Perioperative anaphylactic risk score for risk-oriented premedication.

Basing on the current knowledge, this paper is aimed to review the core characteristics of the most relevant therapeutic agents (steroids and antihistamines), administered to prevent perioperative anaphylaxis. Moreover, the Authors propose the validation of a Global Anaphylactic Risk Score, built up by recording the individual scores related to the most relevant anaphylaxis parameters (i.e. medical history, symptoms and medication for asthma, rhinitis and urticaria etc) and by adding them on all together; the score could be used in the preoperative phase to evaluate the global anaphylactic risk and to prescribe risk-oriented premedication protocols.

Seguridad y eficacia de la colocación del catéter de diálisis peritoneal aguda por punción en pacientes con síndrome urémico hemolítico asociado a diarrea / Safety and efficacy of percutaneous acute peritoneal dialysis catheter placement in patients with post-diarrheal hemolytic uremic syndrome

Introducción: La diálisis peritoneal aguda (DPA) es la modalidad dialítica preferentemente seleccionada para niños con injuria renal aguda por síndrome urémico hemolítico postdiarreico (SUH D+). Evaluamos la seguridad y eficacia de la colocación por punción percutánea del catéter de DPA con anestesia local en niños con SUH D+. Pacientes y métodos: Se revisaron las historias clínicas de todos los pacientes con SUH D+ internados entre el 1 de enero de 1998 y el 31 de diciembre de 2008 en el Hospital de Pediatría Prof. Dr. Juan P. Garrahan. La seguridad se evaluó por la presencia de eventos adversos mayores relacionados con la colocación del catéter (per foración de vísceras y/o vasos mayores abdominales, sangrado que requiera transfusión) y menores (infección del sitio de salida y peritonitis dentro de las 48 hs del procedimiento). La eficacia se evaluó a través de la colocación exitosa del catéter y su buen funcionamiento. Además se registró la necesidad de recambio luego de su uso por mal funcionamiento. Resultados: Identificamos 149 pacientes que realizaron DPA, edad de 20.2 meses (rango 2,9-111) y peso de 11,35 kg (rango 5-24.4). Recuento de plaquetas previo al procedimiento de 89000 (22000-148000) mm3. Seguridad: el único efecto adverso detectado fue el desarrollo de peritonitis en un paciente. No se registró perforación de órganos ni de vasos mayores abdominales, ni sangrado severo, ni infección del sitio de salida. Eficacia: en todos los casos el catéter fue colocado exitosamente y en 48 pacientes (32.2%) hubo que recambiarlo por mal funcionamiento. Tanto la colocación como el recambio fueron realizadas en todos los casos por el nefrólogo al pie de la cama. Conclusión: la colocación del catéter de DPA por punción es un procedimiento seguro y eficaz.

ntroduction: Acute peritoneal dialysis (DPA) is the dialytictreatment of choice for children with acute kidney injury dueto post-diarrheal hemolytic uremic syndrome (D+HUS). In thisstudy safety and efficacy of percutaneous placement of anAPD catheter under local anesthesia in children with D+HUSwas assessed. Patients and methods: We reviewed the cli-nical charts of all patients with D+HUS admitted to thePediatric Hospital Prof. Dr. Juan P. Garrahan betweenJanuary 1, 1998 and December 31, 2008. Safety was eva-luated based on the presence of major (perforation of theviscera and/or major abdominal vessels, bloody dialysaterequiring red-blood-cell transfusion) and minor (exit-siteinfection and peritonitis within 48 hs of the procedure) adverse events associated with catheter insertion. Efficacy was assessed based on successful catheter insertion and func-tioning. Additionally, the need for catheter replacement dueto malfunction was recorded. Results: We identified 149patients with a mean age of 20.2 months (range, 2.9-111)and weight of 11.35 kg (range, 5-24.4) who underwent APD.Median platelet count previous to the procedure was 89000(range, 22000-148000) mm3. Safety: The only adverse eventfound was the development of peritonitis in one patient.Organ or major vessel perforation, severe bleeds, or exit-site infection were not observed. Efficacy: In all patients the catheter was successfully inserted and in 48 patients (32.2%) the catheter had to be replaced due to malfunctioning. Both placement and replacement were performed by a nephrologist at the bedside in all cases. Conclusion: Percutaneous APD catheter insertion is a safe and efficacious procedure.

The effect of an enhanced infection-control policy on the incidence of Clostridium difficile infection and methicillin-resistant Staphyloccocus aureus colonization in acute elderly medical patients.

BACKGROUND: Clostridium difficile (CD) infection and methicillin-resistant Staphylococcus aureus (MRSA) colonization are increasingly common in elderly patients, are associated with cephalosporin or prolonged aminopenicillin courses and can be transmitted by direct contact. Management is by side-room isolation. Ward closure may be required to control outbreaks. METHODS: following prolonged bed closures due to CD and MRSA in an acute age-related geriatric service, an enhanced infection control policy was introduced-emphasis on handwashing, cephalosporin restriction, 7-day time limits on antibiotics and feedback of infection rates. The effect of this policy was evaluated by investigating 2,467 consecutive admissions in the 9 months before and after its introduction. RESULTS: CD infection fell from 36/1,075 admissions (3.35 per 100) to 27/1,392 (1.94 per 100; P < 0.05). MRSA incidence fell from 3.95 per 100 to 1.94 (P < 0.01) whilst that in the rest of the hospital continued to fluctuate. Cephalosporin use fell (and aminopenicillin and trimethoprim use rose) by a factor of three. Unoccupied bed days fell from 1,164 (12.6%) to 513 (5.1%) over the winter, an increase in bed availability of 4.95 a day. CONCLUSIONS: introduction of the policy was associated with significant reductions in CD infection and unoccupied bed-days and helped maintain a lower incidence of MRSA. It is not clear which elements of the policy most influenced outcome. A multi-centre study is needed to determine whether our findings are generally applicable.

Dolor torácico atípico: estudio mediante la prueba de provocación del ácido clorhídrico / Atypical chest pain: study by the hydrochloric acid provocation test

El propósito del trabajo es estudiar el origen del dolor torácico (DT) atípico en pacientes con coronariografía normal (CN) y patológica (CP) mediante la prueba de provocación de Bernstein evaluándolo por medio de electrocardiograma (ECG), índice tensión tiempo (ITT) y electromanometría de esófago (EMM). Se estudiaron dos grupos, uno de 16 controles sanos en quienes se hizo manometría determinando la presión de la zona de alta presión (ZAP), presióm de la onda peristálica (PO), duración (DO) y velocidad de propagación (VPO) de la misma y porcentaje de ondas aperistálicas (%Ap). El segundo grupo estaba constituido por 21 pacientes con dolor torácico con coronariografía patológica (10 pacientes). En ellos se determinó en formas simultánea la presencia de DT, ECG, ITT y EMM; luego de un período basal y de la perfución esofática de placebo y ácido clorhídrico 0.1 N. El 61,9% de los pacientes con DT mostraron transtornos basales de la dinámica esofágica tales como aumento de la ZAP, DO, VPO y % Ap. El análisis estadístico global fue significativo en cuanto a la relación FC/ITT. La prueba de provocación del DT por medio de la perfusión de HCI 0.1 fue positiva en 14.2% de los pacientes (AU)

Dolor torácico atípico: estudio mediante la prueba de provocación del ácido clorhídrico / Atypical chest pain: study by the hydrochloric acid provocation test

El propósito del trabajo es estudiar el origen del dolor torácico (DT) atípico en pacientes con coronariografía normal (CN) y patológica (CP) mediante la prueba de provocación de Bernstein evaluándolo por medio de electrocardiograma (ECG), índice tensión tiempo (ITT) y electromanometría de esófago (EMM). Se estudiaron dos grupos, uno de 16 controles sanos en quienes se hizo manometría determinando la presión de la zona de alta presión (ZAP), presióm de la onda peristálica (PO), duración (DO) y velocidad de propagación (VPO) de la misma y porcentaje de ondas aperistálicas (%Ap). El segundo grupo estaba constituido por 21 pacientes con dolor torácico con coronariografía patológica (10 pacientes). En ellos se determinó en formas simultánea la presencia de DT, ECG, ITT y EMM; luego de un período basal y de la perfución esofática de placebo y ácido clorhídrico 0.1 N. El 61,9% de los pacientes con DT mostraron transtornos basales de la dinámica esofágica tales como aumento de la ZAP, DO, VPO y % Ap. El análisis estadístico global fue significativo en cuanto a la relación FC/ITT. La prueba de provocación del DT por medio de la perfusión de HCI 0.1 fue positiva en 14.2% de los pacientes

[Atypical chest pain: study by the hydrochloric acid provocation test]. / Dolor torácico atípico: estudio mediante la prueba de provocación del ácido clorhídrico.

Evaluation by means of gastroenterological and cardiological methods. The purpose of this paper was to study the origin of chest pain (CP) in patients with normal and pathological coronary arteries as characterized by coronary arteriogram (CA). Sixteen normal control individuals (X 27 years -7 females and 9 males) were studied by means of esophageal manometry (EM) with a 3 way catheter perfused by a low compliance capillary system. Twenty-one patients with chest pain were studied and divided according to coronary arteriogram in normal (NC) and pathological arteries (PC). They were simultaneously studied by means of EM, heart rate/pressure product (RPP), and 12 lead ECG monitoring. After a basal period they were given a Bernstein's provocative chest pain test, and after each of its stages we determined in a simultaneous fashion CP, EM, ECG and RPP. In 61.9% of the patients abnormal basal EM was found. It was characterized by increase in HPZ, duration, propagation velocity and pressure of the peristaltic waves: as well as an increase in the percentage of aperistaltic waves. In 14.2% of the patients the Hydrochloric provocative test was positive. The only statistically significant datum was the heart rate/RPP relationship. We conclude that in future studies it would be of interest to combine 24 hour monitoring EM and pH as well as a more sensitive provocation test such as edrophonium chloride.

Dolor torácico atípico: estudio mediante la prueba de provocación del ácido clorhídrico. / [Atypical chest pain: study by the hydrochloric acid provocation test]

Evaluation by means of gastroenterological and cardiological methods. The purpose of this paper was to study the origin of chest pain (CP) in patients with normal and pathological coronary arteries as characterized by coronary arteriogram (CA). Sixteen normal control individuals (X 27 years -7 females and 9 males) were studied by means of esophageal manometry (EM) with a 3 way catheter perfused by a low compliance capillary system. Twenty-one patients with chest pain were studied and divided according to coronary arteriogram in normal (NC) and pathological arteries (PC). They were simultaneously studied by means of EM, heart rate/pressure product (RPP), and 12 lead ECG monitoring. After a basal period they were given a Bernsteins provocative chest pain test, and after each of its stages we determined in a simultaneous fashion CP, EM, ECG and RPP. In 61.9

of the patients abnormal basal EM was found. It was characterized by increase in HPZ, duration, propagation velocity and pressure of the peristaltic waves: as well as an increase in the percentage of aperistaltic waves. In 14.2

of the patients the Hydrochloric provocative test was positive. The only statistically significant datum was the heart rate/RPP relationship. We conclude that in future studies it would be of interest to combine 24 hour monitoring EM and pH as well as a more sensitive provocation test such as edrophonium chloride.

Penbutolol and molsidomine synergism in angina pectoris. A double blind ergometric trial.

In order to test the additional efficacy of the combination of a beta blocker (penbutolol 40 mg single dose) with molsidomine (2 mg single dose), a double blind cross-over trial was performed in 30 patients with stable angina pectoris. Stress tests were done before and 1 h after the beta blocker alone and the combination therapy. Some training effect could be detected on comparing results from the first and second days. Combined therapy showed a better response of resting systolic arterial pressure, resting and maximal diastolic pressure, heart rate gain (from rest to maximal effort) and particularly in the angina severity score. All of these variables changed significantly in comparison to the beta blocker alone, 46 out of 60 post-drug ergometric studies were negative; of the 14 positive tests, 11 followed the beta blocker and only 3 the combined therapy. The combination of a preload reducer molsidomine and a beta blocker may be adequate for patients only partially compensated or with cardiomegaly and/or a depressed ejection fraction.