Rinoplastia secundaria: infección nasal en el postoperatorio / Secondary rhinoplasty: postoperative nasal infection

La rinoplastia es una de las intervenciones más comunes en cirugía plástica. Se opera aquí una rinoplastia secundaria por vía abierta injertando los alares y la punta con cartílagos auriculares, mientras el tabique cartilaginoso fue usado para los spreader grafts. Se describe aquí una infección posoperatoria de su punta nasal. Al 9no día de su posoperatorio comienza con la punta nasal congestiva y levemente inflamada. Se medica con una crema con antibióticos, pero el día 14 aparece con la punta nasal muy inflamada y con colección. Cuando en el consultorio el cirujano la ve, como cualquier absceso, decide realizarle drenaje con un trocar 18G, 3 miniincisiones en la piel debajo de la punta nasal, de la que drena un líquido amarronado. Luego con el mismo trocar se realiza un lavado dentro de la cavidad con rifampicina solución. Se medica con trimetoprima-sulfametoxazol (Bactrimforte®) 2 comp/día. Al otro día se observa una notable mejoría. Se continuó con lavado diario durante 4 días con el mismo antibiótico evolucionando rápidamente bien. El Bactrim se lo continúa por 20 días. Al mes la punta nasal está muy bien, deshinchada con cicatrices apenas visibles. A los cuatro meses, la punta está muy blanda, las alas nasales y las narinas normales, la punta con buena proyección igual que el dorso con los spreader graft.

Rhinoplasty is one of the most common interventions in plastic surgery. A secondary open rhinoplasty was carried out grafting the allae and the tip of the nose with conchae cartilage, while the septum was used for spreader grafts. We are here describing this post operatory with a tip of the nose infection.In the control, at the 9th postoperative day, the nasal tip began to be congested and at the 14th post op day the patient showed a clear inflammatory collection. In the office, the surgeon decided to evacuate it with three punctureslike little incisions at the inferior part of the skin tip with a trocar 18G. Through them, drained brownish purulent secretion. With the same trocar, rifampicin solution was injected through these little incisions, like washing the subdermal area. It was medicated with trimethoprim-sulfamethoxazole (Bactrim forte®) 2 tablets/day. The following day, there was a clear improvement in the congestion and erythema of the nose. This procedure of washing was repeated for four days. There was a quick evolution of the inflammatory process and 20 more days, there was no sign of the infection. Four months later, the tip of the nose was soft and the result was considered optimal by the patient and doctors.

O manejo de infecções nos pacientes em cuidados paliativos em fase final de vida e processo ativo de morte / The management of infections in palliative care patients in the end-of-life and active process of death

Introdução: O cuidado paliativo é uma abordagem que visa melhorar a qualidade de vida de indivíduos, adultos e crianças e seus familiares, que convivem com doenças que ameaçam a vida. As pessoas em cuidados paliativos podem apresentar quadros de infecção devido a imunossupressão, presença de comorbidades, desidratação e ressecamento da pele, diminuição da função dos neutrófilos e da imunidade celular, pelo uso de corticoides, além da caquexia. As infecções podem provocar sintomas como fadiga, dor, desconforto e representam um grande desafio no cuidado. Os indivíduos com esse quadro demandam ações de enfermagem específicas mediante as terapias propostas pela equipe multiprofissional. Objetivo: Analisar como ocorre o manejo de infecções nos pacientes em cuidados paliativos em fase final de vida e processo ativo de morte em dois serviços hospitalares de saúde. Método: Trata-se de um estudo observacional, analítico e retrospectivo, que foi realizado em dois hospitais localizados no município de Ribeirão Preto, estado de São Paulo, que prestam atendimento a indivíduos em cuidados paliativos e seus familiares. Foram incluídos os prontuários de indivíduos em cuidados paliativos em fase final de vida ou processo ativo de morte, de ambos os sexos, com idade superior a 18 anos, que foram diagnosticados com infecção no período de janeiro a dezembro de 2019 em sua última internação antes do óbito. Foram coletadas, dos prontuários, informações referentes às variáveis sociodemográficas, clínicas e as ações implementadas pela equipe de enfermagem. Resultados: A amostra foi constituída por 113 prontuários, nos quais o diagnóstico oncológico foi o mais prevalente. Houve predominância do diagnóstico clínico para infecção, sendo o foco principal o pulmonar, em indivíduos em fase final de vida. A terapia antimicrobiana foi indicada para 97,3% dos casos. A mediana da duração da antibioticoterapia foi de 7 dias para os indivíduos em fase final de vida e de 2 dias para aqueles em processo ativo de morte. Já o tempo decorrido do início da antibioticoterapia até o óbito foi de 9 dias para os indivíduos em fase final de vida e de 2 dias para aqueles em processo ativo de morte. As intervenções de enfermagem mais frequente foram aferição de sinais vitais, cuidados com a pele e mudança de decúbito; e os procedimentos mais frequentes realizados pela enfermagem foram troca de fralda, punção venosa para inserção de cateter e punção venosa para coleta de exames. Conclusão: O manejo da infecção nos pacientes em cuidados paliativos em fase final de vida e processo ativo de morte ocorre por meio de cuidados e procedimentos que geram desconforto físico, entretanto visando o alívio dos sintomas. Além disso, nota-se a alta frequência de prescrição de antibióticos, principalmente pela via endovenosa. Tais achados devem ser documentados, uma vez que nos convida a refletir sobre nossas atitudes práticas e sobre o que significa estar confortável para essas pessoas, possibilitando incorporar esta informação no desenho de intervenções focadas para potencializar a experiência de conforto

Introduction: Palliative care is an approach that improves the quality of life of individuals, adults and children and their families, who live with life-threatening diseases. People in palliative care may present with infection due to immunosuppression, presence of comorbidities, dehydration and dryness of the skin, decrease in neutrophil function and cellular immunity, due to the use of corticosteroids, in addition to cachexia. Infections can cause symptoms such as fatigue, pain, discomfort and represent a major challenge in care. Individuals with this condition demand specific nursing actions through the therapies proposed by the multidisciplinary team. Objective: To analyze how infections are managed in palliative care patients in the final stage of life and in the active process of death in two hospital health services. Method: This is an observational, analytical and retrospective study, which was carried out in two hospitals located in the city of Ribeirão Preto, state of São Paulo, which provide care to individuals in palliative care and their families. The medical records of individuals in palliative care in the final stage of life or in the active process of death, of both sexes, aged over 18 years, who were diagnosed with infection in the period from January to December 2019 in their last hospitalization before death. Information regarding sociodemographic and clinical variables and the actions implemented by the nursing team were collected from the medical records. Results: The sample consisted of 113 medical records, in which the oncological diagnosis was the most prevalent. There was a predominance of the clinical diagnosis for infection, the main focus being the pulmonary, in individuals in the final stage of life. Antimicrobial therapy was indicated for 97.3% of cases. The median duration of antibiotic therapy was 7 days for individuals in the final stage of life and 2 days for those in the active process of dying. The time elapsed from the beginning of antibiotic therapy to death was 9 days for individuals in the final stage of life and 2 days for those in the active process of death. The most frequent nursing interventions were measuring vital signs, skin care and changing positions; and the most frequent procedures performed by nursing were diaper changes, venipuncture for catheter insertion and venipuncture for collection of exams. Conclusion: The management of infection in palliative care patients in the final stage of life and in the active process of death occurs through care and procedures that generate physical discomfort, however aiming at relieving symptoms. In addition, there is a high frequency of prescription of antibiotics, mainly by the intravenous route. Such findings must be documented, as they invite us to reflect on our practical attitudes and on what it means to be comfortable for these people, making it possible to incorporate this information into the design of interventions focused on enhancing the experience of comfort

Apoptosis in infectious diseases as a mechanism of immune evasion and survival.

In pluricellular organisms, apoptosis is indispensable for the development and homeostasis. During infection, apoptosis plays the main role in the elimination of infected cells. Infectious diseases control apoptosis, and this contributes to disease pathogenesis. Increased apoptosis may participate in two different ways. It can assist the dissemination of intracellular pathogens or induce immunosuppression to favor pathogen dissemination. In other conditions, apoptosis can benefit eradicate infectious agents from the host. Accordingly, bacteria, viruses, fungi, and parasites have developed strategies to inhibit host cell death by apoptosis to allow intracellular survival and persistence of the pathogen. The clarification of the intracellular signaling pathways, the receptors involved and the pathogen factors that interfere with apoptosis could disclose new therapeutic targets for blocking microbial actions on apoptotic pathways. In this review, we summarize the current knowledge on pathogen anti-apoptotic and apoptotic approaches and the mechanisms involving in disease.

Patologías del niño inmigrante en la Unidad de Cuidados Intensivos: actualización / Pathologies of the immigrant child in the Intensive Care Unit: update

Resumen: Cada vez es más frecuente la atención médica en la Unidad de Cuidados Intensivos (UCI) de niños o adolescentes inmigrantes como también de aquellos nacidos en nuestro país con padres en tal condición. Esto ha ocasionado, en la actualidad, que el equipo de salud se deba enfrentar con problemas diagnósticos derivados del escaso conocimiento de condiciones genéticas propias de esta población y/o el desarrollo de diversas patologías infrecuentes en nuestro país, algunas resultantes de su condi ción sanitaria. En esta revisión se abordan diversos aspectos de la patología hematológica, infecciosa, parasitaria, respiratoria y cardiovascular, todos tópicos relevantes de conocer durante su estadía en la UCI. Es un deber del equipo de salud actualizarse sobre patologías de baja prevalencia en nuestro país, algunas de ellas muy poco conocidas hasta hace una década, pero que, actualmente, están cada vez más presentes en las UCI del sistema de salud público chileno.

Abstract: It is increasingly common to provide medical care in the Intensive Care Unit (ICU) for immigrant children and adolescents as well as those born in Chile with parents in such condition. Currently, this has caused that the health team has to face diverse infrequent pathologies in our country and/ or diagnostic problems derive from the poor knowledge of genetic conditions of this population, some resulting from their health conditions. This review addresses several aspects of hematological, infectious, parasitic, respiratory, and cardiovascular pathologies, all relevant topics to know during their stay in the ICU. It is a duty of the health team to be updated on pathologies of low prevalence in our country, some of them very little known until a decade ago, but which are currently increasingly present in the ICUs of the Chilean public health system.

Current status of pediatric neurocritical care in Argentina. / Estado actual del soporte neurológico crítico en pediatría en la Argentina.

INTRODUCTION: Patients with neurocritical injuries account for 10-16 % of pediatric intensive care unit (PICU) admissions and frequently require neuromonitoring. OBJECTIVE: To describe the current status of neuromonitoring in Argentina. METHODS: Survey with 37 questions about neuromonitoring without including patients' data. Period: April-June 2017. RESULTS: Thirty-eight responses were received out of 71 requests (14 districts with 11 498 annual discharges). The PICU/hospital bed ratio was 21.9 (range: 4.2-66.7). Seventy-four percent of PICUs were public; 61 %, university-affiliated; and 71 %, level I. The availability of monitoring techniques was similar between public and private (percentages): intracranial pressure (95), electroencephalography (92), transcranial Doppler (53), evoked potentials (50), jugular saturation (47), and bispectral index (11). Trauma was the main reason for monitoring. CONCLUSION: Except for intracranial pressure and electroencephalography, neuromonitoring resources are scarce and active neurosurgery availability is minimal. A PICU national registry is required.

Introducción. Los pacientes con lesiones neurocríticas representan el 10-16 % de los ingresos a unidades de cuidados intensivos pediátricas (UCIP) y, frecuentemente, requieren neuromonitoreo. Objetivo. Describir el estado actual del neuromonitoreo en la Argentina. Métodos. Encuesta con 37 preguntas sobre neuromonitoreo sin incluir datos de pacientes. Período: abril-junio, 2017. Resultados. Se recibieron 38 respuestas a 71 solicitudes (14 distritos con 11 498 egresos anuales). La relación camas de UCIP/hospitalarias fue 21,9 (rango: 4,2-66,7). El 74 % fueron públicas; el 61 %, universitarias, y el 71 %, nivel 1. La disponibilidad fue similar entre públicas y privadas (porcentajes): presión intracraneana (95), electroencefalografía (92), doppler transcraneano (53), potenciales evocados (50), saturación yugular (47) e índice bispectral (11). El principal motivo de monitoreo fue trauma. Conclusión. Excepto la presión intracraneana y la electroencefalografía, los recursos de neuromonitoreo son escasos y la disponibilidad de neurocirugía activa es mínima. Se necesita un registro nacional de UCIP.

[Pathologies of the immigrant child in the Intensive Care Unit. Update]. / Patologías del niño inmigrante en la Unidad de Cuidados Intensivos. Actualización.

It is increasingly common to provide medical care in the Intensive Care Unit (ICU) for immigrant children and adolescents as well as those born in Chile with parents in such condition. Currently, this has caused that the health team has to face diverse infrequent pathologies in our country and/ or diagnostic problems derive from the poor knowledge of genetic conditions of this population, some resulting from their health conditions. This review addresses several aspects of hematological, infectious, parasitic, respiratory, and cardiovascular pathologies, all relevant topics to know during their stay in the ICU. It is a duty of the health team to be updated on pathologies of low prevalence in our country, some of them very little known until a decade ago, but which are currently increasingly present in the ICUs of the Chilean public health system.

Valor do ecocardiograma na Endocardite Infecciosa associada aos dispositivos cardíacos implantáveis / Use of echocardiography in Infectious Endocarditis associated with implantable cardiac devices

Nas últimas décadas, o aumento das indicações para dispositivos cardíacos eletrônicos implantáveis tem sido acompanhado pela elevação dos casos de complicações relacionadas ao seu uso, dentre elas a endocardite infecciosa. Apesar dos avanços diagnósticos e terapêuticos da doença, esta mantém elevada morbimortalidade. Os casos relacionados aos dispositivos apresentam importantes limitações referentes aos critérios e aos métodos diagnósticos que implicam na tomada de decisão terapêutica sobre retirada do dispositivo, com risco de morte e outras complicações. Ainda assim, o ecocardiograma mantém um grande valor no diagnóstico da endocardite infecciosa relacionada a dispositivos cardíacos e de suas complicações. O entendimento das limitações e dos desafios acerca do diagnóstico reforça a necessidade de mais estudos sobre do tema. O presente artigo visa descrever a epidemiologia, a microbiologia, os fatores de risco, a patogenia, o diagnóstico e o tratamento da endocardite infecciosa associada aos dispositivos cardíacos eletrônicos implantáveis, visando demonstrar, principalmente, o valor dos exames de imagem na abordagem dessa condição clínica, com ênfase nos achados ao ecocardiograma.

In recent decades, the increase in indications for implantable electronic cardiac devices has been accompanied by an increase in cases of complications related to their use, including infectious endocarditis. Despite the diagnostic and therapeutic advances of the disease, it maintains high morbidity and mortality. The cases related to the devices have important limitations regarding the criteria and diagnostic methods that imply in making a therapeutic decision about removing the device, with risk of death and other complications. Still, echocardiography remains of great value in the diagnosis of infective endocarditis related to cardiac devices and their complications. Understanding the limitations and challenges regarding diagnosis reinforces the need for further studies on the topic. This article aims to describe the epidemiology, microbiology, risk factors, pathogenesis, diagnosis and treatment of infective endocarditis associated with implantable electronic cardiac devices, aiming to demonstrate, mainly, the value of imaging tests in addressing this clinical condition , with emphasis on echocardiogram findings.

Analyses of the effectiveness of a Brazilian pediatric home care service: a preliminary study.

BACKGROUND: Technological advances in health care currently provide better care conditions and have increased survival rates of premature infants, along with increasing the life expectancy of chronically ill children. In this context, the home care service has emerged as an effective tool for the treatment of this group of children. Thus, this preliminary study aimed at evaluating the effectiveness of the Home Care Service (HCS) with regard to pediatric care. METHODS: A cross-sectional study was performed through a medical record analysis of a tertiary hospital in Minas Gerais/Brazil. Two groups were compared: 36 patients from the HCS (home group) and 13 patients hospitalized with an indication for home care (hospital group). To analyze the effectiveness of HCS, we evaluated the number of readmissions, infection rate, number of procedures, and optimization of beds. RESULTS: The hospital group presented 6.04 times more infections and was submitted to 6.43 times more procedures. The home group presented lower readmission rates; with 41.66% of children studied not being readmitted and 76.19% of those who needed readmissions did so after more than 30 days from hospital discharge. HCS optimized hospital beds and allowed, over five (5) years, the hospitalization of around 102 patients in the hospital studied. CONCLUSION: In this preliminary study, HCS reduced the number of procedures and infections compared to hospitalized patients. Moreover, HCS presented lower readmission rates and optimized hospital beds, which could be considered an indication of effectiveness.

[Dialyzed leukocyte extracts for the treatment of recurrent and severe infections in pediatric patients with cellular immunodeficiency: 15 years of experience]. / Extractos dializados de leucocitos para el tratamiento de infecciones recurrentes y severas en pacientes pediátricos con inmunodeficiencia celular: 15 años de experiencia.

BACKGROUND: Dialyzable leukocyte extracts (DLE) have been used to treat several cellular immunodeficiency. OBJECTIVE: To review the experience of a tertiary hospital in the use of DLE for the treatment of recurrent or severe infections in children with acquired cellular immunodeficiency not due to HIV. METHODS: We reviewed the medical records of all children who received treatment with EDL of human or bovine origin between 1986 and 2000 to detect recurrent or severe infections without response to a specific antimicrobial therapy and with a quantitative or qualitative deficit in the cellular immune response. The dose of DLE was adjusted according to the percentage of T lymphocytes; the evolution of the patient was evaluated retrospectively for 5 years, the immune response was evaluated by subpopulation of lymphocytes and intradermal tests and inhibition of the leukocyte migration assay (LIF) to PPD, coccidioidin, varidase and candidin. RESULTS: 150 children received DLE, age 7.0 ± 5.9 years. The most frequent indications included upper respiratory tract (71%), lower respiratory tract (43%), gastrointestinal tract (15%), urinary tract (15%) and neurological infections (4%) and coccidioidomycosis (3%). After starting the DLE, the numbers of T lymphocytes, LIF to PPD and varidase (> 20%) and the intradermal induration of the test increased (p <0.001). In 6 patients (4%) recurrences of respiratory and gastrointestinal tract infections were observed, which resolved, no adverse effects attributable to the DLE were reported. CONCLUSIONS: The use of DLE for recurrent or severe infectious processes in children with cellular immune deficit improved the clinical evolution and the immunological parameters evaluated without adverse effects attributable to their use.

Antecedentes: Los extractos dializados de leucocitos (EDL) han sido utilizados en el tratamiento de diversos defectos de la inmunidad celular. Objetivo: Revisar la experiencia en el uso de EDL para tratar infecciones recurrentes o severas en niños con inmunodeficiencia celular adquirida no debida a virus de la inmunodeficiencia oportuna. Métodos: Se revisaron expedientes de niños tratados con EDL humano o bovino entre 1986 y 2000, por infecciones recurrentes o severas sin respuesta a antimicrobianos y con déficit en la respuesta inmune celular. La dosis se ajustó por el porcentaje de poblaciones de linfocitos T. En el seguimiento a cinco años, la respuesta inmune se evaluó por subpoblaciones de linfocitos, intradermorreacción e inhibición de la migración de leucocitos (LIF) a PPD, coccidioidina, varidasa y candidina. Resultados: 150 niños recibieron EDL, edad 7.0 ± 5.9 años. Las indicaciones más frecuentes incluyeron infección respiratoria superior (71 %), respiratoria inferior (43 %), gastrointestinal (15 %), urinaria (15 %), neuroinfección (4 %) y coccidioidomicosis (3 %). Se incrementaron los linfocitos T, el LIF a PPD y varidasa (> 20 %), así como la induración en pruebas de intradermorreacción (p < 0.001). Se resolvieron las infecciones que se presentaron (4 %). No se reportaron efectos adversos. Conclusiones: El uso de EDL mejoró los parámetros inmunológicos y la evolución clínica en niños con déficit inmune celular.

Proteína C-reativa nos processos inflamatórios agudos e nas doenças infecciosas caninas

A Proteína C-reativa (PCR) é uma proteína prototípica de fase aguda, que apresenta um rápido aumento de concentração no soro sanguíneo como resposta a um estímulo insultuoso inflamatório ao organismo. Foi a primeira proteína de fase aguda a ser descrita, em 1930 por Tillet e Francis, que relataram a sua existência no soro do sangue de doentes infetados por Streptococcus pneumoniae. Foi descrita como uma substância que possuía a capacidade de precipitar o polissacárido “C” da parede celular do pneumococcus e foi primeiramente denominada de substância C reativa. A pcr canina foi identificada apenas em 1966 por Dillman e Coles, sendo isolada em 1970 por Riley e Coleman e caracterizada em 1984 por Caspi. Os primeiros estudos, conduzidos por Dillman, revelaram a propriedade da pcr em aumentar a sua concentração sérica em resposta a um processo inflamatório. Foi induzida em cães, uma resposta inflamatória, por meio de uma injeção por via subcutânea de diversas substâncias.

Proteína C-reativa nos processos inflamatórios agudos e nas doenças infecciosas caninas

A Proteína C-reativa (PCR) é uma proteína prototípica de fase aguda, que apresenta um rápido aumento de concentração no soro sanguíneo como resposta a um estímulo insultuoso inflamatório ao organismo. Foi a primeira proteína de fase aguda a ser descrita, em 1930 por Tillet e Francis, que relataram a sua existência no soro do sangue de doentes infetados por Streptococcus pneumoniae. Foi descrita como uma substância que possuía a capacidade de precipitar o polissacárido “C” da parede celular do pneumococcus e foi primeiramente denominada de substância C reativa. A pcr canina foi identificada apenas em 1966 por Dillman e Coles, sendo isolada em 1970 por Riley e Coleman e caracterizada em 1984 por Caspi. Os primeiros estudos, conduzidos por Dillman, revelaram a propriedade da pcr em aumentar a sua concentração sérica em resposta a um processo inflamatório. Foi induzida em cães, uma resposta inflamatória, por meio de uma injeção por via subcutânea de diversas substâncias.(AU)

Recommendations for Management of Endemic Diseases and Travel Medicine in Solid-Organ Transplant Recipients and Donors: Latin America.

The Recommendations for Management of Endemic Diseases and Travel Medicine in Solid-Organ Transplant Recipients and Donors: Latin America clinical practice guideline is intended to guide clinicians caring for solid-organ transplant (SOT) donors, candidates and recipients regarding infectious diseases (ID) issues related to this geographical region, mostly located in the tropics. These recommendations are based on both systematic reviews of relevant literature and expert opinion from both transplant ID and travel medicine specialists. The guidelines provide recommendations for risk evaluation and laboratory investigation, as well as management and prevention of infection of the most relevant endemic diseases of Latin America. This summary includes a brief description of the guideline recommendations but does not include the complete rationale and references for each recommendation, which is available in the online version of the article, published in this journal as a supplement. The supplement contains 10 reviews referring to endemic or travel diseases (eg, tuberculosis, Chagas disease [ChD], leishmaniasis, malaria, strongyloidiasis and schistosomiasis, travelers diarrhea, arboviruses, endemic fungal infections, viral hepatitis, and vaccines) and an illustrative section with maps (http://www.pmourao.com/map/). Contributors included experts from 13 countries (Brazil, Canada, Chile, Denmark, France, Italy, Peru, Spain, Switzerland, Turkey, United Kingdom, United States, and Uruguay) representing four continents (Asia, the Americas and Europe), along with scientific and medical societies.

Association of Clinical Hypoperfusion Variables With Lactate Clearance and Hospital Mortality.

BACKGROUND: Lactate has shown utility in assessing the prognosis of patients admitted to the hospital with confirmed or suspected shock. Some findings of the physical examination may replace it as screening tool. We have determined the correlation and association between clinical perfusion parameters and lactate at the time of admission; the correlation between the change in clinical parameters and lactate clearance after 6 and 24 h of resuscitation; and the association between clinical parameters, lactate, and mortality. METHODS: Prospective cohort study of adult patients hospitalized in the emergency room with infection, polytrauma, or other causes of hypotension. We measured serum lactate, capillary refill time, shock index, and pulse pressure at 0, 6, and 24 h after admission. A Spearman's correlation was performed between clinical variables and lactate levels, as well as between changes in clinical parameters and lactate clearance. The operative characteristics of these variables were determined by area under the receiver operating characteristic curve analysis and the association between lactate, clinical variables, and mortality through logistic regression. RESULTS: A total of 1,320 patients met the inclusion criteria, 66.7% (n = 880) confirmed infection, 19% (n = 251) polytrauma, and 14.3% (n = 189) another etiology. No significant correlation was found between any clinical variable and lactate values (r < 0.28). None of the variable had an adequate discriminatory capacity to detect hyperlactatemia (AUC < 0.62). In the multivariate model, lactate value at admission was the only variable independently associated with mortality (OR 1.2; 95% CI = 1.1-1.1). CONCLUSIONS: Among patients with hypoperfusion risk or shock, no correlation was found between clinical variables and lactate. Of the set of parameters collected, lactate at admission was the only independent marker of mortality.

[Syndromic approach for the diagnosis and management of acute febrile infestious diseases in emergencies]. / Enfoque sindrómico para el diagnóstico y manejo de enfermedades infecciosas agudas en situaciones de emergencia.

Several of the acute diseases with infectious etiology (viral, bacterial or parasitic) initially start with a syndrome which can be febrile, febrile icteric, febrile hemorrhagic, febrile with respiratory manifestations, febrile with neurological impairment, febrile with dermal eruptions, febrile anemic, diarrheal, necrotic cutaneous ulcer, or deaths of febrile patients may occur without a defined diagnosis, with some variants according to the ecological-social niche in which they occur; the syndromic approach is important, to quickly classify the case or the outbreak and thus have an appropriate and timely diagnosis that allows to orient both the individual management and the prevention and control measures in the population, even if there are limitations for the diagnosis of all the cases. This article describes the syndromic approach, the syndromes of importance in public health (collective) and their approach, all this is important because of its presentation in outbreaks that are occurring in the various ecological niches of our country, exacerbated by climate change.

Varias de las enfermedades agudas con etiología infecciosa (viral, bacteriana o parasitaria) cursan inicialmente con un síndrome que puede ser febril, febril ictérico, febril hemorrágico, febril con manifestaciones respiratorias, febril con compromisio neurológico, febril con erupciones dérmicas, febril anémico, o pueden ocurrir muertes de pacientes febriles sin un diagnóstico definido, con algunas variantes según el nicho ecológico-social en el que se dan; es importante el enfoque sindrómico, para luego tipificar el caso o el brote y así tener un diagnóstico adecuado y oportuno que permita orientar tanto el manejo individual como las medidas de prevención y control en la población, aun cuando haya limitaciones para el diagnóstico de todos los casos. En este artículo se describe el enfoque sindrómico, los síndromes de importancia en salud pública (colectiva) y su abordaje, todo ello es importante por su presentación en brotes que vienen ocurriendo en los variados nichos ecológicos de nuestro país, exacerbados por el cambio climático.

FOCIS goes south: advances in translational and clinical immunology.

FOCIS goes South: Advances in Translational and Clinical Immunology was the first Federation of Clinical Immunology Societies (FOCIS) ( www.focisnet.org ) meeting held in Latin America (May 15-17, 2017, Santiago de Chile, Chile). The meeting was organized as a 3-day workshop and was fostered by the Millennium Institute on Immunology and Immunotherapy, a recently nominated FOCIS Center of Excellence. The workshop brought together FOCIS associates, such as members of the FOCIS Board of Directors, Directors of different Centers of Excellence, regional speakers and 350 attendees. The Meeting covered aspects of immune regulation and modulation, as well as immunotherapy in areas of autoimmunity, transplantation, cancer and infectious diseases, among others. The activity also had a full-day immunology course and a day-long flow cytometry course.

Integrated community case management (iCCM) of childhood infection saves lives in hard-to-reach communities in Nicaragua.

OBJECTIVE: To describe Nicaragua's integrated community case management (iCCM) program for hard-to-reach, rural communities and to evaluate its impact using monitoring data, including annual, census-based infant mortality data. METHOD: This observational study measured the strength of iCCM implementation and estimated trends in infant mortality during 2007-2013 in 120 remote Nicaraguan communities where brigadistas ("health brigadiers") offered iCCM services to children 2-59 months old. The study used program monitoring data from brigadistas' registers and supervision checklists, and derived mortality data from annual censuses conducted by the Ministry of Health. The mortality ratio (infant deaths over number of children alive in the under-1-year age group) was calculated and point estimates and exact binomial confidence intervals (CIs) were reported. RESULTS: Monitoring data revealed strong implementation of iCCM over the study period, with medicine availability, completeness of recording, and correct classification always exceeding 80%. Treatments provided by brigadistas for pneumonia and diarrhea closely tracked expected cases and caregivers consistently sought treatment more frequently from brigadistas than from health facilities. The infant mortality ratio decreased more in iCCM areas compared to the non-iCCM areas. Statistically significant reduction ranged from 52% in 2010 (mortality rate ratio 0.48; 95% CI: 0.25-0.92) to 59% in 2013 (mortality rate ratio 0.41; 95% CI: 0.21-0.81). CONCLUSIONS: The iCCM has been found to be an effective and feasible strategy to save infant lives in hard-to-reach communities in Nicaragua. The impact was likely mediated by increased use of curative interventions, made accessible and available at the community level, and delivered through high-quality services, by brigadistas.

Enfoque sindrómico para el diagnóstico y manejo de enfermedades infecciosas agudas en situaciones de emergencia / Syndromic approach for the diagnosis and management of acute febrile infestious diseases in emergencies

RESUMEN Varias de las enfermedades agudas con etiología infecciosa (viral, bacteriana o parasitaria) cursan inicialmente con un síndrome que puede ser febril, febril ictérico, febril hemorrágico, febril con manifestaciones respiratorias, febril con compromisio neurológico, febril con erupciones dérmicas, febril anémico, o pueden ocurrir muertes de pacientes febriles sin un diagnóstico definido, con algunas variantes según el nicho ecológico-social en el que se dan; es importante el enfoque sindrómico, para luego tipificar el caso o el brote y así tener un diagnóstico adecuado y oportuno que permita orientar tanto el manejo individual como las medidas de prevención y control en la población, aun cuando haya limitaciones para el diagnóstico de todos los casos. En este artículo se describe el enfoque sindrómico, los síndromes de importancia en salud pública (colectiva) y su abordaje, todo ello es importante por su presentación en brotes que vienen ocurriendo en los variados nichos ecológicos de nuestro país, exacerbados por el cambio climático.

ABSTRACT Several of the acute diseases with infectious etiology (viral, bacterial or parasitic) initially start with a syndrome which can be febrile, febrile icteric, febrile hemorrhagic, febrile with respiratory manifestations, febrile with neurological impairment, febrile with dermal eruptions, febrile anemic, diarrheal, necrotic cutaneous ulcer, or deaths of febrile patients may occur without a defined diagnosis, with some variants according to the ecological-social niche in which they occur; the syndromic approach is important, to quickly classify the case or the outbreak and thus have an appropriate and timely diagnosis that allows to orient both the individual management and the prevention and control measures in the population, even if there are limitations for the diagnosis of all the cases. This article describes the syndromic approach, the syndromes of importance in public health (collective) and their approach, all this is important because of its presentation in outbreaks that are occurring in the various ecological niches of our country, exacerbated by climate change.

Contribution of structured therapeutic play in a nursing care model for hospitalised children. / Contribuição do brinquedo terapêutico estruturado em um modelo de cuidado de enfermagem para crianças hospitalizadas.

Objective To analyse how therapeutic play structured in a nursing care model contributes to the care of hospitalised children. Method This is a qualitative study based on convergent care research (CCR). Seven children participated in the study. Data were collected in September and October of 2014 by means of interviews with open-end questions and participant observation of therapeutic and dramatic play sessions and/or instructional play sessions based on the stages "Welcoming/Playing/Concluding" of the nursing model Care with Play. Data were analysed according to the analysis and interpretation stages of the CCR. Results The following three categories emerged: Meanings attributed by the child to hospitalisation and its influence on nursing care; Perception of the therapeutic procedures through therapeutic play, and Importance of the family in care. Final considerations It is concluded that the application of therapeutic play structured in the care model contributes to systematic and specialised nursing care.

Implante de marcapasso atrioventricular epicárdico subxifoide como estratégia para extração transvenosa de cabos-eletrodos em paciente com infecção / Epicardial atrioventricular pacemaker implantation through subxiphoid approach as a strategy for transvenous lead extraction in a patient with infection

A despeito da utilização de profilaxia antibiótica, tanto nos implantes iniciais como nos procedimentos de reoperação, as taxas de infecção relacionada aos dispositivos cardíacos eletrônicos implantáveis têm aumentadoprogressivamente, causando impacto na mortalidade e custos hospitalares. O tratamento de processos infecciososrelacionados aos dispositivos cardíacos eletrônicos implantáveis consiste na remoção completa do sistema deestimulação cardíaca, associada a terapia antimicrobiana sistêmica e reimplante de um novo dispositivo cardíaco. Neste artigo, relatamos o caso clínico de paciente com infecção na loja do gerador de pulsos sem evidênciasde infecção intravascular. O implante de marcapasso atrioventricular epicárdico subxifoide foi utilizado como estratégia para diminuir o risco de contaminação do novo sistema e facilitar a remoção transvenosa dos eletrodos antigos abandonados sob melhores condições técnicas...

Despite the use of antibiotic prophylaxis at the time of cardiac implantable electronic device implantation or reoperations, rates of cardiac implantable electronic device-related infection have increasedprogressively causing an impact on mortality and treatment costs. The treatment of cardiac implantable electronic device-related infections demands a complete removal of the infected device followed by systemic antimicrobial therapy and reimplantation of a new system. In this article, we report the case of a patient with pulse generator pocket infection without evidence of intravascular infection. Epicardial atrioventricular pacemaker implant through subxiphoid approach was used as a strategy to decrease the risk of contamination of the new system and to facilitate the removal of the abandoned transvenous leads under better technical conditions...