Elevación de enzimas hepáticas inducida por COVID-19 en embarazada / Elevated liver enzimes induced by COVID-19 in pregnancy

INTRODUCCIÓN: Las alteraciones del perfil hepático durante el embarazo ocurren en 3-5% de las gestantes. Una nueva etiología que se ha presentado en el contexto de pandemia actual es el síndrome respiratorio agudo severo relacionado con el nuevo coronavirus (SARS-CoV-2). Éste es responsable de alteraciones hepáticas en 2 a 11% de la población general infectada por este virus, y de hasta un 30% en las embarazadas que se infectan con SARS-CoV-2. Con el objetivo de mostrar una presentación poco frecuente del SARS-CoV-2 se expone un caso clínico de elevación de transaminasas en embarazada inducida por este nuevo virus. CASO CLÍNICO: Paciente de 36 años, cursando embarazo de 20+6 semanas, consulta por dolor abdominal asociado a ictericia y coluria. Se solicita estudio donde destaca elevación de transaminasas. Ecografía abdominal con vía biliar fina. Se descartan diferentes etiologías de hepatitis aguda y crónica (dada la falta de antecedentes). Finalmente se solicita PCR para COVID-19 que resulta positiva. CONCLUSIÓN: Luego de un estudio exhaustivo de diferentes etiologías de elevación de transaminasas, se atribuye esta alteración enzimática a SARS-CoV-2. Se decide seguimiento ambulatorio estricto con pruebas hepáticas cada dos semanas. La paciente evoluciona estable con exámenes normales luego de un mes desde que se indica el alta hospitalaria. Después de descartar etiologías frecuentes de elevación de transaminasas durante el embarazo, sugerimos solicitar el estudio de este virus con PCR para COVID-19, ya que podría ser una presentación poco frecuente de SARS-CoV-2.

INTRODUCTION: Approximately 3-5% of women present alterations of hepatic enzymes during pregnancy. Under the new circumstances that the world is facing with the SARS-COV2 pandemic, a new etiology for hepatic enzyme alterations has risen. The severe acute respiratory syndrome that the novel coronavirus causes is responsible for hepatic enzyme alterations in 2 to 11% of the sick population that did not have a previous underlying hepatic condition. Furthermore, hepatic enzyme alterations in pregnant women infected with SARS-COV2 presents in up to 30% of the cases. An infrequent presentation of SARS-COV2 is presented as our clinical case. CLINICAL CASE: A 36-year-old patient with a 20+6 week pregnancy presents abdominal pain, jaundice and choluria. General blood workup shows elevated transaminases. The abdominal ultrasound revealed a thin bile duct. Acute and chronic hepatitis etiologies were discarded. Finally, a PCR of COVID-19 was solicited, which turned out to be positive. CONCLUSIÓN: After an exhaustive study to determine the etiology of the elevated transaminases, the hepatic alterations were attributed to SARS-COV2 infection. A conservative management was adopted, with outpatient follow-up with liver testing every two weeks. The patient progresses with a stable steady decline in hepatic enzyme levels, and one-month post hospital discharge, her transaminases had reached normal values. Based on this clinical case, after ruling out frequent etiologies for elevated transaminases during pregnancy, it seems reasonable to request a PCR for COVID-19, since it could be a rare presentation of SARS-CoV-2.

¿Es posible disminuir la incidencia de encefalopatía hipóxico isquémica? / Is it possible to reduce the incidence of hypoxic-ischemic encephalopathy?

Objetivo: Determinar si una política local, establecida en la Maternidad del Hospital Padre Hurtado (HPH), para bajar la incidencia de Encefalopatía Hipóxico Isquémica es efectiva, sin incrementar en forma relevante la tasa de cesáreas. Diseño: Estudio de cohorte. Escenario: Unidad de Gestión Clínica de la Mujer y el Recién Nacido del Hospital Padre Hurtado. Población: Neonatos mayores de 33 semanas de edad gestacional, nacidos en el Hospital Padre Hurtado durante los años 1999 y 2015. Método: Se revisaron los resultados de una política de intervención para prevención de asfixia neonatal establecida en la Maternidad del Hospital Padre Hurtado durante un periodo de 14 años. Resultados: Al analizar los datos de un total de 102.612 nacidos vivos, se constató una disminución en la incidencia de EHI en sus 3 grados de una tasa de 4.75/1.000 nacidos vivos previo a la intervención (grupo control) a una tasa de 1.46 por 1.000 nacidos vivos post intervenciones, con alta significancia estadística (p=0,008), llegando en los últimos 6 años a tasa promedio de 0.87/1.000 nacidos vivos. La tasa de EHI moderada y severa bajó de 1.15 por mil nacidos vivos a 0.62, también con alta significancia estadística (p=0.02). La tasa de cesáreas oscilo entre 26-29 % en estos años. Conclusión: La introducción de intervenciones protocolizadas y sistematizadas por medio de la implementación de guías de manejo del trabajo de parto, la capacitación del equipo de profesionales y la auditoría continua de los casos de EHI en el Servicio de Maternidad del Hospital Padre Hurtado se asoció a una disminución significativa de EHI, manteniendo la tasa de cesáreas bajo 30%.

Objectives: Determine whether a local policy to reduce the incidence of neonatal hypoxic-ischemic encephalopathy (HIE), established at the Maternity Unit of Hospital Padre Hurtado (HPH), is effective without significantly increasing the cesarean rate. Design: Cohort study. Setting: Maternity unit of Hospital Padre Hurtado. Population: Newborns older than 33 weeks born at Hospital Padre Hurtado between 1999 and 2015. Methods: The results of a training policy to prevent HIE and perinatal asphyxia established at the Maternity unit of Hospital Padre Hurtado were reviewed during a period of 14 years. Results: From a total of 102.612 newborns analyzed, results showed a decrease in all grades of HIE incidence, from a rate of 4.75 / 1,000 live births prior to intervention (control group) to a rate of 1.46 per 1,000 live births after interventions, with high statistically significance (p=0.008), it reached an average rate of 0.87/1000 for the last 6 years. The moderate and severe HIE rate decreased from 1.15/1000 to 0.62/1000, also with high statistically significance (p=0.02). During the same period of time, the cesarean rate varied between 26-29%. Conclusion: The introduction of protocolized and systematized interventions trough the implantation of Management guides, obstetrics emergency trainings to the professional team and continues audit of the HIE cases at the Maternity unit Hospital Padre Hurtado was associated to a significant decrease of HIE, maintaining the rate of cesareans below 30%.

Gobierno del parto en el Hospital Padre Hurtado: un modelo para contener la tasa de cesárea y prevenir la encefalopatía hipóxico-isquémica / Management of labor in the Padre Hurtado Hospital: an model for the reduction of the cesarean sections and to prevent the hypoxic ischemic encephalopathy

La tasa de cesáreas en Chile se ubicó entre las más altas del mundo en el año 2000: 39 por ciento a 83 por ciento en la práctica privada y 20 por ciento a 28 por ciento en los hospitales públicos. El objetivo de nuestro estudio es comunicar el impacto que ha tenido en la tasa de cesáreas y el resultado neonatal la aplicación de Guías Clínicas para el manejo del trabajo de parto y monitoreo fetal. Entre el 1 de enero de 1999 y el 31 de diciembre de 2004, la tasa global de cesáreas del período fue de 23,2 por ciento y la tasa de fórceps osciló entre 7,5 y 9,7 por ciento. La incidencia de encefalopatía hipóxico-isquémica (EHI) para el período de estudio fue de 3,5/1.000 nacidos vivos, con una progresiva tendencia a la disminución. Las tasas de cesárea y de EHI son comparables a las reportadas en la literatura internacional. Luego de revisar la literatura, ésta es la primera comunicación nacional sobre el impacto de Guías Clínicas en la atención del parto.

Manejo exitoso de la hemorragia postparto por acretismo placentario mediante tamponamiento con balón de Bakri / Treatment of postpartum haemorrhage due to placenta accreta with Bakri balloon

Antecedentes: La hemorragia del postparto es una de las complicaciones de mayor morbimortalidad materna. Objetivo: Comunicar el uso exitoso del balón de Bakri en un caso de metrorragia del postparto. Metodología: Se presenta el dispositivo utilizado. Resultado: Control eficiente de la metrorragia postparto por acretismo placentario mediante el uso del balón de Bakri, que permitió conservar el útero. Conclusión: El balón de Bakri es una alternativa no quirúrgica para el control de la hemorragia del postparto.

Periodic perturbations in Shaker K+ channel gating kinetics by deletions in the S3-S4 linker.

Upon depolarization positive charges contained in the transmembrane segment S4 of voltage-dependent channels are displaced from the cytoplasmic to the external milieu. This charge movement leads to channel opening. In Shaker K+ channels four positively charged arginines in the S4 domain are transferred from the internal to the external side of the channel during activation. The distance traveled by the S4 segment during activation is unknown, but large movements should be constrained by the S3-S4 linker. Constructing deletion mutants, we show that the activation time constant and the midpoint of the voltage activation curve of the Shaker K+ channel macroscopic currents becomes a periodic function of the S3-S4 linker length for linkers shorter than 7 aa residues. The periodicity is that typical of alpha-helices. Moreover, a linker containing only 3 aa is enough to recover the wild-type phenotype. The deletion method revealed the importance of the S3-S4 linker in determining the channel gating kinetics and indicated that the alpha-helical nature of S4 extends toward its N terminus. These results support the notion that a small displacement of the S4 segment suffices to displace the four gating charges involved in channel opening.

Signal transduction networks and the biology of plant cells.

The development of plant transformation in the mid-1980s and of many new tools for cell biology, molecular genetics, and biochemistry has resulted in enormous progress in plant biology in the past decade. With the completion of the genome sequence of Arabidopsis thaliana just around the corner, we can expect even faster progress in the next decade. The interface between cell biology and signal transduction is emerging as a new and important field of research. In the past we thought of cell biology strictly in terms of organelles and their biogenesis and function, and researchers focused on questions such as, how do proteins enter chloroplasts? or, what is the structure of the macromolecules of the cell wall and how are these molecules secreted? Signal transduction dealt primarily with the perception of light (photomorphogenesis) or hormones and with the effect such signals have on enhancing the activity of specific genes. Now we see that the fields of cell biology and signal transduction are merging because signals pass between organelles and a single signal transduction pathway usually involves multiple organelles or cellular structures. Here are some examples to illustrate this new paradigm. How does abscisic acid (ABA) regulate stomatal closure? This pathway involves not only ABA receptors whose location is not yet known, but cation and anion channels in the plasma membrane, changes in the cytoskeleton, movement of water through water channels in the tonoplast and the plasma membrane, proteins with a farnesyl tail that can be located either in the cytosol or attached to a membrane, and probably unidentified ion channels in the tonoplast. In addition there are highly localized calcium oscillations in the cytoplasm resulting from the release of calcium stored in various compartments. The activities of all these cellular structures need to be coordinated during ABA-induced stomatal closure. For another example of the interplay between the proteins of signal transduction pathways and cytoplasmic structures, consider how plants mount defense responses against pathogens. Elicitors produced by pathogens bind to receptors on the plant plasma membrane or in the cytosol and eventually activate a large number of genes. This results in the coordination of activities at the plasma membrane (production of reactive oxygen species), in the cytoskeleton, localized calcium oscillations, and the modulation of protein kinases and protein phosphatases whose locations remain to be determined. The movement of transcription factors into the nucleus to activate the defense genes requires their release from cytosolic anchors and passage through the nuclear pore complexes of the nuclear envelope. This review does not cover all the recent progress in plant signal transduction and cell biology; it is confined to the topics that were discussed at a recent (November 1998) workshop held in Santiago at which lecturers from Chile, the USA and the UK presented recent results from their laboratories.

Localization of the K+ lock-In and the Ba2+ binding sites in a voltage-gated calcium-modulated channel. Implications for survival of K+ permeability.

Using Ba2+ as a probe, we performed a detailed characterization of an external K+ binding site located in the pore of a large conductance Ca2+-activated K+ (BKCa) channel from skeletal muscle incorporated into planar lipid bilayers. Internal Ba2+ blocks BKCa channels and decreasing external K+ using a K+ chelator, (+)-18-Crown-6-tetracarboxylic acid, dramatically reduces the duration of the Ba2+-blocked events. Average Ba2+ dwell time changes from 10 s at 10 mM external K+ to 100 ms in the limit of very low [K+]. Using a model where external K+ binds to a site hindering the exit of Ba2+ toward the external side (Neyton, J., and C. Miller. 1988. J. Gen. Physiol. 92:549-568), we calculated a dissociation constant of 2.7 mircoM for K) at this lock-in site. We also found that BK(Ca) channels enter into a long-lasting nonconductive state when the external [K+] is reduced below 4 microM using the crown ether. Channel activity can be recovered by adding K+, Rb+, Cs+, or NH4+ to the external solution. These results suggest that the BK(Ca) channel stability in solutions of very low [K+] is due to K+ binding to a site having a very high affinity. Occupancy of this site by K+ avoids the channel conductance collapse and the exit of Ba2+ toward the external side. External tetraethylammonium also reduced the Ba2+ off rate and impeded the channel from entering into the long-lasting nonconductive state. This effect requires the presence of external K+. It is explained in terms of a model in which the conduction pore contains Ba2+, K+, and tetraethylammonium simultaneously, with the K+ binding site located internal to the tetraethylammonium site. Altogether, these results and the known potassium channel structure (Doyle, D.A., J.M. Cabral, R.A. Pfuetzner, A. Kuo, J.M. Gulbis, S.L. Cohen, B.T. Chait, and R. MacKinnon. 1998. Science. 280:69-77) imply that the lock-in site and the Ba2+ sites are the external and internal ion sites of the selectivity filter, respectively.

Role of the S4 segment in a voltage-dependent calcium-sensitive potassium (hSlo) channel.

We investigated the role of individual charged residues of the S4 region of a MaxiK channel (hSlo) in channel gating. We measured macroscopic currents induced by wild type (WT) and point mutants of hSlo in inside-out membrane patches of Xenopus laevis oocytes. Of all the residues tested, only neutralizations of Arg-210 and Arg-213 were associated with a reduction in the number of gating charges as determined using the limiting slope method. Channel activation in WT and mutant channels was interpreted using an allosteric model. Mutations R207Q, R207E, and R210N facilitated channel opening in the absence of Ca2+; however, this facilitation was not observed in the channels Ca2+-bound state. Mutation R213Q behaved similarly to the WT channel in the absence of Ca2+, but Ca2+ was unable to stabilize the open state to the same extent as it does in the WT. Mutations R207Q, R207E, R210N, and R213Q reduced the coupling between Ca2+ binding and channel opening when compared with the WT. Mutations L204R, L204H, Q216R, E219Q, and E219K in the S4 domain showed a similar phenotype to the WT channel. We conclude that the S4 region in the hSlo channel is part of the voltage sensor and that only two charged amino acid residues in this region (Arg-210 and Arg-213) contribute to the gating valence of the channel.

Calcium-activated potassium channels.

Calcium-activated potassium channels are fundamental regulators of neuronal excitability, participating in interspike interval and spike-frequency adaptation. For large-conductance calcium-activated potassium (BK) channels, recent experiments have illuminated the fundamental biophysical mechanisms of gating, demonstrating that BK channels are voltage gated and calcium modulated. Structurally, BK channels have been shown to possess an extracellular amino-terminal domain, different from other potassium channels. Domains and residues involved in calcium-gating, and perhaps calcium binding itself, have been identified. For small- and intermediate-conductance calcium-activated potassium channels, SK and IK channels, clones have only recently become available, and they show that SK channels are a distinct subfamily of potassium channels. The biophysical properties of SK channels demonstrate that kinetic differences between apamin-sensitive and apamin-insensitive slow afterhyperpolarizations are not attributable to intrinsic gating differences between the two subtypes. Interestingly, SK and IK channels may prove effective drug targets for diseases such as myotonic muscular dystrophy and sickle cell anemia.

Outward currents in Drosophila larval neurons: dunce lacks a maintained outward current component downregulated by cAMP.

Outward current modulation by cAMP was investigated in wild type (wt) and dunce (dnc) Drosophila larval neurons. dnc is deficient in a cAMP phosphodiesterase and has altered memory. Outward current modulation by cAMP was investigated by acute or chronic exposure to cAMP analogs. The analysis included a scrutiny of outward current modulation by cAMP in neurons from the mushroom bodies (mrb). In Drosophila, the mrb are the centers of olfactory acquisition and retention. Based on outward current patterns, neurons were classified into four types. Downmodulation of outward currents induced by acute application of cAMP analogs was reversible and found only in type I and type IV neurons. In the general wt neuron population, approximately half of neurons exhibited cAMP-modulated, 4-aminopyridine (4-AP)-sensitive currents. On the other hand, a significantly larger fraction of mrb neurons in wt (70%) was endowed with cAMP-modulated, 4-AP-sensitive currents. Only 30% of the dnc neurons displayed outward currents modulated by cAMP. The deficit of cAMP-modulated outward currents was most severe in neurons derived from the mrb of dnc individuals. Only 4% of the mrb neurons of dnc were cAMP-modulated. The dnc defect can be induced by chronic exposure of wt neurons to cAMP analogs. These results document for the first time a well defined electrophysiological neuron phenotype in correlation with the dnc defect. Moreover, this study demonstrates that in dnc mutants such a deficiency affects most severely neurons in brain centers of acquisition and retention.

How do calcium channels transport calcium ions?

Calcium channel activity is crucial for many fundamental physiological processes ranging from the heart beat to synaptic transmission. The channel-forming protein, of about 2000 amino acids, comprises four domains internally homologous to each other. Voltage-dependent Ca2+ channels are the most selective ion channels known. Under physiological conditions, they prefer Ca2+ over Na+ by a ratio of about 1000:1. To explain at the same time the exquisite ion selectivity and the large Ca2+ ion turnover rate of Ca2+ channels (approximately 3 x 10(6) ions/s), two kind models have been proposed. In one, the conduction pathway possesses two high-affinity binding sites. When two Ca2+ ions are bound to each site, the mutual repulsion between them speeds the exit rate for the ions, causing greater ion permeation through the pore. The second model hypothesizes the existence of a single site having a charged structure able to attract multiple, interacting ions, simultaneously. Recent studies that combine mutagenesis and electrophysiology show that the high-affinity binding site is formed by a ring of glutamate residues located in the pore forming region of the Ca2+ channel. As proposed in the second class of models, the results suggest that four glutamate residues, one glutamate donated by each repeat, combine to form a single high-affinity site. In this review the different conduction models for Ca2+ channels are discussed and confronted with structural data.

Ion channel classes in purified olfactory cilia membranes: planar lipid bilayer studies.

Ciliary membrane fragment fusion to planar lipid bilayers resulted in the insertion of four ion channel types. cAMP-activated, cation-selective channels could be detected only in the absence of Ca2+ and had a conductance of 23 pS. They exhibited an apparent dissociation constant (Kd) for the cyclic nucleotide of approximately 30 microM and an estimated permeability ratio (PNa/PK) of 2.4. The cAMP cation-selective channel coinserted with a K(+)-selective channel refractory to cAMP, Ca2+, and D-myo-inositol 1,4,5-trisphosphate. This K+ channel was voltage independent and exhibited open-conductance substates of 60 and 112 pS. cAMP was also found to modulate a novel K+ channel with a Kd = 140 microM. It displayed three nearly equally spaced open substates with conductances of 34, 80, and 130 pS. In the absence and in the presence of cAMP the probability of occurrence of the open substates was binomially distributed. A fourth channel type was a Ca(2+)-activated K+ channel with a conductance of 240 pS. It was blocked by charybdotoxin at nanomolar concentrations (Kd = 3 nM). These results add support to the idea that, besides cAMP-activated cation-selective channels, vertebrate chemosensory olfactory membranes possess an arrangement of ion channels.

Molecular determinants of ion conduction and inactivation in K+ channels.

K+ channel-forming proteins can be grouped into three families that differ by the number of potential membrane-spanning segments. The largest of these families is composed of tetrameric channels with subunits containing six putative membrane-spanning segments (S1-S6). Inward rectifiers comprise a second family of K+ channels with subunits having two transmembrane domains (M1, M2). Monomers in the third family are proteins containing only one membrane-spanning segment, and they give origin to minK+ channels. Joining together segments S5 and S6 in the case of voltage-gated K+ channels and M1 and M2 in inward rectifiers, there is a highly conserved region with a hairpin shape called the H5 or P region. The P region, the loop connecting the S4 and S5 domains and the S6 transmembrane segment in Shaker-type K+ channels and the COOH-terminal in inward rectifiers, appears to play crucial roles in ion conduction. In Shaker K+ channels the NH2-terminal has been identified as responsible for fast inactivation (N-type inactivation). If the fast-inactivation gate is removed, a slower inactivation process persists, and its rate can be altered by mutations of amino acid residues forming part of the region in the neighborhood of the COOH-terminal (C-type inactivation). In this review we discuss the strategies followed to identify the different structures of K+ channels involved in ion conduction and inactivation processes and how they interplay.

Shaker mutants lack post-tetanic potentiation at motor end-plates.

The two-electrode voltage clamp technique was employed to measure end-plate currents in larval neuromuscular junctions of wild-type (Canton-S) and of three different Drosophila Shaker mutants: ShakerKS133, Shaker102 and f5Shaker5. In the Shaker mutants, nerve-evoked end-plate currents (neepc) were 4-5-fold larger than those measured in Canton-S. Shaker motor end-plates were found to lack post-tetanic potentiation (PTP), but could undergo facilitation. Moreover, PTP but not facilitation was lost in wild-type larvae if the neuromuscular junction was exposed to 4-aminopyridine (4-AP), a blocker of Shaker A-type K+ currents. End-plate currents were depressed by Ca2+ channel blockers like Mg2+, at millimolar concentrations, and Co2+ and Cd2+, at micromolar concentrations, but not by nifedipine (100 nM) and verapamil (100 nM). After exposure to Ca2+ channel blockers, Shaker end-plates exhibited PTP. In particular, Cd2+ was most effective in depressing neepcs and in restoring PTP in all Shaker mutants. The results obtained indicate the abnormal function of Shaker K+ channels at motor nerves specifically abolishes PTP in Drosophila larval neuromuscular junctions.

[Hepatitis B virus vaccine: early and late response in Chileans with high risk of infection]. / Vacuna contra el virus de la hepatitis B: respuesta precoz y tardía en Chilenos con alto riesgo de infección.

BACKGROUND: Hepatitis B vaccine has demonstrated to be very effective and safe preventing hepatitis B virus infection. Long term protection induced by hepatitis B vaccination depends on the initial immune response and the declining rate of anti-HBs titers. AIM. To investigate early and late response to hepatitis B vaccine in a sample of high risk Chilean population. MATERIAL AND METHODS: Thirty one subjects (20 relatives of hepatitis B chronic carriers, 10 health service workers and one HIV seropositive) were vaccinated with a plasma derivated hepatitis B vaccine. Early and late response were estimated by anti-HBs titers. RESULTS: Twenty eight subjects (90%) produced protective titers of anti-HBs after 2 months from the third dose of vaccine (early response), and they remained at these levels in 75% of vaccinated individuals after three years (late response). All the subjects without protective titers after the three year follow up had produced anti-HBs levels lower than 300 UI at the early response. Hepatitis B vaccination was not associated with significant side effects. CONCLUSIONS: This experience confirms that hepatitis B vaccine is safe and effective inducing immunity in high risk subjects. Our data suggest that the early response to hepatitis B vaccine is able to identify those subjects requiring closer surveillance for boosters.

K(+)-channel blockers restore synaptic plasticity in the neuromuscular junction of dunce, a Drosophila learning and memory mutant.

The effects of K(+)-channel blockers on synaptic transmission in dunce (dnc), a Drosophila learning and memory mutant, were investigated. Larvae dnc mutants lack facilitation and post-tetanic potentiation (PTP) at their motor end-plates; dnc mutants are also deficient in a form of phosphodiesterase, and exhibit abnormally high levels of cyclic adenosine 3',5'-monophosphate (cAMP). A two-microelectrode voltage-clamp was used to record end-plate currents and spontaneous end-plate currents from longitudinal ventrolateral third-instar larval muscle. The K(+)-channel blockers 3,4-diaminopyridine (3,4-DAP) and tetraethylammonium (TEA), at micromolar concentrations, caused a reversible decrease in end-plate current amplitudes both in wild-type and mutant end-plates. In the presence of blockers, a period of high-frequency stimulation (tetanus) of the nerve gave way to a transient increase in the end-plate currents of dnc mutants resembling facilitation and PTP in normal end-plates; 3,4-DAP and TEA also restored facilitation and PTP in normal end-plates after incubation with a non-hydrolysable analogue of cAMP (8Br-cAMP). It is suggested that a specific K+ conductance might be relevant to the lack of synaptic plasticity at the dnc neuromuscular synapses.