Experiencia en shock séptico en emergencias. Factores asociados a falta de respuesta a fluídos / Experience in septic shock in Emergencies. Factors associated with lack of response to fluid resuscitation

Introducción: La sepsis es una de las principales causas de muerte infantil a nivel mundial. Las guías de tratamiento utilizadas en nuestro servicio se basan en parámetros clínicos para un soporte hemodinámico temprano con énfasis en el uso de fluidos e inotrópicos guiados por metas clínicas. Objetivos: Describir las características epidemiológicas y clínicas en una cohorte de niños con diagnóstico de shock séptico (SS) en el área de emergencias, controlando tasa de respuesta a fluidos, mortalidad y su relación con las características de los pacientes. Materiales y métodos: Estudio observacional de cohorte prospectivo entre Julio del 2009 y Julio del 2010. Se incluyeron 83 pacientes entre 0 a 18 años que cumplieron con los criterios diagnósticos de SS. La respuesta a volumen se definió como: respondedores (RE) a los pacientes que solo requirieron expansión con volumen y no respondedores (nRE) a aquellos que requirieron inotrópicos luego de llegar a 60 ml/kg o aparición de signos de sobrecarga cardíaca. Resultados: 64% fueron varones con mediana de edad de 5,8 años (RIC 2-12). 71% presentaban alguna enfermedad crónica preexistente, siendo 40% pacientes oncológicos. El 25 % requirió asistencia respiratoria mecánica y 65% inotrópicos. La mediana de estadía hospitalaria fue 10 días (RIC 7-16 días). Un 35% fue RE. Solo la hipotensión al ingreso resultó ser factor de riesgo para nRE (p0,035), pero en el modelo multivariado no resultó estadísticamente significativo. El 8% de los pacientes fallecieron. Conclusiones: En nuestra población, los pacientes con enfermedades oncológicas representan un número importante de los casos de SS y posiblemente tengan una mayor mortalidad. La tasa de respuesta a volumen ocurrió en 35% de los casos. La hipotensión inicial constituye un probable factor de riesgo para nRE (AU)

Introduction: Sepsis is one of the main causes of childhood death worldwide. Treatment guidelines used at our department are based on clinical parameters for early hemodynamic support with emphasis on fluid resuscitation and inotropics use guided by clinical goals. Objectives: To describe the epidemiologic and clinical features of a cohort of children with septic shock (SS) seen at the emergency department evaluating response rate to fluid resuscitation and mortality related to patient characteristics. Materials and methods: A prospective, observational cohort study was conducted between July 2009 and July 2010. Overall, 83 patients between 0 and 18 years of age that met the diagnostic criteria of SS were included. Response to fluid resuscitation was defined as: responders (RE), those patients that only required volume expansion, and non-responders (nRE), those that required inotropes after having reached 60 ml/kg or appearance of signs of fluid overload. Results: 64% were boys; median age was 5.8 years (IQR 2-12); 71% had some type of preexisting chronic disease, consisting of cancer in 40%. Overall, 25% required mechanical ventilation and 65% inotropes. Median length of hospital stay was 10 days (IQR 7-16 days). 35% of the patients were RE. Only hypotension on admission was found to be a risk factor for nRE (p 0.035); however, in a multivariate model, this finding did not show to be statistically significant. Eight percent of the patients died. Conclusions: In our cohort, patients with cancer accounted for a large number of those who developed SS; in these patients mortality may be increased. Response rate to fluid resuscitation was 35%. Initial hypotension may be a risk factor for nRE.

Uso de tarjetas de medicación en el manejo de estado epiléptico en un servicio de emergencias. Mejoras en prescripción, preparación y administración de drogas / Use of medication cards in the management of statu epilepticus at an emergency department. Improvements in drug prescription, preparation and administration

Introducción: Los errores de medicación (EM) causan una elevada morbimortalidad y generan costos innecesarios. El servicio de emergencias (SE) presenta un mayor riesgo de EM que otras áreas. El desarrollo de una herramienta que estandarice el uso de fármacos podría mejorar la seguridad y el proceso de medicación. Objetivos: Evaluar las mejoras en el proceso de medicación mediante el uso de tablas de medicación (TM) durante la atención del estado epiléptico (EE). Materiales y métodos: Se realizó un estudio de tipo antes y después no controlado. La intervención fue el desarrollo e implementación de TM. Se relevó in situ la prescripción, preparación y administración de fármacos incluidos en las TM durante segunda quincena de Octubre y mes de Noviembre 2016, previo a la implementación de la herramienta, y en el mismo período de 2017, luego de la inducción e implementación de las tablas. Se registraron los EM y se categorizaron de acuerdo a la etapa del proceso en que ocurrieron. Resultados: En el período pre-intervención se realizaron 14 registros, 86% (12) tenía al menos un error; 57% (8) errores en la etapa de prescripción, 57% (8) en la de preparación y 21% (3) en la de administración. En el período post-intervención se realizaron 17 registros, 12% (2) tenía por lo menos un EM. No se registraron errores en la fase de prescripción, hubo 12% (2) de errores de preparación y 6% (1) de administración. Conclusión: La implementación de las TM para la estandarización del uso de fármacos en EE resultó una medida muy positiva, mejorando la seguridad en el proceso de medicación (AU)

Introduction: Medication errors (ME) are associated with high morbidity mortality and lead to unnecessary costs. The risk of ME is higher at the emergency department (ED) than in other areas. Developing a tool that standardizes drug use may improve safety and medication processes. Objectives: To evaluate improvements in the medication process by using medication cards (MCs) during status epilepticus (SE) care. Materials and methods: An uncontrolled before-and-after study was conducted. The intervention was the development and implementation of MCs. The in situ prescription, preparation, and administration of drugs included in the MCs was recorded during the second half of October and November 2016, prior to the implementation of the tool, and in the same period of 2017, after the introduction and implementation of the MCs. ME were recorded and categorized according to the stage of the process in which they occurred. Results: In the pre-intervention period 14 episodes were recorded; in 86% (12) at least one error occurred; 57% (8) were ME in the prescription stage, 57% (8) were ME in the preparation stage, and 21% (3) were ME in the administration stage. In the post-intervention period 17 errors were recorded, in 12% (2) at least one ME occurred. No errors were recorded in the prescription stage, 12% (2) were preparation errors, and 6% (1) administration errors. Conclusion: The implementation of MCs for the standardization of medications used in the RU was successful, improving safety in the medication process (AU)

FRET mechanism between a fluorescent breast-cancer drug and photodynamic therapy sensitizers.

Tamoxifen is one of the most frequently used drugs for the treatment of estrogen receptor positive breast cancer, which is the most prevalent form of hormone dependent breast cancer. A few years ago, we developed a fluorescent derivative of tamoxifen formed by the covalent binding of tamoxifen to a common dye biomarker. The new compound, known as FLTX1, showed the pharmacological activity of the tamoxifen moiety and efficient fluorescence properties, which could be used synergistically to improve the effect of the drug. In this paper, we demonstrate that irradiation at the absorption band of FLTX1 can result in fluorescence resonance energy transfer to photosensitizers such as Rose Bengal and Merocyanine 540, activating the production of reactive oxygen species (ROS). Indeed, the generation of ROS was demonstrated using a colorimetric assay. Since FLTX1 mostly binds estrogen-receptor overexpressing cancer cells, the results obtained are very promising and suggest a new therapeutic strategy combining chemo- and photodynamic therapies.

Metal-free, direct conversion of α-amino acids into α-keto γ-amino esters for the synthesis of α,γ-peptides.

An efficient, metal-free synthesis of unusual α-keto γ-amino esters from α-amino acids is achieved by a radical scission-oxidation-addition of silyloxy acrylates procedure, where no purification of the reaction intermediates is needed. This protocol can be applied to the selective modification of the C-terminal position in peptides to give α,γ-hybrids.

Synthesis of 2,3-disubstituted pyrrolidines and piperidines via one-pot oxidative decarboxylation-beta-iodination of amino acids.

A new synthesis of 2,3-disubstituted pyrrolidines and piperidines is described. This mild procedure is based on the one-pot oxidative decarboxylation-beta-iodination of alpha-amino acid carbamates or amides. The iodine is introduced at the previously unfunctionalized 3-position. Different substituents can be introduced at C-2, e.g., hydroxy, alkoxy, allyl, alkyl, etc. A trans relationship between the C-2 and C-3 substituents is exclusively obtained. The influence of the solvent and the ring size of the starting amino acid are studied, as well as the nature of the protecting group on the nitrogen. The stereoselectivity of the reaction was also studied using chiral methyl (2S,4S)-4-acetyloxyproline-1-carboxylate (8). The products obtained can be manipulated to give bicyclic systems present in many natural products. By using the tandem decarboxylation-iodination-alkylation reaction, 2-substituted-3-iodopyrrolidines are formed, which are precursors of 2-substituted-2,5-dihydropyrrols.

Tandem radical decarboxylation-oxidation of amino acids: A mild and efficient method for the generation of N-acyliminium ions and their nucleophilic trapping

A convenient methodology for the synthesis of 2-substituted pyrrolidines from alpha-amino acids is described. A number of cyclic and acyclic alpha-amino acid derivatives have been prepared in order to test the scope and diastereoselectivity of this method. These substrates were treated with iodosylbenzene or (diacetoxyiodo)benzene (DIB) and iodine in order to generate the corresponding carboxyl radical, which evolves by loss of carbon dioxide to produce a carbon radical which in turn undergoes oxidation to an N-acyliminium ion. This postulated intermediate could be trapped inter- or intramolecularly by oxygen, nitrogen and carbon nucleophiles. In the case of carbon nucleophiles, a Lewis acid is required for the concomitant carbon-carbon bond formation. High yields and modest diastereoselectivities were obtained. The present methodology was applied to the synthesis of omega-amino aldehydes or hemiaminals 8-14, 2-aminopyrrolidine derivative 15, aminolactone derivative 16, and azasugar analogues 17 and 18. When carbon nucleophiles were used, alkaloid precursors such as 2-allyl- or 2-alkylpyrrolidines 19-23 and 25 were obtained.

Haemophilus aphrophilus as a rare cause of arthritis.

A case of septic arthritis due to Haemophilus aphrophilus is presented. This organism has rarely been reported as a cause of bone or joint infections. We believe this is the third reported case of septic arthritis caused by this microorganism. We review the clinical and bacteriologic findings and the previously reported cases of infection caused by H. aphrophilus. Treatment with ceftriaxone was followed by full recovery without sequelae.