Characterization of skeletal parameters in a cohort of North Italian rugby players.

BACKGROUND: Vitamin D deficiency is common in the general population and may impair skeletal muscle function. Very few data are available regarding this condition in professional athletes. AIM: To evaluate some skeletal parameters and in particular serum 25-hydroxyvitamin D status in professional rugby players during two different sunlight exposure times (October and early April) and to assess its impact on bone metabolism. MATERIALS AND METHODS: Twenty-one male healthy professional rugby players living in northern Italy at latitude of 44°55'N (age 24.6 ± 4.3 years; height 182.0 ± 0.05 cm; mass 96.3 ± 14.6 kg; BMI 28.9 ± 3.7 kg/m(2)) participated in this observational study. During 2012/2013 Italian rugby season, 25-hydroxyvitamin D, PTH and other related biochemical parameters were monitored. Dietary calcium intake and body composition by DXA were also evaluated. RESULTS: Significant changes were observed between October and April data for 25-hydroxyvitamin D concentration (22.8 ± 5.8 vs. 19.1 ± 5.3 ng/ml; p = 0.001) whereas serum PTH, calcium and phosphorus plasma levels did not change. They presented with an appropriate daily intake of calcium (1,304.8 ± 477.9 mg; max 1,939 mg; min 228 mg). CONCLUSIONS: Professional rugby athletes practicing a sport characterized by intense outdoor training and with good calcium intake are at higher risk of hypovitaminosis D that worsens significantly during times of low cutaneous vitamin D production. Further studies are warranted to evaluate whether an appropriate supplementation with cholecalciferol in professional athletes is needed.

Prevalencia de la hipertensión arterial en poblaciones rurales del norte argentino / Prevalence of arterial hypertension in rural areas of the north of Argentina

Como parte de un proyecto de atención médica primaria llevado a cabo en localidades rurales de la provincia del Chaco (Argentina), se realizó un estudio epidemiológico sobre la HTA (hipertensión arterial). La población analizada incluyó a 473 adultos. Según la clasificación del JNC-VII la prevalencia de HTA fue del 32,3%, prehipertensión arterial del 34,7%, y presión arterial normal del 33%. El sexo no era significativamente distinto en la población general, nientre los subgrupos de hipertensos y no hipertensos. La diabetes fue significativamente mayor entre los hipertensos, y los fumadores eran estadísticamente menos frecuentes en el grupo de HTA. En un subgrupo de paciente con diagnóstico de HTA, el 2,5% tenía criterios de hipertrofiaventricular izquierda en el electrocardiograma; el 14% retinopatía leve, y el 5% moderada en el examen del fondo de ojo (AU)

An epidemiological study on hypertension was carried out as part of a primary medical care program conducted in the rural areas of the Chaco state (Argentina). The population studied included 473 adults. According to the JNC-VII classification criteria, prevalence of hypertension was 32.3%, prehypertension 34.7%, and normal blood pressure 33%. Gender was not statistically different in the general population or between the subgroups of subjects with hypertension or normal blood pressure. Diabetes was significantly greater among the hypertensive group and smokers were statistically less frequent in the arterial hypertensive group. In the subgroup of patients with a diagnosis of hypertension, 2.5% had criteria for left ventricular hypertrophy (LVH) on the electrocardiogram whereas the eye fundus examination showed that14% had mild retinopathy and 5% had moderate retinopathy (AU)

[Septic thrombophlebitis of the portal vein associated with reversible portal hypertension]. / Tromboflebitis séptica de la vena porta asociada a hipertension portal reversible.

Septic thrombophlebitis of the portal vein is an unusual and serious complication of abdominal infection. We present a patient with thrombophlebitis of the portal vein of unknown origin, suffering from fever, abdominal pain, jaundice, abnormal liver test function and bacteremia related to Bacteroides fragilis. Ultrasonography, with doppler of the portal vein, was performed which showed thrombosis of the portal vein together with signs of portal hypertension. The patient underwent six weeks of antibiotic treatment. The evolution was favourable, the infection was overcome and the portal vein was de-obstructed as a consequence of which the signs of portal hypertension disappeared.

Tromboflebitis séptica de la vena porta asociada a hipertension portal reversible. / [Septic thrombophlebitis of the portal vein associated with reversible portal hypertension]

Septic thrombophlebitis of the portal vein is an unusual and serious complication of abdominal infection. We present a patient with thrombophlebitis of the portal vein of unknown origin, suffering from fever, abdominal pain, jaundice, abnormal liver test function and bacteremia related to Bacteroides fragilis. Ultrasonography, with doppler of the portal vein, was performed which showed thrombosis of the portal vein together with signs of portal hypertension. The patient underwent six weeks of antibiotic treatment. The evolution was favourable, the infection was overcome and the portal vein was de-obstructed as a consequence of which the signs of portal hypertension disappeared.

[Application of a preoperative evaluation model in patients undergoing elective abdominal surgery]. / Aplicación de un modelo de evaluación preoperatoria en pacientes operados de cirugia abdominal electiva.

We used a preoperative evaluation model based on the clinical history in order to determine the clinical characteristics of the patients. We also estimated the prevalence of asymptomatic disease in ASA1 patients and described the frequency of diagnosis that motivated suspension of the surgery during the preoperative time. Another purpose was to establish the perioperative complications according to the risk index and to detect the medical reasons for suspension of surgery during hospitalization. A total of 777 patients having an indication of surgery were evaluated in this program. Only 507 completed the preoperative evaluation. Of these, 57.79%, had at least one known disease or were diagnosed by their clinical history. Preoperative tests were indicated according to age in ASA1 patients. Complementary studies were indicated in relationship to the history and physical examination in ASA2 and ASA3 patients. After the evaluation, 27 surgeries were suspended: 21 were considered high risk, 2 suffered unknown active infections, and 4 ASA1 patients had severe asymptomatic anemia. A total of 328 patients were admitted for surgery. In 5 of these patients the anesthesiologist stopped the procedure in the operating room. The causes were acute decompensations of known pathologies. There were no complications or deaths related to unknown diseases and no patients died from cardiopulmonary or metabolic complications. In ASA1 patients, there were no complications related to this evaluation. This study allowed us to determine the clinical status of the patients and in consequence high-risk surgeries were canceled. In admitted patients a few surgeries were canceled for clinical reasons. This program probably decreased patient morbimortality, unnecessary hospitalization and costs.

Aplicación de un modelo de evaluación preoperatoria en pacientes operados de cirugia abdominal electiva. / [Application of a preoperative evaluation model in patients undergoing elective abdominal surgery]

We used a preoperative evaluation model based on the clinical history in order to determine the clinical characteristics of the patients. We also estimated the prevalence of asymptomatic disease in ASA1 patients and described the frequency of diagnosis that motivated suspension of the surgery during the preoperative time. Another purpose was to establish the perioperative complications according to the risk index and to detect the medical reasons for suspension of surgery during hospitalization. A total of 777 patients having an indication of surgery were evaluated in this program. Only 507 completed the preoperative evaluation. Of these, 57.79

, had at least one known disease or were diagnosed by their clinical history. Preoperative tests were indicated according to age in ASA1 patients. Complementary studies were indicated in relationship to the history and physical examination in ASA2 and ASA3 patients. After the evaluation, 27 surgeries were suspended: 21 were considered high risk, 2 suffered unknown active infections, and 4 ASA1 patients had severe asymptomatic anemia. A total of 328 patients were admitted for surgery. In 5 of these patients the anesthesiologist stopped the procedure in the operating room. The causes were acute decompensations of known pathologies. There were no complications or deaths related to unknown diseases and no patients died from cardiopulmonary or metabolic complications. In ASA1 patients, there were no complications related to this evaluation. This study allowed us to determine the clinical status of the patients and in consequence high-risk surgeries were canceled. In admitted patients a few surgeries were canceled for clinical reasons. This program probably decreased patient morbimortality, unnecessary hospitalization and costs.

[Intra-abdominal infection and new quinolones]. / Infección intraabdominal y nuevas quinolonas.

Intra-abdominal infection is defined as the presence of an infectious process within the peritoneal cavity. It may be local or have a systemic consequence generating multiple organic disfunction. Most of the studies report a mortality of 30% in severe intra-abdominal infection. Secondary peritonitis is caused by the loss of integrity of the gastrointestinal apparatus, which contaminates with pathogens the peritoneal cavity. Invariably they are polymicrobial infections, mostly due to facultative anaerobic and anaerobic Gram negative bacilli. Prognosis of peritonitis depends on the struggle between two forces: local and systemic immunity of the host and the volume, nature and length of the contamination. Microorganisms and their products estimulate cellular defenses in the host and activate numerous inflammatory mediators responsible for sepsis. Antibiotic treatment of secondary peritonitis must act mainly against Escherichia coli and Bacteroides fragilis. The adequate and early empirical administration of antibiotics against these bacteria is well established. It is necessary to consider if the infection is localized or generalized and if it is accompanied or not by organic disfunction. It also has to be taken into account if peritonitis is community or hospital-acquired when choosing the antibiotic scheme. In community-acquired peritonitis with low to moderate infections a combination of metronidazole-ceftriaxone, metronidazole-gentamycin or a monodrug like ampicillin-sulbactam may be used. In severe hospital-acquired peritonitis imipenem or the combination piperacillin-tazobactam are effective. New quinolones such as trovafloxacin or clinafloxacin, with excellent activity against aerobes and anaerobes producing intra-abdominal infections, may be effective. Future clinical trials are needed to determine their utility. Tertiary peritonitis represent a systemic inflammatory response with multiorganic failure due to the uncontrolled activation of the inflammatory cascade. It is considered a persistent, systemic peritoneal inflammation. Antibiotics and new surgery do not seem to be useful in this situation.

Infección intraabdominal y nuevas quinolonas. / [Intra-abdominal infection and new quinolones]

Intra-abdominal infection is defined as the presence of an infectious process within the peritoneal cavity. It may be local or have a systemic consequence generating multiple organic disfunction. Most of the studies report a mortality of 30

in severe intra-abdominal infection. Secondary peritonitis is caused by the loss of integrity of the gastrointestinal apparatus, which contaminates with pathogens the peritoneal cavity. Invariably they are polymicrobial infections, mostly due to facultative anaerobic and anaerobic Gram negative bacilli. Prognosis of peritonitis depends on the struggle between two forces: local and systemic immunity of the host and the volume, nature and length of the contamination. Microorganisms and their products estimulate cellular defenses in the host and activate numerous inflammatory mediators responsible for sepsis. Antibiotic treatment of secondary peritonitis must act mainly against Escherichia coli and Bacteroides fragilis. The adequate and early empirical administration of antibiotics against these bacteria is well established. It is necessary to consider if the infection is localized or generalized and if it is accompanied or not by organic disfunction. It also has to be taken into account if peritonitis is community or hospital-acquired when choosing the antibiotic scheme. In community-acquired peritonitis with low to moderate infections a combination of metronidazole-ceftriaxone, metronidazole-gentamycin or a monodrug like ampicillin-sulbactam may be used. In severe hospital-acquired peritonitis imipenem or the combination piperacillin-tazobactam are effective. New quinolones such as trovafloxacin or clinafloxacin, with excellent activity against aerobes and anaerobes producing intra-abdominal infections, may be effective. Future clinical trials are needed to determine their utility. Tertiary peritonitis represent a systemic inflammatory response with multiorganic failure due to the uncontrolled activation of the inflammatory cascade. It is considered a persistent, systemic peritoneal inflammation. Antibiotics and new surgery do not seem to be useful in this situation.

[Digoxin: continuous or discontinuous treatment?]. / Digoxina: tratamiento continuo o discontinuo?

In our country, patients with congestive heart failure who are treated chronically with digoxin are usually advised by their physicians to stop taking the medication two days a week. This is probably aimed at decreasing digitalis toxicity. Based on digoxin pharmacokinetics we assumed that the drug plasmatic level should diminish by 40 to 50%, below the therapeutic concentration of 0.8 to 2 milligrams, after two days of suspension. The objectives of this study were: a) to analyze the reduction of the plasmatic concentration of digoxin after a two day interruption of treatment, b) to compare the plasmatic levels of the drug between patients who received continuous and discontinuous treatment. A prospective, randomized and simple blind trial was designed. A total of 36 patients with congestive heart failure and systolic dysfunction with atrial fibrillation or sinus rythm were included. Group 1 (19 patients) received continuous treatment and Group 2 (17 patients) took the drug from Monday to Friday. In the continuous treatment group there was no significant difference between the Monday (1.06 +/- 0.55 milligrams) and the Friday (1.1 +/- 0.57 milligrams) digoxin concentrations. In the discontinuous treatment group the Monday digoxin concentration (0.611 +/- 0.396 milligrams) was lower than the Friday one (1.04 +/- 0.58 milligrams). The difference was statistically significant with a p = 0.000002. In conclusion, the two days a week suspension schedule reduces the plasmatic concentration of digoxin to subtherapeutic levels while the continuous regime maintains stable concentrations within the therapeutic range. Adjusting the dose to the creatinine clearance, average concentrations of 1 milligram are obtained. These results suggest that digitalis intoxication could be prevented by adjusting the dose according to renal function rather than interrupting the treatment as it is usually done in our country.

[Renal vascular lesion and microangiopathic hemolytic anemia in systemic lupus erythematosus]. / Lesión vascular renal y anemia hemolítica microangiopática en lupus eritematoso sistémico.

A 22 year-old woman with a seven year history of (SLE) was readmitted because of oliguria, edema, dyspnea and arterial hypertension. She had a previous biopsy diagnosis of focal glomerulonephritis, (WHO III b), and had been treated with immunosuppressors and steroids. Laboratory data showed lupus activity, AHM with thrombocytopenia, nephrotic-range proteinuria and renal failure. A second renal biopsy was performed showing diffuse proliferative nephritis, (WHO IV), in association with noninflammatory necrotizing vasculopathy with luminal obliteration. She started with hemodialysis and was subsequently treated with methylprednisolone pulses, plasmapheresis, cyclophosphamide and oral steroids. During the inpatient period, she had generalized seizures, acute lung injury and pulmonary hemorrhage. These complications, the AHM and the thrombocytopenia receded totally. Renal function was never resumed. We emphasize that this association of diffuse proliferative nephritis with noninflammatory necrotizing vasculopathy is not infrequent and has a poor renal prognosis. The AHM with thrombocytopenia was interpreted as secondary to endothelial cell damage due to vasculopathy.

[Preoperative clinical evaluation]. / Evaluación clínica preoperatoria.

The purpose of preoperative evaluation is to reduce the morbidity and mortality of surgical interventions. The operative risk is related to: the nosocomial environment, the anesthetic procedure, the surgical team, the magnitude of the intervention and the patient's psychological, physical and pathological conditions. An adequate history and physical examination are essential to evaluate the patient's clinical situation. In our country, an electrocardiogram (EKG) with an estimation of the "surgical risk" and a number of laboratory tests are usually done. This article discusses the evidence and recommendations on the usefulness and indications of the EKG, the laboratory test, the coagulation tests and the chest X-ray. The decision to order preoperative tests should be based on positive clinical findings, the need to obtain basal values before major interventions and the existence of risk factors for certain diseases. The ambulatory preoperative clinical evaluation is the best method for the detection of diseases that could modify the surgical risk. It is also the opportunity to consult specialists if needed and to indicate necessary prophylactic measures.

Hipokalemia crónica, tetraplejía y coma / Chronic hypokalemia, quadriplegia and coma

Hemos observado la evolución de una paciente de 36 años con menopausia precoz, hipokalemia crónica, grave y persistente, con episodios de astenia, adinamia, hipotonía muscular y arreflexia osteotendinosa y, en su mayor grado de expresión, con kalemia de 0,9 mEq/L, tetraplejía, coma y una arritmia ventricular severa tipo torsades de pointes. Durante su internación se pensaron en numerosas etiologías sospechando, en primer término, en un síndrome de Bartter debido al cuadro de hipokalemia normotensiva. Las cifras de aldosterona y angiotensina I en rangos normales nos hicieron abandonar el diagnóstico por el cual fue medicada en forma sucesiva con indometacina, enalapril, acetazolamida y amiloride. Con este último fármaco y el aumento de las dosis orales de potasio, la paciente normalizó su kalemia, recuperó sus potencialidades psicofísicas y se le dio el alta para su estudio por consultorio externo. Los diagnósticos diferenciales se detallan en los cuadros correspondientes. Los repetidos balances positivos de potasio nos hicieron sospechar en un cuadro clínico aún no determinado de desplazamiento del K+ del LEC al LIC. Destacamos la importancia semiológica por su infrecuencia, sus implicancias reales y potenciales, además de la recuperación con amiloride y aumento de la ingestión de potasio (AU)

Hipokalemia crónica, tetraplejía y coma / Chronic hypokalemia, quadriplegia and coma

Hemos observado la evolución de una paciente de 36 años con menopausia precoz, hipokalemia crónica, grave y persistente, con episodios de astenia, adinamia, hipotonía muscular y arreflexia osteotendinosa y, en su mayor grado de expresión, con kalemia de 0,9 mEq/L, tetraplejía, coma y una arritmia ventricular severa tipo torsades de pointes. Durante su internación se pensaron en numerosas etiologías sospechando, en primer término, en un síndrome de Bartter debido al cuadro de hipokalemia normotensiva. Las cifras de aldosterona y angiotensina I en rangos normales nos hicieron abandonar el diagnóstico por el cual fue medicada en forma sucesiva con indometacina, enalapril, acetazolamida y amiloride. Con este último fármaco y el aumento de las dosis orales de potasio, la paciente normalizó su kalemia, recuperó sus potencialidades psicofísicas y se le dio el alta para su estudio por consultorio externo. Los diagnósticos diferenciales se detallan en los cuadros correspondientes. Los repetidos balances positivos de potasio nos hicieron sospechar en un cuadro clínico aún no determinado de desplazamiento del K+ del LEC al LIC. Destacamos la importancia semiológica por su infrecuencia, sus implicancias reales y potenciales, además de la recuperación con amiloride y aumento de la ingestión de potasio

Anastomosis mecánicas circulares colónicas y rectales / Mechanical circular colonic and rectal anastomoses

Se realizaron 536 anastomosis mecánicas, en distintos niveles del aparato digestivo. Los instrumentos de sutura utilizados fueron los conocidos con las siglas: TA, GIA y EEA. Las 404 anastomosis circulares colónicas y rectales se discriminan en 85 ileotransversas, 4 ileosigmoideas, 10 ileorrectales, 42 colocolónicas y 263 colorrectales. El ileo posoperatorio se resolvió en el 88 % de los casos en las primeras 96 horas. Se hicieron presentes 7 fístulas latentes, 5 fístulas piostercoráceas 9 peritonitis, 4 hemorragias y 3 estrecheces, en todas de ellas se había afectuado reparación manual y 7 recidivas. La mortalidad por dehiscencia de peritonitis, inherente al método, fue del 1,23 %. La facilidad que otorga el EEA para realizar las anastomosis con la porción baja del recto, no debe hacer variar los principios oncológicos que rigen la táctica quirúrgica en los cánceres de esta localización. Se concluye que el empleo de estos instrumentos incorporados a la práctica diaria constituyen un notable progreso en el campo de la cirugía digestiva

Restablecimiento de la continuidad intestinal luego de la operacion de Hartmann con el aparato E.E.A. de sutura mecanica. / Restoration of intestinal continuity after Hartmann's operation with EEA stapler

Se presentan 12 casos de reconstruccion de operacion de Hartmann con sutura mecanica E.E.A. Se describen la tactica y tecnica operatorias, preferindo los autores la anastomosis terminolateral. En 6 casos se efectuo colostomia transversa contemporanea. No se observaron dehiscencias anastomoticas, ni se registro mortalidad

Restablecimiento de la continuidad intestinal luego de la operacion de Hartmann con el aparato E.E.A. de sutura mecanica. / Restoration of intestinal continuity after Hartmanns operation with EEA stapler

Se presentan 12 casos de reconstruccion de operacion de Hartmann con sutura mecanica E.E.A. Se describen la tactica y tecnica operatorias, preferindo los autores la anastomosis terminolateral. En 6 casos se efectuo colostomia transversa contemporanea. No se observaron dehiscencias anastomoticas, ni se registro mortalidad