Adición de melatonina a terapia con hipotermia para encefalopatía hipóxico-isquémica neonatal / Addition of melatonin to hypothermia therapy for neonatal hypoxic-ischemic encephalopathy

Introducción La encefalopatía hipóxico-isquémica neonatal es una patología caracterizada por una disfunción neurológica aguda, de severidad variable, causada por un episodio asfíctico perinatal. Se presenta en uno a seis de cada 1000 recién nacidos de término, asociándose a una alta morbimortalidad neonatal y a desenlaces neurológicos adversos. El uso de hipotermia es considerado como la terapia estándar para esta condición. Sin embargo, debido a su limitada eficacia clínica, se han propuesto diferentes opciones terapéuticas adyuvantes, incluyendo el uso de fármacos como la melatonina. Existe controversia sobre si la terapia combinada con melatonina es superior a la monoterapia con hipotermia. Métodos Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el tamizaje de múltiples fuentes de información, incluyendo MEDLINE/PubMed, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un meta-análisis y preparamos una tabla de resumen de los resultados utilizando el método Grading of Recommendations Assessment, Development and Evaluation, GRADE Resultados Identificamos dos revisiones sistemáticas que en conjunto incluyeron dos estudios primarios, ambos ensayos aleatorizados. Se incluyeron los dos ensayos aleatorizados en el análisis del presente trabajo. Conclusiones No es posible establecer con claridad si la adición de melatonina disminuye la mortalidad o la probabilidad de presentar alteraciones reflejadas en la resonancia magnética cerebral, debido a que la certeza de la evidencia existente ha sido evaluada como muy baja. Por otro lado, adicionar melatonina a la terapia con hipotermia, comparado con la monoterapia con hipotermia, podría aumentar la probabilidad de que el examen neurológico sea normal a los seis meses, y que la cognición sea normal a los 18 meses. Finalmente, la adición de melatonina a la terapia con hipotermia probablemente disminuya la probabilidad de presentar convulsiones.

Introduction Neonatal hypoxic-ischemic encephalopathy is caused by perinatal asphyxia, resulting in an acute neurological dysfunction of variable severity. It occurs in one to six of every 1000 full-term newborns and is associated with high neonatal morbimortality and adverse neurological outcomes. The use of hypothermia is considered the standard therapy for this condition. However, different adjuvant therapeutic options have been proposed due to limited clinical efficacy, including drugs like melatonin. There is controversy about whether combined therapy with melatonin is superior to monotherapy with hypothermia. Methods We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, and Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of the findings table using the GRADE approach. Results We identified two systematic reviews that included two primary studies, both randomized trials. The two randomized trials were included in the analysis of the present work. Conclusion It is not possible to establish whether the addition of melatonin decreases mortality or the probability of alterations in brain magnetic resonance imaging because the certainty of the existing evidence has been assessed as very low. On the other hand, the addition of melatonin to hypothermia therapy, compared to hypothermia monotherapy, may increase the probability of normal neurological examination at six months and the probability of normal cognition at 18 months. Finally, adding melatonin to hypothermia therapy likely reduces the probability of seizures.

Luxofractura posterior bilateral de hombro secundaria a episodio de convulsión: importancia del diagnóstico oportuno. A propósito de un caso / Bilateral posterior glenohumeral fracture-dislocation secondary to a seizure episode: the importance of early diagnosis. A case review

Resumen: Introducción: la luxofractura glenohumeral posterior (LFGHP) es una lesión poco frecuente. Puede ser secundaria a una crisis convulsiva, casos de electrocución, o por traumatismo directo. Su diagnóstico suele ser tardío, lo que aumenta la tasa de complicaciones y secuelas. Caso clínico: paciente de sexo masculino de 52 años, trasladado a centro de alta complejidad por convulsión tónico-clónica y LFGHP derecha. En el estudio inicial con radiografías se confirma lesión de hombro derecho y se diagnostica luxación glenohumeral posterior simple de hombro izquierdo no pesquisada previamente. Se complementa estudio con tomografía computarizada (TC) de ambos hombros, observándose una LFGHP bilateral, lo que demuestra agravamiento intrahospitalario de la lesión del hombro izquierdo. Se realiza reducción abierta y osteosíntesis con placa bloqueada bilateral en un tiempo. El hombro izquierdo requirió dos reintervenciones, una por falla de osteosíntesis y otra para liberación articular. Dos años después del procedimiento el paciente evoluciona satisfactoriamente con 5% en la escala Quick DASH y un puntaje de 72 y 76 en la escala de Constant en el hombro derecho e izquierdo, respectivamente. Conclusión: la LFGHP es una lesión poco frecuente que requiere un alto índice de sospecha para evitar el retraso diagnóstico y la aparición de secuelas. En casos de convulsión se debe sospechar compromiso bilateral. Con un tratamiento quirúrgico oportuno se pueden obtener resultados satisfactorios y reintegración del paciente a sus actividades habituales.

Abstract: Introduction: posterior glenohumeral fracture dislocation (PGHFD) is a rare injury. It may present secondary to a seizure, electrocution or due to direct trauma. It is usually missed, and late diagnosis is common which increases the rate of complications and sequalae. Case report: 52 year old male, transferred to a reference trauma center due to a tonic-clonic seizure and a right PGHFD. Upon admission radiographs are requested and right shoulder injury is confirmed. Additionally, a simple left posterior glenohumeral dislocation (that was missed in the initial assessment of the patient) is observed. A computed tomography (CT) scan is obtained for both shoulders to plan surgery. The CT scan showed a bilateral PGHFD with severe comminution in the left shoulder, showing considerable worsening of the left shoulder since admission. Open reduction and bilateral locked plate osteosynthesis were performed in a one stage surgery. At two years follow up the patient evolved favorably with a Quick DASH score of 5% and a CONSTANT score of 72 and 76 for his right and left shoulder, respectively. Conclusion: PGHFD is an infrequent injury, which requires a high level of suspicion to avoid diagnostic delay and prevent complications and sequelae. Bilateral cases may be seen in cases of seizure. With prompt surgical treatment, satisfactory results can be achieved with a complete return to normal activities.

[Bilateral posterior glenohumeral fracture-dislocation secondary to a seizure episode: the importance of early diagnosis. A case review]. / Luxofractura posterior bilateral de hombro secundaria a episodio de convulsión: importancia del diagnóstico oportuno. A propósito de un caso.

INTRODUCTION: posterior glenohumeral fracture dislocation (PGHFD) is a rare injury. It may present secondary to a seizure, electrocution or due to direct trauma. It is usually missed, and late diagnosis is common which increases the rate of complications and sequalae. CASE REPORT: 52 year old male, transferred to a reference trauma center due to a tonic-clonic seizure and a right PGHFD. Upon admission radiographs are requested and right shoulder injury is confirmed. Additionally, a simple left posterior glenohumeral dislocation (that was missed in the initial assessment of the patient) is observed. A computed tomography (CT) scan is obtained for both shoulders to plan surgery. The CT scan showed a bilateral PGHFD with severe comminution in the left shoulder, showing considerable worsening of the left shoulder since admission. Open reduction and bilateral locked plate osteosynthesis were performed in a one stage surgery. At two years follow up the patient evolved favorably with a Quick DASH score of 5% and a CONSTANT score of 72 and 76 for his right and left shoulder, respectively. CONCLUSION: PGHFD is an infrequent injury, which requires a high level of suspicion to avoid diagnostic delay and prevent complications and sequelae. Bilateral cases may be seen in cases of seizure. With prompt surgical treatment, satisfactory results can be achieved with a complete return to normal activities.

INTRODUCCIÓN: la luxofractura glenohumeral posterior (LFGHP) es una lesión poco frecuente. Puede ser secundaria a una crisis convulsiva, casos de electrocución, o por traumatismo directo. Su diagnóstico suele ser tardío, lo que aumenta la tasa de complicaciones y secuelas. CASO CLÍNICO: paciente de sexo masculino de 52 años, trasladado a centro de alta complejidad por convulsión tónico-clónica y LFGHP derecha. En el estudio inicial con radiografías se confirma lesión de hombro derecho y se diagnostica luxación glenohumeral posterior simple de hombro izquierdo no pesquisada previamente. Se complementa estudio con tomografía computarizada (TC) de ambos hombros, observándose una LFGHP bilateral, lo que demuestra agravamiento intrahospitalario de la lesión del hombro izquierdo. Se realiza reducción abierta y osteosíntesis con placa bloqueada bilateral en un tiempo. El hombro izquierdo requirió dos reintervenciones, una por falla de osteosíntesis y otra para liberación articular. Dos años después del procedimiento el paciente evoluciona satisfactoriamente con 5% en la escala Quick DASH y un puntaje de 72 y 76 en la escala de Constant en el hombro derecho e izquierdo, respectivamente. CONCLUSIÓN: la LFGHP es una lesión poco frecuente que requiere un alto índice de sospecha para evitar el retraso diagnóstico y la aparición de secuelas. En casos de convulsión se debe sospechar compromiso bilateral. Con un tratamiento quirúrgico oportuno se pueden obtener resultados satisfactorios y reintegración del paciente a sus actividades habituales.

Addition of photodynamic therapy to anti-vascular endothelial growth factor drugs compared to anti-vascular endothelial growth factor monotherapy for polypoidal choroidal vasculopathy. / Adición de terapia fotodinámica a anti factor de crecimiento vascular endotelial en comparación a monoterapia con anti factor de crecimiento vascular endotelial para vasculopatía coroidea polipoidea.

INTRODUCTION: Polypoidal choroidal vasculopathy is characterized by multiple and recurrent serosanguineous detachments of the retinal pigment epithelium and aneurysmal protrusions in the choroidal vessels. Different therapeutic options have been proposed, including anti-vascular endothelial growth factor drugs and photodynamic therapy. Controversy exists as to whether combination therapy is superior to anti-vascular endothelial factor drugs alone. METHODS: We searched Epistemonikos, the largest database of systematic reviews in health, maintained by screening multiple sources of information, including MEDLINE/PubMed, EMBASE, and Cochrane. We extracted data from the identified reviews, analyzed the data from the primary studies, performed a meta-analysis, and prepared a summary table of the results using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. RESULTS: We identified three systematic reviews that together included twelve primary studies. Of these, two were randomized trials, and only one of them was included in the analysis. CONCLUSIONS: The addition of photodynamic therapy may result in little or no difference in the incidence of retinal hemorrhage and visual acuity gain at six months (low certainty of evidence). On the other hand, the combination of photodynamic therapy and anti-vascular endothelial growth factor drugs compared to anti-vascular endothelial growth factor alone is likely to increase polyp regression at three and six months and reduce central retinal thickness at six months.

INTRODUCCIÓN: La vasculopatía coroidea polipoidea es una enfermedad caracterizada por la aparición de múltiples y recurrentes desprendimientos serosanguíneos del epitelio pigmentario retinal, junto con la presencia de protuberancias aneurismáticas en los vasos coroideos. Se han propuesto diferentes opciones terapéuticas, incluyendo los fármacos anti factor de crecimiento vascular endotelial y la terapia fotodinámica. Existe controversia sobre si la terapia combinada es superior a la monoterapia con anti factor de crecimiento vascular endotelial. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el tamizaje de múltiples fuentes de información, incluyendo MEDLINE/PubMed, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método Grading of Recommendations Assessment, Development and Evaluation, GRADE. RESULTADOS: Identificamos tres revisiones sistemáticas que, en conjunto, incluyeron doce estudios primarios. De ellos, dos corresponden a ensayos aleatorizados. Solo se incluyó un ensayo aleatorizado en el análisis del presente trabajo. CONCLUSIONES: La adición de terapia fotodinámica podría resultar en poca o nula diferencia sobre la incidencia de hemorragia retinal y ganancia de agudeza visual a los seis meses (certeza de la evidencia baja). Por otro lado, adicionar terapia fotodinámica a anti factor de crecimiento vascular endotelial comparada con la monoterapia con anti factor de crecimiento vascular endotelial, probablemente aumente la regresión de pólipos a los tres y seis meses, y reduzca el grosor central retinal a los seis meses.

Fasciolosis errática / Erratic fascioliasis

Se notifica el caso de una paciente de 19 años, procedente de Chupaca, Junín en la sierra central del Perú; que presenta una pápula eritematosa, indurada y pruriginosa en el flanco derecho, la cual evoluciona en una vesícula dolorosa de donde se extrae un espécimen aplanado identificado como Fasciola hepatica, además presentó eosinofilia y la prueba de doble difusión arco 2 fue positiva, no se encontraron huevos en el análisis de heces. Se presenta las fotografías del parásito hallado y una breve revisión al respecto.

This is a case report of a 19 year old patient from Chupaca, Junin, in central Peruvian highlands, who presented with an erythematous, indurated, and pruriginous papule in the right flank, which evolved to a painful vesicle. From this latter lesion, a flattened worm was excised, which was identified as Fasciola hepatica. The patient also had eosinophilia, double diffusion test was reported as positive, and no Fasciola eggs were found in feces. Photographs of the parasite are shown, and we present a brief summary of the infection.

[Acute effects of air pollution on health: evidence from epidemiological studies]. / Los efectos agudos de la contaminación del aire en la salud de la población: evidencias de estudios epidemiológicos.

OBJECTIVE: To summarize the evidence of acute health effects from exposure to particulate matter and ozone. MATERIAL AND METHODS: A meta-analysis was performed using random effect models, to summarize the health effects of pollution, published in major international and Mexican journals up to June 2000. RESULTS: Results were given as percent increase in ten units of PM10 (microgram/m3) and ozone (ppb). PM10 was found to have an effect on mortality (0.96%), hospital admissions (1.39%), emergency room visits (3.11%), respiratory symptoms (7.72%), pulmonary forced vital capacity (1.42%), and restricted activity days (7.74%). Ozone effects were equally significant. CONCLUSIONS: These findings show the great impact that air pollutants may have on the health of populations living in large metropolis.

[Difficulties of the methods for studying environmental exposure and neural tube defects]. / Dificultades en los métodos de estudio de exposiciones ambientales y defectos del tubo neural.

OBJECTIVE: To discuss the attitudes in the assessment of environmental exposures as risk factors associated with neural tube defects, and to present the main risk factors studied to date. RESULTS: Environmental exposures have been suggested to have a roll in the genesis of birth defects. However, studies conducted in human populations have found difficulties in the design and conduction to show such an association for neural tube defects (anencephaly, espina bifida and encephalocele) because of problems raised from: a) the frequency measures used to compare time trends and communities, b) the classification of heterogeneous malformations, c) the inclusion of maternal, paternal and fetal factors as an integrated process and, d) the assessment of environmental exposures. CONCLUSIONS: Hypothetically both maternal and paternal environmental exposures can produce damage before and after conception by direct action on the embryo and the fetus-placenta complex. Therefore, in the assessment of environmental exposures we need to take into account: a) both paternal and maternal exposures; b) the critical exposure period, three months before conception for paternal exposures and one month around the conceptional period for maternal exposures; c) quantitatively evaluate environmental exposures when possible, avoiding a dichotomous classification; d) the use of biological markers of exposure is highly recommended as well as markers of genetic susceptibility.

Arsenic resistance determinants from environmental bacteria.

Arsenic resistance determinants from 42 environmental bacterial isolates (32 Gram negative) were analyzed by DNA: DNA hybridization using probes derived from Escherichia coli and Staphylococcus plasmid or chromosomal arsenic resistance (ars) genes. In colony hybridization assays, 11 and 1 Gram negative strains hybridized with the E. coli chromosome and plasmid probes, respectively. No hybridization was detected using a probe containing only the arsA (ATPase) gene from E. coli plasmid or with a Staphylococcus plasmid ars probe. From Southern hybridization tests of some of the positive strains it was concluded that homology to ars chromosomal genes occurred within chromosome regions, except in an E. coli isolate where hybridization occurred in both the chromosome and a 130-kb plasmid. Our results show that DNA sequences homologous to E. coli ars chromosomal genes are commonly present in the chromosomes of environmental arsenic-resistant Gram negative isolates.

[Embryonic mortality and hatching rate of Trachemys scripta (Testudines: Emydidae) eggs artificially grown in a protected natural area]. / Mortalidad embrionaria y éxito de eclosión en huevos de Trachemys scripta (Testudines: Emydidae) incubados en un área natural protegida.

In the northeast of Costa Rica, illegal collecting, habitat destruction and heavy predation on adult females, young and eggs of Trachemys scripta produced a population decline in recent years. The slider turtle has a high reproductive potential and nests were relocated. Between January and March 1991, 179 nests (3220 eggs) were collected from natural areas of Caño Negro National Wildlife Refuge, Costa Rica and relocated for incubation under natural conditions in a protected site. The mean of number of eggs per clutch was 19.5 +/- 4.5 (range 8 to 31) and the mean incubation period was 77.4 +/- 11.4 days (range 50 to 110 days). The mean hatching success was 89.6 +/- 3.4% (range 60.0 to 100%). The mean early and mid embryonic mortality was 5.5 +/- 4.3%, the average late embryonic mortality was 8.5 +/- 3.5% and infertility 1.8 +/- 1.0%.

[Morbimortality at a second-level neonatology unit]. / Morbimortalidad en una sala de neonatología de segundo nivel.

In order to detect existing problems and opportunely pinpoint failures, an evaluation was conducted to determine the most frequent causes of morbidity and mortality in a neonatal ward. A retrospective analysis was carried out on the total number of births attended per year (1,003) at the hospital and of those newborns, those transferred to the neonatal ward (213, 21.2%). Of the 213 newborns placed in the neonatal ward, 30 of them (14.08%) were transferred to a Third Level Hospital (Neonatal Intensive Care Unit) while the rest remained in the neonatal ward. The five most frequent pathologies seen at the ward were reviewed. A high percentage (28.1%) of the patients were considered as potentially infected, while the remaining pathologies encountered were found to be similar to others reported elsewhere in the literature. Of the 183 babies looked after in the neonatal ward, 176 (96.17%) were cured and later discharged from the ward while the other seven died (3.8%) due to hyaline membrane disease, intracranial hemorrhaging, ischemic hypoxic encephalopathy and hospital-acquired septicemia. We conclude that specialized prenatal care and the early detection of high risk pregnancy decreases morbidity and mortality in second level hospital wards. Recommendations are given on the management of neonatal ward.

[Diagnostic problems in neonatal hypocalcemia]. / Problemas de diagnóstico en hipocalcemia neonatal.

Fifteen newborns were studied in the neonatal ICU of the Infantile Hospital of Tamaulipas in whom ICH, neural infection, tetanus, HIE++ and electrolyte disturbances were ruled out, with clinical data highly suggestive of hypocalcemia. Determination of both QTc and QoTc intervals by ECG and measurement of levels of total serum calcium and calcium in CSF and calculation of ionic calcium by means of the McLean Hastings nomogram were made in each patient. Calcium gluconate was administered IV as a therapeutic test. Presence and disappearance of clinical manifestations were correlated with laboratory tests during the suspicious period, 8 and 24 hours after treatment was begun. There was no correlation between clinical features and QTc or QoTc, nor between total serum, CSF or ionic calculated calcium. We conclude that the diagnosis of hypocalcemia in centers that do not have the specific electrode for direct Ca +/- measurement, should be sustained basically when after IV administration of Ca, symptomatology disappears and that the real usefulness of laboratory determination of total C, of ionic calcium, of QTc and QoTc is very limited.

Neuropsychological effects of brain autograft of adrenal medullary tissue for the treatment of Parkinson's disease.

We describe the pre- and postoperative neuropsychological profiles of seven patients who received an autograft of adrenal medullary tissue to the caudate nucleus for the treatment of Parkinson's Disease (PD). The preoperative neuropsychological evaluations revealed specific cognitive deficits of varying degree. The patients showed frontal lobe-type deficits with alterations in behavioral programming leading to difficulties in the organization of motor sequences and alternating programs. They also showed memory disorders and visuospatial and visuoperceptual deficiences such as a loss of figure-ground perspective and fragmentation. Postoperative evaluations, carried out 3 months after neurosurgery, revealed a significant amelioration of the frontal lobe-type symptoms and visuospatial deficits, as well as an improvement in memory tasks that require an active organization of the response. Immediate and delayed memory difficulties remained unchanged. These observations were compared to neuropsychological data obtained from neurologically intact subjects and from unoperated PD patients. The improvements of the operated PD patients resulted in performance levels close to normal values and clearly distinguishable from those of unoperated PD patients, and were unrelated to improved mood, increased alertness, or sustained attention. Autotransplantation of adrenal medullary tissue to the caudate nucleus of PD patients showing a decreased effective response to L-dopa therapy can partially restore motor functions and frontal-type cognitive symptoms.

Intraventricular somatostatin-14, arginine vasopressin, and oxytocin: analgesic effect in a patient with intractable cancer pain.

The analgesic effect of intraventricular somatostatin-14 (SOM-14), arginine vasopressin (AVP), and oxytocin (OT) were tested in one terminally ill cancer patient with a diffuse mesothelioma suffering intractable continuous and incapacitating thoracic pain. SOM-14 reduced pain by 90% for 48 min; AVP reduced pain by 95% for 75 min, and OT reduced pain by 88% for 77 min. The only notable side effects were seen after the administration of AVP, which induced anesthesia and flaccid paralysis of the lower limbs, from which the patient fully recovered after 20 h.