Unusual adult-onset cardiac rhabdomyomas in tuberous sclerosis complex: a case report.

Background: Tuberous sclerosis complex is a genetic neurocutaneous autosomal dominant syndrome, characterized by the development of multiple benign tumors (hamartomas) affecting various systems. Heart-benign tumors that result from the complex are called cardiac rhabdomyomas. Unlike hamartomas that occur in other organs, cardiac rhabdomyomas are most prevalent in infants and very young children with tuberous sclerosis complex. We present a case of a young adult with tuberous sclerosis who had an unusually late diagnosis of cardiac rhabdomyomas. Case report: A 22-year-old male patient of Afro-descendant, diagnosed with tuberous sclerosis complex in childhood, presented with refractory epilepsy and was treated only with lacosamide. The patient came to medical consultation due to a recent history of episodic, persistent chest pain in the sternal region, associated with physical effort. Echocardiography revealed a non-dilated left ventricle, with several rounded masses of high echogenicity without pedicles at the apical level, the largest measuring 14 × 11 mm, consistent with cardiac rhabdomyomas. Conclusion: Cardiac rhabdomyomas rarely develop in adulthood for individuals with tuberous sclerosis. These late-onset cases can exhibit various symptoms, from simple to complex presentations. Regular clinical checkups are essential for adults with tuberous sclerosis complex.

Low-Flow, Low-Gradient Severe Aortic Stenosis in patients with preserved or reduced ejection fraction: a systematic literature review.

OBJECTIVES: A systematic review of the literature was conducted to analyze the current evidence on low-flow, low-gradient severe aortic stenosis. This analysis aimed to differentiate between subgroups of patients with reduced and preserved left ventricular ejection fraction (LVEF). METHODS: After conducting a systematic literature review, 35 observational studies were included. Out of these, 28 were prospective and 7 retrospective. The studies that included a mortality risk stratification of low-flow, low-gradient aortic stenosis (LF- LG AS) with both preserved and reduced LVEF were reviewed. RESULTS: The importance of considering multiple clinical and echocardiographic variables in diagnostic evaluation and therapeutic decision-making was highlighted. CONCLUSIONS: LF- LG AS, in any of its subgroups, is a common and challenging valve lesion. A careful assessment of severity and, in specific scenarios, a thorough reclassification is important. More high-quality studies are required to more precisely define the classification and prognosis of this entity.

Application of eligibility criteria from DAPA-HF, EMPEROR-Reduced, and PARADIGM-HF trials to a population with heart failure with reduced ejection fraction at a specialized cardiology Clinic in Medellin, Colombia: A retrospective cohort study.

INTRODUCTION: The evidence supporting pharmacological heart failure treatment relies on randomized clinical trials with stringent inclusion and exclusion criteria. OBJECTIVES: Assess the eligibility of outpatients with chronic heart failure for the trials DAPA-HF, EMPEROR-reduced, and PARADIGM-HF, while exploring potential differences among study populations. METHODS: By reviewing medical records, we determined the eligibility rate for each study and evaluated the incidence of heart failure hospitalizations and all-cause mortality during this period. RESULTS: A total of 446 patients were included in the cohort. Approximately 75% would be ineligible for the trials, mainly because of their comorbidities. Ineligible patients had a higher all-cause mortality, but a similar incidence of hospitalization. CONCLUSION: Approximately 1 in 4 patients from a heart failure clinic in Medellin, Colombia would meet the eligibility criteria for the DAPA-HF, EMPEROR-reduced, and PARADIGM-HF trials. These findings highlight the need to complement randomized clinical trials with real-world data.

Myxoma Mimic in a Patient With Acute Myeloid Leukemia.

Cardiac masses are rare conditions that, depending on their size and location, can cause several cardiac and systemic symptoms. We describe a case of a 21-year-old male with a history of syphilis, pulmonary tuberculosis, and acute myeloid leukemia (AML), in whom a transthoracic echocardiogram assessment was solicited before the initiation of induction chemotherapy. The study revealed a pedunculated, highly mobile mass in the right atrium that protruded to the right ventricle. Surgical resection was performed. During surgery, tricuspid valve perforation was noted and was associated with severe tricuspid valve regurgitation. Histopathological analysis of the resected mass determined that the lesion was a cardiac thrombus.

Effectiveness of the use of platelet-rich fibrin associated with open flap debridement compared to open flap debridement alone for the treatment of periodontal intrabony defects: Overview of systematic reviews.

In the recent years, platelet-rich fibrin (PRF) has gained importance in regenerative medicine due to its attributed tissue-inducing properties. However, it is still unclear whether there are benefits from using PRF with open flap debridement (OFD) for the treatment of intrabony defects compared to OFD alone. For this reason, in this study, we performed an overview of systematic reviews with Friendly Summaries of the Body of Evidence using Epistemonikos methodology on the use of PRF with OFD compared to OFD alone for the treatment of intrabony defects. We performed a systematic search in the Epistemonikos database. We extracted data from the included systematic reviews and reanalyzed the data of primary studies and generated a summary of the findings table. We used Review Manager (RevMan) v5.3 software and GRADEpro software for data analysis and data presentation. Eighteen systematic reviews were included after full-text screening, which had 16 clinical trials. Results were reported by the mean difference (MD); the following outcomes were analyzed: change in intrabony defect depth (MD: 1.37 mm more), change in radiographic bone defect filling (MD: 37.26% more), change in probing depth (MD: 1.22 mm more), change in clinical attachment level (MD: 1.32 mm more), and change in gingival margin level (MD: 0.31 more). We concluded that applying PRF with OFD to treat an intrabony defect has some clinical advantages compared to OFD alone.

Clinical outcomes and complications following percutaneous closure of patent foramen ovale

Introduction: patent foramen ovale (PFO) has been associated with systemic embolic events, and evidence in favor of its closure is increasing. Our objective is to describe the main clinical outcomes and complications of percutaneous closure of patent foramen ovale. Materials and methods: patients who underwent percutaneous PFO closure from January 1, 2016, through September 1, 2021, were recorded retrospectively. Immediate outcomes (<72 hours), and early and late-onset clinical outcomes were evaluated. In-hospital and follow-up mortality were evaluated through medical chart reviews or telephone calls. Results: forty patients who underwent percutaneous PFO closure were included. There was a mean follow up of 2.3 years, the mean age was 43 ± 13.6 years, 7% were over 60 years old, 72.5% were women, 25% were hypertensive, 20% had diabetes, and 10% had a history of migraines. The mean RoPE score was 6, and 50% had a score greater than 7. Out of all the cases, three (7.5%) had serious adverse events and four had immediate complications. During follow-up, 2.5% had early-onset events consisting of atrial fibrillation and 2.5% had late-onset events due to CVA recurrence. There were no deaths from neurological causes and we reported a 100% survival. Discussion: From our experience, we highlight a low percentage of serious adverse events, and a low number of immediate, early and late-onset events, with a 100% survival, showing excellent results for percutaneous PFO closure. (Acta Med Colomb 2022; 48. DOI:https://doi.org/10.36104/amc.2023.2585).

Opportunistic infections according to the CD4+ T lymphocyte count in patients with HIV at a tertiary care referral center

Opportunistic infections (OIs) have marked the prognosis in the natural course of patients with human immunodeficiency virus (HIV) infection. Objective: identifying the most common OIs and determining their relationship with the CD4+ lymphocyte count (CD4+TL) can improve our clinical practice and facilitate early diagnosis, the use of empiric treatments and prompt targeted treatment. Materials and methods: an observational, retrospective study aimed at describing the characteristics and variations of the OIs diagnosed clinically, using direct or indirect methods, which occur in patients with HIV (related to their CD4+TL count) who are admitted to a tertiary care center in Cali, Colombia. Adult patients hospitalized from January 2018 to January 2019 with a diagnosis of HIV/AIDS and a history or current diagnosis of OI were included. Individuals under the age of 18 and pregnant women were excluded. Results: a sample of 190 patients with at least one opportunistic infection was obtained, of whom 65.3% were men with a median age of 37 years (29.0-46.0), and the rest were women with a median age of 35.5 years (31.2-43.0). Eighty-three percent had a C3 classification on admission, 86% with a CD4+TL count < 200 cells/mm3. The most frequent OIs included tuberculosis, with 28.4%, pneumocystosis with 27.9% and toxoplasmosis with 27.4%. Conclusions: in our population, despite advances in and greater availability of highly-effective antiretroviral therapy, most patients with HIV are hospitalized in advanced stages with opportunistic infections, in some cases with two or more concomitant infections, and with evidence of severe virological and immunological involvement. (Acta Med Colomb 2022; 48. DOI:https://doi.org/10.36104/amc.2023.2327).

Factores predictores de mortalidad en pacientes con enfermedad coronaria y compromiso del tronco principal izquierdo / Predictors of mortality in patients with coronary artery disease and involvement of the left main artery

Resumen: Introducción: el compromiso del tronco principal izquierdo no protegido (TPInp) en pacientes con enfermedad arterial coronaria (EAC) conlleva alto riesgo de eventos cardiovasculares. La cirugía de revascularización coronaria (CABG) ha sido el estándar de tratamiento; sin embargo, estudios recientes proponen la intervención coronaria percutánea (PCI) como alternativa. Objetivo: evaluar los desenlaces intrahospitalarios y durante el seguimiento del tratamiento de pacientes con compromiso del TPInp. Método: estudio observacional multicéntrico de cohorte retrospectivo, se evaluaron pacientes con EAC y afección del TPI. Muerte de cualquier causa, infarto de miocardio no fatal, accidente cerebrovascular, reintervención y/o readmisión hospitalaria fueron valorados como un desenlace compuesto e individualmente durante la hospitalizacioì n y el tiempo de seguimiento. Resultados: se incluyeron 82 pacientes, con edad promedio 71 ± 9.9 años; 35 recibieron PCI, 31 CABG y 16 manejo meìdico (MM). La mortalidad intrahospitalaria fue del 16%. En el seguimiento medio de 12.3 meses la tasa de mortalidad fue del 20%, la de reinfarto del 6% y la de readmisioìn hospitalaria del 4%. La tasa de incidencia de muerte para MM fue 5.19 por 10.000 personas/diìa, para PCI de 2.3 por 10.000 personas/diìa y para CABG de 1.06 por 10.000 personas/diìa; en el seguimiento la mortalidad fue mayor en el grupo de PCI (HR: 3.6; IC 95% 1.13-11.9; p = 0.02). La frecuencia cardiaca elevada al ingreso se asocioì con mayor mortalidad (0.05). Conclusión: el compromiso del TPI se asocia con alto riesgo de muerte y se presenta con anatomiìa coronaria compleja.

Abstract: Introduction: involvement of the unprotected left main coronary artery (TPInp) in patients with coronary artery disease (CAD) leads to a high risk of cardiovascular events. Coronary artery bypass grafting (CABG) has been the standard of management; however, recent studies propose percutaneous coronary intervention (PCI) as an alternative treatment. Objective: to evaluate the in-hospital and follow-up outcomes of patients with compromised TPInp. Method: retrospective multicenter observational cohort study, we evaluated patients with CAD and TPI involvement. Death from any cause, nonfatal myocardial infarction, stroke, reoperation, and/or hospital readmission were assessed as a composite endpoint and individually during hospitaliza- tion and follow-up time. Results: 82 patients were included, mean age 71 ± 9.9 years; 35 received PCI, 31 CABG, and 16 medical management (MM). In-hospital mortality was 16%. In the mean follow-up of 12.3 months, mortality was 20%, rein- farction 6% and hospital readmission 4%. The incidence rate of death was 5.19 per 10,000 people/day for MM, 2.3 per 10,000 people/day for PCI, and 1.06 per 10,000 people/day for CABG; at follow-up, mortality was higher in the PCI group (HR 3.6; 95%CI 1.13-11.9; p = 0.02). Elevated heart rate on admission was associated with higher mortality (p < 0.05). Conclusion: TPInp involvement is associated with a high risk of death and presents with complex coronary anatomy.

Tuberculosis ovárica, manifestación infrecuente de tuberculosis extrapulmonar / Ovarian tuberculosis, extra pulmonary tuberculosis infrequent manifestation

La tuberculosis es una de las enfermedades infecciosas de más amplia distribución en el mundo y constituye una de las primeras causas de muerte de pacientes con sida, especialmente en países pobres. La forma extrapulmonar de la tuberculosis varía entre el 15 al 30 % de los casos; de estas, la forma pélvica representa tan solo del 6 al 10 %, y la afectación ovárica es aún más rara. Presentamos el caso clínico de una paciente colombiana, quien manifestó un cuadro de dos semanas de cambios del comportamiento y posterior alteración de la consciencia, y a quien se realizó el diagnóstico de infección por virus de la inmunodeficiencia humana. Durante su evolución se documentó infección extrapulmonar por Mycobacterium tuberculosis con compromiso meníngeo y ovárico. Se inició tratamiento contra la tuberculosis meníngea con un esquema de isoniazida (H), rifampina (R), etambutol (E) y pirazinamida (Z) y esteroide, según el protocolo, y se realizó salpingooforectomía más la resección de la masa anexial del ovario derecho. Se continuó con el tratamiento instaurado previamente contra la tuberculosis. La paciente evolucionó de forma satisfactoria, y fue dada de alta tras 134 días de hospitalización(AU)

Tuberculosis is one of the most widely distributed infectious diseases in the world and is one of the leading causes of death in AIDS patients, especially in low-income countries. The extrapulmonary form of tuberculosis varies between 15 to 30% of all cases, of these, the pelvic form represents only 6 to 10%, with ovarian involvement even rarer. We describe the case of a patient from southwestern Colombia, who presents with two-week symptoms of behavioral disturbances and altered consciousness, a diagnosis of infection by human immunodeficiency virus was made, during her evolution extrapulmonary infection by Mycobacterium tuberculosis with meningeal and ovarian involvement was documented(AU)

Experiencia en el diagnóstico de tuberculosis meníngea en un hospital de alta complejidad en Colombia / The experience of a tertiary care hospital in Colombia in the diagnosis of meningeal tuberculosis

Resumen Introducción: la tuberculosis es una de las enfermedades infecciosas de mayor distribución mundial y la tuberculosis meníngea es una de sus manifestaciones más devastadoras. Su diagnóstico y confirmación microbiológica no siempre es fácil. Objetivo: describir la experiencia en el diagnóstico de tuberculosis meníngea por pruebas moleculares comparado con cultivo, caracterizando las principales manifestaciones clínicas y determinar los factores asociados a mortalidad. Métodos: identificamos retrospectivamente a los pacientes adultos con diagnóstico de tuberculosis meníngea, mediante técnicas de pruebas moleculares y/o cultivo para M. tuberculosis, que ingresaron en nuestra institución entre enero de 2018 y marzo de 2020, se realizó un análisis estadístico descriptivo. Se excluyeron mujeres gestantes, pacientes que no contaran con prueba molecular para M. tuberculosis. Resultados: se obtuvo una muestra de 33 pacientes, los hallazgos más relevantes en el citoquímico de líquido cefalorraquídeo (LCR) fue la presencia de hipoglucorraquia, con una mediana de 34.2 mg/dL (RIQ 2.0-95.0 mg/dL) y de hiperproteinorraquia, con mediana de 265 mg/dL (RIQ 24.0-600 mg/dL). El resultado más significativo fue la presencia de proteína C reactiva elevada en suero en todos los casos, con una mediana de 53.3 mg/L (RIQ 22.9-89.6 mg/L) y neutrofilia en 75.8% (25). La mortalidad fue de 54.5% (18), la sensibilidad de la prueba molecular en LCR fue del 38.46% y el valor predictivo positivo de 58.82%. Conclusiones: el diagnóstico de TB meníngea sigue siendo todo un reto, aunque las pruebas moleculares pueden ayudar en el diagnóstico temprano, su sensibilidad es baja en formas extrapul-monares. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2115).

Abstract Introduction: tuberculosis is one of the most widely disseminated infectious diseases worldwide, and meningeal tuberculosis is one of its most devastating manifestations. Its diagnosis and microbiological confirmation is not always easy. Objective: to describe the experience in diagnosing meningeal tuberculosis through molecular tests compared to a culture, characterize the main clinical manifestations, and determine factors associated with mortality. Methods: we retrospectively identified adult patients diagnosed with meningeal tuberculosis through molecular and/or culture tests for M. tuberculosis who were admitted to our institution between January 2018 and March 2020. A descriptive analysis was performed. Pregnant women and patients who did not have a molecular test for M. tuberculosis were excluded. Results: a sample of 33 patients was obtained. The most relevant cerebrospinal fluid (CSF) cytochemical analysis findings were low glucose, with a median of 34.2 mg/dL (IQR 2.0-95.0 mg/ dL) and high protein, with a median of 265 mg/dL (IQR 24.0-600 mg/dL). The most significant result was elevated serum C-reactive protein in all cases, with a median of 53.3 mg/L (IQR 22.9 -89.6 mg/L) and neutrophilia in 75.8% (25). Mortality was 54.5% (18), the sensitivity of the CSF molecular test was 38.46% and the positive predictive value was 58.82%. Conclusions: the diagnosis of meningeal TB continues to be a challenge. While molecular tests can help provide an early diagnosis, their sensitivity is low in extrapulmonary forms. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2115).

Current treatment for heart failure with reduced ejection fraction. A systematic review of the new therapies

Abstract Introduction: heart failure with reduced ejection fraction has a growing therapeutic arsenal. Thus, the indications for each therapy must be refined. Methods: a systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, to update the systematic search performed in the development of the "Clinical Practice Guidelines for Prevention, Diagnosis, Treatment and Rehabilitation" (CPG) of the Colombian Ministry of Health. Results: six new clinical trials were found which substantially modify the main recommendations of the CPG. Angiotensin receptor antagonists combined with neprilysin inhibitors (ARNI), sodium-glucose cotransporter 2 (SGLT2) inhibitors, betablockers and mineralocorticoid receptor antagonists (MRA) are now the main core of treatment for patients with heart failure with reduced ejection fraction. Other therapeutic options should be considered after beginning and titrating the doses of these four medications. Discussion: given the robustness of the evaluating studies, the proposed practical scheme, as the central core with four fundamental therapeutic strategies, will improve the treatment of patients with heart failure and allow the stepwise inclusion of other alternatives, plotted as orbits, to impact on other individual outcomes. (Acta Med Colomb 2021; 46. DOI: https://doi.org/10.36104/amc.2021.2108).

[Valve thrombosis and thrombolytic therapy in modern era: a case report]. / Trombosis valvular y terapia trombolítica en la era moderna: reporte de un caso.

Prosthetic valve thrombosis is a feared complication with an annual incidence ranging between 0.3 to 1.3%. Diagnostic approach is essential for a better prognosis and ultimately determines the chosen therapeutic strategy. Emergent valvular surgery is usually recommended in hemodinamically unstable patients, large thrombus or recurrent embolic episodes. These high-risk conditions are often not the case. Therefore, in many patients the surgical risk is much greater than that of bleeding associated with thrombolytic administration. Ultra-slow infusions have been reported with similar efficacy and lower rates of bleeding complications. We present a case of mitral prosthetic valve thrombosis considered not feasible to surgical management and subsequently treated with an ultra-slow tissue plasminogen activator infusion.

Histoplasmosis diseminada asociada a síndrome de reconstitución inmune en un paciente con virus de la inmunodeficiencia humana / Disseminated histoplasmosis associated to immune reconstitution syndrome in a patient with human immunodeficiency virus

Introducción: La histoplasmosis es una micosis profunda o sistémica causada por un hongo dimórfico que se puede diseminar principalmente en pacientes con inmunosupresión, como los que tienen diagnóstico de virus de la inmunodeficiencia humana. El síndrome de reconstitución inmune consiste en un empeoramiento paradójico de una condición conocida o de nueva aparición después del inicio de la terapia antirretroviral. Objetivo: Describir un caso de histoplasmosis diseminada asociada a síndrome de reconstitución inmune en un paciente con infección por virus de la inmunodeficiencia humana. Caso clínico: Paciente masculino de 32 años con diagnóstico de infección por virus de la inmunodeficiencia humana, con cuadro clínico de tres semanas de evolución. Este cuadro inició posterior al comienzo de la terapia antirretroviral, que consistió en pápulo-nódulos umbilicados diseminados, con compromiso pulmonar; además, tenía histopatología y cultivo positivos para Histoplasma capsulatum sl. y prueba de antigenuria para histoplasma también positiva. Se consideró un diagnóstico de histoplasmosis diseminada con presentación cutánea, fue la expresión de un síndrome de reconstitución inmune por desenmascaramiento. Se inició manejo con anfotericina B liposomal y se mantuvo la terapia antirretroviral; posteriormente se continuó el tratamiento con itraconazol durante 12 meses con mejoría de las lesiones. Conclusiones: El diagnóstico clínico, histopatológico y microbiológico fue oportuno; el paciente presentó una adecuada respuesta al tratamiento. Esta es una micosis curable e incluso prevenible, si se diagnostica a tiempo, se inicia tratamiento precoz y se mantiene la terapia retroviral(AU)

Introduction: Histoplasmosis is a deep or systemic mycosis caused by a dimorphic fungus which may disseminate mainly in immunocompromised patients, such as those diagnosed with human immunodeficiency virus. Immune reconstitution syndrome is a paradoxical worsening of a known condition or a condition appearing after the start of antiretroviral therapy. Objective: Describe a case of disseminated histoplasmosis associated to immune reconstitution syndrome in a patient with human immunodeficiency virus infection. Case report: A case is presented of a male 32-year-old patient diagnosed with human immunodeficiency virus with a clinical status of three weeks' evolution. The current status developed after the start of antiretroviral therapy. It consisted in disseminated umbilicated papular nodules with pulmonary involvement, as well as positive Histoplasma capsulatum sl. histopathology and culture, and a positive histoplasma antigen test. A diagnosis of disseminated histoplasmosis with a cutaneous presentation was considered. It was the expression of immune reconstitution syndrome by unmasking. Treatment was started with liposomal amphotericin B, maintaining the antiretroviral therapy. Management was then continued with itraconazole for 12 months with improvement of the lesions. Conclusions: Timely clinical, histopathological and microbiological diagnosis was performed. The patient displayed an adequate response to treatment. This mycosis is curable and even preventable when a diagnosis is made in time, treatment is started early and the retroviral therapy is maintained(AU)

Conditional cash transfers, spillovers, and informal health care: Evidence from Peru.

Conditional cash transfer programs have become instrumental in encouraging the use of formal health services in developing countries, but little is known about their effect on the use of low-quality informal care. Using a large survey of Peruvian rural households and a regression discontinuity design, we find a sizeable reduction in the use of informal health care providers not only by targeted but also by nontargeted members of households that qualify for the program. This indicates the existence of spillover effects within the household. We also provide evidence that beyond the direct increase in income, the availability of better information about institutional services is a potential mechanism that drives these effects.

Cambio climático y su impacto en los recién nacidos / Climate change and its impact in newborns

El documento define: objetivos: i) determinar los efectos diferenciadores de la variabilidad de la temperatura durante la gestación en la salud neonatal según las características de los niños; ii) estimar los costos asociados al deterioro de la salud neonatal como causa de la variabilidad de la temperatura, y iii) predecir los efectos del cambio climático en la salud neonatal para los próximos años. Se recurre a una fuente de datos que provee la temperatura global de cada mes durante el período 1900-2010, que reporta datos a un detalle de 0,5 x 0,5 grados y cubre la totalidad del territorio peruano, los que se combinan con datos de indicadores de salud neonatal provistos por la Encuesta Demográfica de Salud Familiar (Endes) del Instituto Nacional de Estadística e Informática (INEI). Dado que la variabilidad de la temperatura no puede ser anticipada entre un año y otro, la estrategia empírica consiste en comparar a niños nacidos en un mes en particular y dentro de un mismo distrito, y que fueron expuestos a distinta variabilidad climática a lo largo de los años. Los resultados sugieren que un aumento de la temperatura por encima de una desviación estándar con respecto al promedio histórico distrital (aproximadamente 2,25 °C) reduce en 22 gramos el peso al nacer y aumenta la prevalencia de bajo peso al nacer en 1,1 puntos porcentuales (14%). Los resultados no son estadísticamente significativos para temperaturas desacostumbradamente frías. Esto puede significar que son las temperaturas inusualmente cálidas las que perjudican la salud de los recién nacidos, lo cual es consistente con la hipótesis de que el calentamiento global repercute en la salud de los bebés a futuro.

The perils of climate change: In utero exposure to temperature variability and birth outcomes in the Andean region.

The discussion on the effects of climate change on human activity has primarily focused on how increasing temperature levels can impair human health. However, less attention has been paid to the effect of increased climate variability on health. We investigate how in utero exposure to temperature variability, measured as the fluctuations relative to the historical local temperature mean, affects birth outcomes in the Andean region. Our results suggest that exposure to a temperate one standard deviation relative to the municipality's long-term temperature mean during pregnancy reduces birth weight by 20g. and increases the probability a child is born with low birth weight by a 0.7 percentage point. We also explore potential channels driving our results and find some evidence that increased temperature variability can lead to a decrease in health care and increased food insecurity during pregnancy.

Dispositivo para inserción percutánea del catéter distal en la derivación ventriculoatrial. Reporte técnico / No disponible

Introducción y objetivos El sistema de derivación ventriculoatrial está indicado en el tratamiento de algunos casos de hidrocefalia. El catéter distal se suele insertar a la aurícula derecha mediante la disección venosa cervical. La inserción percutánea ha sido descrita con éxito, sin embargo su uso no está mundialmente extendido. El objetivo es describir las modificaciones del catéter distal del sistema de derivación ventriculoatrial, la técnica para su colocación percutánea y la evolución clínica. Material y métodos Se modificó el catéter distal tras su uso en 4 especímenes animales. Se diseñó «sobre la guía» (over the wire) y se disminuyó su flexibilidad, y además se agregaron accesorios al equipo. Luego se utilizó en humanos bajo ligeras modificaciones de la técnica de punción yugular. Se evaluaron las complicaciones, el tiempo operatorio y la evolución durante 6 meses. Resultados Durante un año se trataron 6 pacientes adultos portadores de hidrocefalia en quienes el peritoneo ya no podía ser receptor del líquido cefalorraquídeo. No se presentaron complicaciones y el tiempo operatorio medio fue de 34min (incluyendo la colocación del catéter proximal). La hidrocefalia remitió. Conclusiones La técnica percutánea ha demostrado ser útil: disminuye el tiempo quirúrgico y presenta un muy bajo índice de complicaciones. Al parecer, las modificaciones hechas al catéter distal no provocan complicaciones y se evita el uso de otros materiales diseñados para otros propósitos. Se requieren más casos para realizar un análisis definitivo (AU)

[Device for percutaneous insertion of a distal catheter in ventriculo-atrial shunt. Technical report]. / Dispositivo para inserción percutánea del catéter distal en la derivación ventriculoatrial. Reporte técnico.

INTRODUCTION AND OBJECTIVES: A ventriculo-atrial shunt is indicated for the treatment of some hydrocephalus cases. The distal catheter is usually inserted into the right atrium through cervical venous dissection. Percutaneous insertion has been described with success; however its use is not widespread. The aim of this work is to describe modifications in the distal catheter of a ventriculo-atrial shunt, the technique for its percutaneous insertion and the clinical outcome of the process. MATERIAL AND METHODS: The distal catheter was modified after its use in 4 animal specimens. It was designed «over the wire¼, with its flexibility being reduced and accessories being added. The device was subsequently used in humans, with slight modifications of the jugular vein catheterization technique. We evaluated complications, surgical time and outcome during 6months. RESULTS: In the course of one year, 6adult patients in whom the peritoneum was no longer receiving cerebrospinal fluid were treated for hydrocephalus. The mean operating time was 34minutes (including proximal catheter insertion). There were no complications and ventricular size improved. CONCLUSIONS: The percutaneous technique has proved useful: it reduces surgical time and has a very low rate of complications. Apparently, modifications made in the distal catheter caused no complications and avoided the use of other materials designed for other purposes. More cases are required to perform a definitive analysis.