploiting minimum fluidization velocity.

The tackiness of aqueous chitosan film coatings and effects of anti-sticking agents on sticking tendency, were evaluated. A novel rapid method exploiting minimum fluidization velocity to determine tackiness was introduced and tested. The pressure difference over the miniaturized fluidized-bed was precisely recorded as a function of velocity of fluidization air. High molecular weight chitosan plasticized with glycerol was used as a film-forming agent. Magnesium stearate, titanium dioxide, colloidal silicon dioxide and glyceryl-1-monostearate (GMS) were studied as anti-sticking agents. Film coatings were performed in a miniaturized top-spray coater. The incorporation of anti-sticking agents led to a clear decrease in tackiness of the chitosan films, and magnesium stearate and GMS were shown the most effective. Film-coated pellets containing magnesium stearate and GMS as an anti-sticking agent were very easily fluidized (showing very low values of minimum fluidization velocity) and were thus classified as the best flowing and the least sticking samples. Both these additives were found anti-sticking agents of choice for aqueous chitosan film coatings. Determination of the experimental minimum fluidization velocity in a fluidized bed, is a useful and sensitive method of measuring the tackiness tendency of film-coated pellets.