Risk factors for worsened quality of life in patients on mechanical ventilation. A prospective multicenter study.

OBJECTIVE: To identify risk factors for worsened quality of life (QoL) and activities of daily living (ADL) at 3 and 12 months after discharge from the Intensive Care Unit (ICU) in patients on mechanical ventilation (MV). DESIGN: A prospective, multicentric observational study was made. SETTING: Three ICUs in Argentina. PATIENTS: The study included a total of 84 out of 129 mainly clinical patients admitted between 2011-2012 and requiring over 24hours of MV. INTERVENTIONS: No interventions were carried out. VARIABLES: Quality of life was assessed with the EQ-5D (version for Argentina), and ADL with the Barthel index. RESULTS: The EQ-5D and Barthel scores were assessed upon admission to the ICU (baseline) and after three months and one year of follow-up. Comorbidities, delirium, ICU acquired weakness (ICUAW), and medication received were daily assessed during ICU stay. The baseline QoL of the global sample showed a median index of [0.831 (IQR25-75% 0.527-0.931)], versus [0.513 (IQR0.245-0.838)] after three months and [0.850 (IQR0.573-1.00)] after one year. Significant differences were observed compared with QoL in the Argentinean general population [mean 0.880 (CI 0.872-0.888), p<0.001; p<0.001; p0.002]. Individual analysis showed that 67% of the patients had worsened their QoL at three months, while 33% had recovered their QoL. In the multivariate analysis, the variables found to be independent predictors of worsened QoL were a hospital stay ≥21 days [OR 12.57 (2.75-57.47)], age ≥50 years [OR 5.61 (1.27-24.83)], previous poor QoL [OR 0.11 (0.02-0.54)] and persistent ICUAW [OR 8.32 (1.22-56.74)]. Similar results were found for the worsening of ADL. CONCLUSIONS: Quality of life is altered after critical illness, and its recovery is gradual over time. Age, length of hospital stay, previous QoL and persistent ICUAW seem to be risk factors for worsened QoL.

Experience with coflex interspinous implant.

A first generation of Coflex implant for non-rigid stabilization of lumbar spine was presented by Samani (Study of a semi-rigid interspinous U fixation system. Spinal Surgery, Child Orthopaedics: 1707, 2000).We started to treat patients with this Coflex device in 2004 and since then more than 600 patients have been operated in our Neurosurgical Department. We are reporting 156 patients treated between December 2004 and 2006 with complete follow-up. The clinical trials of this and other implants provide evidence that this interspinous non-rigid stabilization is useful against low-back pain due to degenerative instability and without serious complications.

[Cranial lesions due to forceps delivery]. / Lesiones craneales secundarias a parto asistido con forceps.

Deliveries with forceps or vacuum-extraction increase the incidence of perinatal craneoencephalic lesions, for which reason cesarean sections are performed more frequently. We report 3 cases of cranial lesions due to forceps deliveries, 2 with depressed skull fractures and 1 with a depressed fracture and an associated epidural hematoma. Diagnosis is made on clinical and radiological founds with CT scan or MRI. Treatment is surgical and consists of elevation of the depressed fracture and evacuation of the hematoma. The correct use of forceps is very important to avoid this kind of lesions in the newborn, especially in cases of difficult delivery.

[Childhood spinal tumours]. / Tumores espinales infantiles

We report a large series of 48 childhood spine tumors diagnosed and treated at our Hospital between 1986 and 2006. Spinal tumors in children are a rare and heterogeneous condition that frequently are diagnosed late because of their uncharacteristic clinical picture. Symptoms are usually limited to diffuse back pain or spinal deformities, prior to leg paresis or sphincter dysfunction. Diagnosis is usually made with MRI or CT. Treatment is surgical in most cases. The prognosis is variable due to the diverse histological findings and it may require the use of complementary treatments as chemotherapy or radiation.

[Brain-stem tumors in children]. / Tumores de tronco cerebral en la población pediátrica.

We report a large series of brain-stem tumors seen during 18 years of at our hospital. We diagnosed and treated a total of 42 patients between 1988 and 2006; 36 of them were operated with partial resection in most cases. Brain-stem tumors constitute a rare condition with very bad prognosis. A surgical complete resection of the mass is not possible in most cases, so the principal surgical objective is reduction and decompression. The best prognosis is seen in patients with low grade tumors with minimal neurologic deficit. Most of these tumors cause death in a short period, usually one year or less.

Angiographic and clinical results after endovascular treatment for middle cerebral artery berry aneurysms.

Sixty-five middle cerebral artery (MCA) aneurysms in 59 patients treated by endovascular treatment (EVT) without the remodelling technique were analyzed. For ruptured aneurysms, the patients in bad condition are predominant and those with Fisher group four is 47.8% and with Hunt and Hess grade (HHG) IV or V are 43.5%. The clinical result is that 58.7% is in mRS 0-3, 21.7% in 4-5 and 19.6% in death. Contrary, 92.3% of the patients in HHG I-III resulted in mRS 0-3. Re-rupture was observed in two cases (4.4%). For all the aneurysms, thromboembolic complications were observed in 12.3% and those were predominant in the aneurysms greater than 10mm in diameter (p<0.05). Hemorrhagic ones occurred in 6.2% which were predominant in the aneurysms less than 10mm in diameter. No mortality was observed by the accidents. In follow-up angiography, Raymond classification was employed and Complete Obliteration or Dog Ear was observed in 24 of 43 cases (55.8%). Recanalization occurred in 10.5% of the cases with complete or almost complete obliterated aneurysms. These results suggested that EVT for the ruptured MCA aneurysms with good grade or the unruptured ones is feasible. Strict follow-up is important like the other aneurysms.

Complex motor behaviors in temporal lobe epilepsy.

Complex motor behaviors differing from typical automatisms were found in 12 of 502 patients with temporal lobe epilepsy. Movements involved proximal limb segments (6) or body axis (6) and were often preceded by auras and followed by automatisms. Seven of 12 patients are seizure free after surgery. The other 5 patients declined surgery.

Cerebral fluid edema: an unusual complication of ventriculoperitoneal shunts.

INTRODUCTION: A case of accumulation of CSF into the brain parenchyma simulating a brain tumor, secondary to an obstructed ventriculoperitoneal shunt, is presented. Until now, only seven cases of this rare complication have been described. CASE REPORT: Magnetic resonance showed an expansive, low-density intracranial lesion on the right frontal and parietal lobe. This mass was biopsied, but no tumor was found and the diagnosis was brain edema. CONCLUSION: The mistake in the diagnosis was due to the clinical symptoms and to the MR images.

Subdural empyema with extension to vertebral canal secondary to salmonellosis in a patient with systemic lupus erythematosus.

CASE REPORT: A case of supratentorial subdural empyema extending to the superior subdural cervical space in a 14-year-old patient with systemic lupus erythematosus is presented. The presumed etiology of the empyema was an intestinal nontyphoidal salmonella infection. DISCUSSION: We review the neurological and neurosurgical complications in systemic lupus erythematosus.

Effects of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure.

The effect of positive end-expiratory pressure (PEEP) on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) has been reported by several investigators, without any consensus being reached. Acute neurological and neurosurgical patients suffer intracranial hypertension and acute lung injury with hypoxemia. Since PEEP may improve hypoxemia but elevate ICP and decrease CPP, it is important to determine the influence of varying levels of PEEP on ICP and CPP. The aim of the study was to investigate the changes in ICP and CPP associated with different levels of PEEP. Twenty patients requiring ICP monitoring and mechanical ventilation were enrolled. Patients had severe head injury (n = 10), spontaneous intracerebral haemorrhage (n = 5), and subarachnoid haemorrhage (n = 5). PEEP was raised from 5 (basal) to 15 cm H2O in steps of 5 cm H2O. After at least 10 minutes of each new PEEP setting, ICP and CPP were measured. PEEP at 10 and 15 cm H2O produced a significant (p < 0.05) increase in intracranial pressure 11.6 +/- 5.6 and 14.6 +/- 6.28 mm Hg, respectively; no significant (p = 0.819) change occurred in CPP.

Defecographic measurements of rectal intussusception and prolapse in patients and in asymptomatic subjects.

OBJECTIVE: The aim of this study was to provide measurements for the defecographic diagnosis of rectal intussusception and rectal prolapse. MATERIALS AND METHODS: Four hundred thirty-seven consecutive patients with defecation and micturition disorders and gynecologic complaints were studied by means of defecography (120 patients), colpodefecography (17 patients), or cystocolpodefecography (300 patients). As a control group, 43 asymptomatic subjects underwent defecographic examination. RESULTS: Thirty-five patients were found to have rectal intussusception and 18, to have rectal prolapse. Anterior and posterior rectal wall folding thickness, intussuscipiens diameter, intussusceptum lumen diameter, and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were measured in all patients. The findings were compared with those obtained in 13 of 43 asymptomatic subjects with rectal outline changes mimicking intussusception. Rectal folding thickness and the ratio between the intussuscipiens diameter and the intussusceptum lumen diameter were significantly greater in subjects with rectal intussusception and rectal prolapse than in asymptomatic subjects with rectal mucosa folding. CONCLUSION: Our findings suggest that dynamic evacuation radiology contributes to making a differential diagnosis between rectal intussusception and mucosal folds in the rectum.

[Acute anemia in high digestive hemorrhage. Margins of security for their handling without transfusion of red globules]. / Anemia aguda en la hemorragia digestiva alta. Márgenes de seguridad para su manejo sin transfusiones de glóbulos rojos.

Red cells transfusion in the patient with acute hemorrhage, must be evaluated in a risk/benefit rate context. The present tendencies appoint that the use of the hematocrit "magic" number is unsafe and uncertain to decide a red cell transfusion. We have conducted a prospective randomized and controlled trial in 60 patients with acute digestive hemorrhage without haemodynamic failure. We realized two groups: 1) control group: the target of transfusion in these patients was the hematocrit value of > or = 28%. 2) treatment group: these patients were supported with normovolemic haemodilution with crystalloid solutions until a hematocrit value of 21%. All patients have endoscopic diagnosis and they went evaluated across the study with clinic and laboratory controls. Both groups were significative differences in the hematocrit value. We did not see differences between the groups in the hospital stay neither the rate of organs failure. We find difference between the groups in the amount of red cell units (0.61 +/- 0.87 vs. 2.14 +/- 1.10; treatment and control respectively, P < 0.001). The APACHE score was greater in the treatment group. This supports that the oldest patients, who probably have least physiologic reserve, could be treated without complications. Acute hemorrhage-normovolemic haemodilution-digestive hemorrhage transfusion.

[Dysembrioplastic neuroepithelial tumors]. / Tumores neuroepiteliales disembrioplásicos.

INTRODUCTION: The dysembryoplastic neuroepithelial tumours, first defined by Dumas-Duport in 1988, are characterized histologically by being found in the cerebral cortex and having a histological pattern of multinodular architecture, foci of cortical dysplasia and a specific glioneuronal element. The clinical condition is characterized by seizures with a long evolution. These seizures are usually simple or complex partial seizures, but occasionally become generalized tonic-clonic seizures. Radiological findings on CAT or MR are cystic images localized to the cortex, with a solid component and do not cause displacement. The surgical operation required involves excision of the lesion or lesionectomy. This may be done so as to include 1 cm of the periphery of the lesion. The evolution is excellent and in most cases the seizures disappear. CLINICAL CASES: We present 4 cases of a series of 470 patients with tumours of the nervous system, operated on over the past 10 years in the Hospital del Niño Jesús. The evolution of these 4 cases has been from 1 to 5 years. In all 4 cases lesionectomy was carried out, and the evolution has been excellent (grade I of Engel's classification). CONCLUSIONS: 1. Dysembryoplastic neuroepithelial tumours are solid and cystic, situated in the cerebral cortex, with foci of cortical dysplasia. They are characterized by having a specific glioneuronal element. 2. Clinically they are characterized by crises with a long evolution. 3. The surgical operation involves lesionectomy or excision of the lesion. The evolution is excellent.

Anemia aguda en la hemorragia digestiva alta. Márgenes de seguridad para su manejo sin transufiones de glóbulos rojo / Acute anemia in high digestive hemorrhage. Margins of securety for their bandling without transfusion of red globules

La transfusión de glóbulos rojos en el paciente con hemorragia aguda, debe siempre ser evaluada en el contexto de una ecuación riesgo beneficio. Las tendencias actuales parecen concluir que resulta inseguro y poco confiable, la utilización de un valor "mágico" de hemotocrito (Hto) para decidir realizar una transfusión de glóbulos rojos. Nosotros hemos realizado un estudio prospectivo, controlado y randomizado, en 60 pacientes con hemorragia digestiva alta aguda, sin deterioro hemodinámico y se los dividió en dos grupos: 1) control: En los que la transfusión se realizaba para mantener el Hito en valores > 28 por ciento. 2) tratamiento: en los que se intensificó hemodilución normovolémica, con soluciones cristaloides y se los montuvo sin transfusión hasta un valor de Hto de 21 por ciento. Todos poseían diagnostico endoscópico de ingreso y fueron evaluados durante el estudio con controles clínicos y de laboratorio. Ambos grupos difirieron significativamente en el valor de el Hto. y Hb. No se observaron diferencias entre los grupos en el número de días de internación requeridos, ni en el número de falla de órganos presentado. Sí hubo diferencia significativa entre los grupos en la cantidad de unidades de glóbulos utilizadas (0.61 + 0.87 vs. 2.14 + 1.10; tratamiento y control respectivamente p < 0.001). El Score APACHE difirió significativamente, siendo mayor en el grupo tratamiento. Ello sugiere que aún los pacientes con mayor edad y probablemente menor reserva fisiológica pueden ser manejados con una conducta transfusional restrictiva, sin complicaciones graves.

Pneumocephalus after shunting for hydrocephalus.

A case of tension pneumocephalus that occurred after ventriculoperitoneal shunting is presented. We have reviewed 12 cases of pneumocephalus in association with ventriculoperitoneal shunt placement. This phenomenon occurs when air is forced through the shunt or enters through the cranial base because of: iatrogenic postsurgical connection, congenital fistula, trauma, or thinning of the cranial base. Ways of preventing and treating this problem are outlined.

[Hydration in diabetic ketoacidosis. What is the effect of the infusion rate?]. / Hidratación en la cetoacidosis diabética. Cómo influye la velocidad de infusión?

Diabetic ketoacidosis (DKA) involves severe volume depletion; usually a large volume of saline solution is used, but fluid reposition rate remains controversial. With the aim of properly defining fluid administration in DKA without associated illness, we performed a prospective, randomized study in 27 patients under two therapeutic regimes which differed only with regard to the repletion rate. Group 1 (14 patients) received 0.9% saline solution at a rate of 1000 ml/h, and group 2 (13 patients) at 500 ml/h. At admission to the hospital, at 2, 4, 8, 12 and 24 hours, arterial acid-base status and plasma sodium, potassium and chloride levels were measured. Both groups had similar biochemical characteristics at admission. All patients corrected the ketoacidotic disorder and there was neither mortality nor complications. We did not find any significant difference in any of the metabolic determinations among the different groups along the evolution. With regard to baseline determinations, in both groups, arterial pH increased after two hours. No changes were observed in anion gap, chloride, sodium or potassium among the therapeutic groups. We conclude that, regarding morbidity and mortality, in DKA patients without severe volume depletion it is equally effective to infuse 500 ml/h as 1000 ml/h as fluid repletion rate. Administration of modest amounts of fluids in these cases would result in reducing costs.

Trigeminal neurinomas in infants: report of two cases.

Two cases of trigeminal neurinoma in two infant girls aged 3 and 6 months are reported. Both presented with temporal cranial vault bulging at birth. The 6-month-old patient suffered onset of focal fits 1 month before admission and her neurological examination revealed no abnormalities. The 3-month-old patient had right exophthalmus and a subcutaneous fronto-orbital plexiform neurofibroma at birth. Neurological examination disclosed a sensory deficit of the first trigeminal nerve division. She also had a family medical history of von Reckling-hausen's disease. The incidence of trigeminal neurinomas in children is reviewed. The patients in these two cases are the youngest recorded; the cases are the only ones reported in infants. Clinical, radiological, and therapeutic aspects are discussed.

Intoxicación barbitúrica grave / Dangerous barbituric intoxication

Se realizó un estudio retrospectivo con los objetivos de establecer la prevalencia de la intoxicación barbitúrica grave en un servicio de Terapia Intensiva, conocer la incidencia de complicaciones y la mortalidad, y evaluar el tratamiento utilizado. Se analizaron 15 pacientes, la mayoría jóvenes y de sexo femenino. Se registraron 19 episodios de complicaciones. El 86 por ciento de los pacientes se hallaba en coma al ingreso (escala de Glasgow < 8). El deterioro hemodinámico se observó en el 46,7 por ciento de los casos, y el 60 por ciento requirió ventilación mecánica. El protocolo de tratamiento incluyó: 1) Diálisis intestinal (utilización de carbón activado y de purgantes salinos con el objetivo de lograr catarsis en las primeras 48 hs del tratamiento); 2) Diuresis alcalina; 3) Sostén de funciones vitales. La mortalidad fue del 13 por ciento. Conclusión: Evitar el lavado gástrico, iniciar precozmente el protocolo de diálisis intestinal y realizar hemodiálisis sólo si aquélla fracasa, durante las primeras 24 hs