La empatía, la comunicación efectiva y la asertividad en la práctica médica actual / Empathy, effective communication and assertiveness in current medical practice

Resumen La empatía, la comunicación efectiva y la asertividad en la práctica médica actual representan habilidades y herramientas necesarias y vigentes en un mundo de grandes avances y realidades tecnológicas que no superan, en nuestra perspectiva, lo indispensable para mantener y fortalecer la relación del profesional de la salud con el paciente, específicamente la relación médico-paciente. Es conveniente identificar y reconocer el hecho de que estas relaciones interpersonales deben ser modificadas mediante el reconocimiento de su bidireccionalidad y deben centrarse en un carácter educativo, de retroalimentación y atención mutua, con una mejora continua de la regla de las "15 C": comunicación, cercanía, comprensión, compasión, confianza, capacidad, consistencia, certificación, creatividad, cooperación/coordinación, compromiso bidireccional y conexión, con las resultantes calidad y calidez.

Abstract Empathy, effective communication and assertiveness in current medical practice represent skills and tools necessary and current, in a world of great advances and technological realities that do not surpass, in our perspective, the indispensable use of such tools to maintain and strengthen the relationship of the health professional with the patient and specifically of the doctor-patient relationship. It is convenient to identify and recognize the fact that these interpersonal relationships must be modified by recognizing their bidirectionality and that they should focus on an educational, feedback and mutual attention, with a continuous improvement of the "15 C" rule: communication, closeness, understanding, compassion, confidence, capacity, consistency, certification, creativity, cooperation/coordination and bidirectional commitment and connection, with the resulting quality and warmth.

Genomic signatures of the evolution of a diurnal lifestyle in Strigiformes.

Understanding the targets of selection associated with changes in behavioral traits represents an important challenge of current evolutionary research. Owls (Strigiformes) are a diverse group of birds, most of which are considered nocturnal raptors. However, a few owl species independently adopted a diurnal lifestyle in their recent evolutionary history. We searched for signals of accelerated rates of evolution associated with a diurnal lifestyle using a genome-wide comparative approach. We estimated substitution rates in coding and noncoding conserved regions of the genome of seven owl species, including three diurnal species. Substitution rates of the noncoding elements were more accelerated than those of protein-coding genes. We identified new, owl-specific conserved noncoding elements as candidates of parallel evolution during the emergence of diurnality in owls. Our results shed light on the molecular basis of adaptation to a new niche and highlight the importance of regulatory elements for evolutionary changes in behavior. These elements were often involved in the neuronal development of the brain.

Local selection signals in the genome of blue tits emphasize regulatory and neuronal evolution.

Understanding the genomic landscape of adaptation is central to understanding microevolution in wild populations. Genomic targets of selection and the underlying genomic mechanisms of adaptation can be elucidated by genome-wide scans for past selective sweeps or by scans for direct fitness associations. We sequenced and assembled 150 haplotypes of 75 blue tits (Cyanistes caeruleus) of a single Central European population by a linked-read technology. We used these genome data in combination with coalescent simulations (i) to estimate an historical effective population size of ~250,000, which recently declined to ~10,000, and (ii) to identify genome-wide distributed selective sweeps of beneficial variants probably originating from standing genetic variation (soft sweeps). The genes linked to these soft sweeps, but also those linked to hard sweeps based on new beneficial mutants, showed a significant enrichment for functions associated with gene expression and transcription regulation. This emphasizes the importance of regulatory evolution in the population's adaptive history. Soft sweeps were further enriched for genes related to axon and synapse development, indicating the significance of neuronal connectivity changes in the brain potentially linked to behavioural adaptations. A previous scan of heterozygosity-fitness correlations revealed a consistent negative effect on arrival date at the breeding site for a single microsatellite in the MDGA2 gene. Here, we used the haplotype structure around this microsatellite to explain the effect as a local and direct outbreeding effect of a gene involved in synapse development.

Female extra-pair behavior is not associated with reduced paternal care in Thorn-tailed Rayadito.

Extra-pair behavior is present in 76% of socially monogamous bird species with biparental care. This behavior may produce costs to females related to a reduction in paternal care. We estimated the percentage of extra-pair offspring and quantified paternal care in 44 nests of Thorn-tailed Rayadito (Aphrastura spinicauda) to assess whether males reduce their parental care when females obtain extra-pair fertilizations. We used data from a sub-Antarctic population of Rayadito located on Navarino Island (55°4'S, 67°40'W), southern Chile. We found no statistical support for a relationship between variation in paternal care and the percentage of extra-pair offspring. We discuss how the inability of breeding males to assess their genetic paternity and potential restrictions on behavioral flexibility may explain this result. Additionally, if paternal care is subjected to sexual selection, this could limit a facultative response to female extra-pair behavior by males. Finally, it is possible that a reduction in paternal care might not have evolved in this particular locality given the low frequency of extra-pair paternity in our study population.

Oxalate Content and Antioxidant Activity of Different Ethnic Foods.

OBJECTIVE: There is not enough information on the classification of oxalate content in several foods, particularly in ethnic foods, to recommend their consumption in subjects with urolithiasis (UL). The objective of the present study was to generate reliable information on the oxalate content and antioxidant activity in different foods and classify them by very low, low, medium, high and very high oxalate content and antioxidant activity. METHODS: The oxalate content of 109 foods including ethnic foods was assessed by an enzymatic assay, and the antioxidant activity was measured by the oxygen radical absorbance capacity to determine the oxalate/antioxidant activity ratio. Oxalate consumption was then evaluated in 400 subjects with overweight and obesity using 24-h dietary recalls. RESULTS: The main foods with high oxalate content were raw spinach, huanzontle, purslane, chard, almond, and toasted and sweetened roasted amaranth. The highest antioxidant activity was found in strawberries, all types of chocolates, roselle, morita peppers, and pinolillo. Subjects with overweight or obesity exceed the dietary oxalate daily intake recommendation. CONCLUSIONS: The classification of foods by their oxalate content and antioxidant activity will be very useful to generate nutritional recommendation in different diseases, mainly UL.

On the relationship between baseline corticosterone levels and annual survival of the thorn-tailed rayadito.

Baseline concentrations of glucocorticoids (i.e., cortisol and/or corticosterone) can moderately increase with the degree of energy demands that an individual faces. This could be a mechanism based on which glucocorticods (GCs) can mediate life history trade-offs, and therefore fitness. The 'cort-fitness hypothesis' predicts a negative relationship between GCs and fitness, meanwhile the 'cort-adaptation hypothesis' predicts the opposite pattern. Field studies on the relation between baseline GCs and survival rate have shown mixed results, supporting both positive and negative effect. These ambiguous results could be partially consequence of the short time frame in that most of the studies are carried on. In this study, we tested the predictions of the 'cort-fitness hypothesis' and 'cort-adaptation hypothesis' by using long-term data (eight-year of capture-mark-recapture) of Thorn-tailed Rayadito (Aphrastura spinicauda) in two populations at different latitudes. We assessed whether survival varied as a function of Cort levels and whether it varied in a linear (positive: 'cort-adaptation hypothesis' or negative: 'cort-fitness hypothesis') or curvilinear way. The two populations in our study had different baseline Cort levels, then we evaluated whether the association between baseline Cort and survival probability varied between them. In the high latitude population (i.e., lower baseline Cort levels), we observed a marginally quadratic relationship that is consistent with the cort-fitness hypothesis. In contrast, in the low altitude population we did not find this relation. Our findings suggests that the association between baseline Cort and survival probability is context-dependent, and highlights the importance of comparing different populations and the use of long-term data.

Inmunodeficiencia Combinada Severa, reporte de pacientes chilenos diagnosticados durante el período 1999-2020 / Severe combined immunodeficiency, report of Chilean patients diagnosed during the 1999-2020 period

INTRODUCCIÓN: La inmunodeficiencia combinada severa (IDCS) corresponde a una de las formas más graves de inmunodeficiencia primaria, existiendo escasos datos nacionales sobre ésta. OBJETIVO: describir la epidemiología, complicaciones, pronóstico y uso de la vacuna BCG en pacientes chilenos con IDCS. PACIENTES Y MÉTODO: Estudio retrospectivo de pacientes diagnosticados con IDCS entre los años 1999 y 2020 por médicos inmunólogos a lo largo de Chile. El diagnóstico de IDCS se realizó conforme a los criterios propuestos por Shearer: linfocitos T (CD3+) < 300 células/μL y prolife ración 10% del límite de normalidad en respuesta a fitohemaglutinina o presencia de linfocitos T de origen materno. Se obtuvieron de la ficha clínica los datos correspondientes a: sexo, edad al diagnóstico, consanguinidad, región de origen, subpoblaciones linfocitarias, diagnóstico genético, complicaciones infecciosas y no infecciosas, vacunación BCG y sus complicaciones, edad de deriva ción al centro de TPH y causa de mortalidad no relacionada al TPH. RESULTADOS: se diagnosticaron 25 casos de IDCS en 22 familias entre los años 1999-2020. 78% varones, la edad media a la primera manifestación fue 2.3 meses (0-7), mientras que la edad media al diagnóstico fue de 3.4 meses (0 7). Un 16% de los casos tenía un antecedente familiar de IDCS. Un 40% de los casos fueron diag nosticados en la Región Metropolitana. El inmunofenotipo más frecuente fue T-B-NK+ (48%). Se realizaron estudios genéticos en 69,5% de los casos, siendo los defectos genéticos en RAG2 (39%) la causa más frecuente. Un 88% de los casos recibió la vacuna Bacillus Calmette-Guerin (BCG) previo al diagnóstico, incluidos 2 pacientes con historia familiar positiva, 36% de los vacunados experimentó complicaciones de la BCG. La edad media a la derivación a trasplante fue de 7,4 meses (5-16). De los 25 pacientes, 11 fallecieron previo a la derivación a un centro de trasplante. CONCLUSIÓN: En Chile existe un retraso clínicamente significativo entre las primeras manifestaciones y el diagnóstico de IDCS, así como un importante retraso en la derivación a centros de trasplante. La mayoría de los pacientes con IDCS reciben la vacuna BCG, pese a tener antecedentes familiares, y experimentan frecuentemente complicaciones de la vacuna.

INTRODUCTION: Severe combined immunodeficiency (SCID) is the most severe form of primary immunodeficiency. To date, there is little local information about this disease. OBJECTIVE: To describe the epidemiology, complications, prognosis, and use of the BCG vaccine in Chilean patients with SCID. PATIENTS AND METHOD: Retrospective review of the clinical records of patients diagnosed with SCID by clinical immunologists between 1999 and 2020 throughout Chile. SCID was diagnosed according to the cri teria proposed by Shearer: T lymphocytes (CD3+) < 300 cells/μL and proliferation 10% of the limit of normality in response to phytohemagglutinin or presence of T lymphocytes of maternal origin. Data collected from the clinical records were: sex, age at diagnosis, consanguinity, region of origin, lymphocyte subpopulations, genetic diagnosis, infectious and non-infectious complications, BCG vaccination and its complications, age at referral to the bone marrow transplant (BMT) center, and cause of non-BMT-related mortality. RESULTS: Between 1999 and 2020, 25 patients were diagnosed with SCID. 78% of them were male, mean age at first manifestation of the disease was 2.3 months (0-7), while the mean age at diagnosis was 3.4 months (0-7). 16% of patients had a family history of SCID. 40% of cases were diagnosed within the Metropolitan Region. The most frequent immuno- phenotype was T-B-NK+ SCID (48%). Genetic studies were done in 69.5% of cases, mutations in the RAG2 gene were the most common etiology of SCID (39%). 88% of SCID patients received the Bacillus Calmette-Guerin (BCG) vaccine before diagnosis, including 2 cases with a known family history of SCID. 36% of those who received the vaccine had BCG-related complications. The mean age at referral to a bone marrow transplant center was 7.4 months (5-16). 11/25 patients died before being transferred to a transplant center. DISCUSSION: There is a clinically significant delay between the first manifestations and the diagnosis of SCID in Chilean patients, as well as an important time gap between the diagnosis of SCID and referral to a center for BMT. Most SCID cases in Chile receive the BCG vaccine, despite a known family history of the disease, and frequently develop vaccine-related complications.

Genomic Evidence for Sensorial Adaptations to a Nocturnal Predatory Lifestyle in Owls.

Owls (Strigiformes) evolved specific adaptations to their nocturnal predatory lifestyle, such as asymmetrical ears, a facial disk, and a feather structure allowing silent flight. Owls also share some traits with diurnal raptors and other nocturnal birds, such as cryptic plumage patterns, reversed sexual size dimorphism, and acute vision and hearing. The genetic basis of some of these adaptations to a nocturnal predatory lifestyle has been studied by candidate gene approaches but rarely with genome-wide scans. Here, we used a genome-wide comparative analysis to test for selection in the early history of the owls. We estimated the substitution rates in the coding regions of 20 bird genomes, including 11 owls of which five were newly sequenced. Then, we tested for functional overrepresentation across the genes that showed signals of selection. In the ancestral branch of the owls, we found traces of positive selection in the evolution of genes functionally related to visual perception, especially to phototransduction, and to chromosome packaging. Several genes that have been previously linked to acoustic perception, circadian rhythm, and feather structure also showed signals of an accelerated evolution in the origin of the owls. We discuss the functions of the genes under positive selection and their putative association with the adaptation to the nocturnal predatory lifestyle of the owls.

Sex prediction by analysis of the morphological characteristics of macerated skulls / Predicción sexual mediante análisis de las características morfológicas de cráneos macerados

The skull is a reliable structure for determining the sex of an adult individual; it is generally resistant in adverse conditions, allowing it to be used for the analysis of sexual dimorphism. In the present study we analysed 10 non-metric characteristics of skulls of Brazilian adult individuals in order to: Determine the strength of association between sex and the morphological characteristics of the skull, the morphological characteristic(s) with greatest diagnostic influence for sex, and analyse whether the morphological characteristics of the skull predict sex. The study included 179 macerated skulls of Brazilian adults, (69 female, 110 male). The sex of all the skulls included was identified. The investigators were calibrated prior to analysis and all the evaluations were carried out under blinding. Pearson's Chi-squared test was used. The sensitivity and specificity were analysed and a ROC curve was constructed. Binary logistic regression was carried out. The SPSS v.22 software was used, with a significance threshold of 5 %. All the characteristics analysed presented statistically significant differences (p<0.05). The frontal profile, the superciliary arch and the glabella presented the greatest sensitivity, best balance between sensitivity and specificity and greatest area under curve. The regression model with the frontal profile, superciliary arch and mastoid process was significant [X2(2) = 115,728 p=0.000, R2 Negelkerke=0.657], and presented correct sex classification in 90 % of cases (Males: 87.4 %; Females: 83.1 %). In unknown individuals for whom the skull is present, non-metric analysis of the frontal profile, superciliary arch, mastoid process and glabella can be used as instruments for sex identification.

El cráneo es una estructura confiable para la determinación sexual de un individuo adulto y suele ser resistente en condiciones adversas, por lo que puede ser utilizado para el análisis del dimorfismo sexual. En el presente estudio analizamos 10 características no métricas de cráneos de individuos brasileños adultos a fin de determinar la fuerza de asociación entre el sexo y características morfológicas del cráneo; determinar la(s) característica(s) morfológica(s) con mejor poder para diagnosticar el sexo; y analizar si las características morfológicas del cráneo son previsoras del sexo. Fueron incluidos 179 cráneos macerados de brasileños adultos, (69 femeninos, 110 masculinos). Todos los cráneos incluidos presentaban identificación de sexo. Los investigadores fueron previamente calibrados y todas las evaluaciones fueron realizadas de forma ciega. Se utilizó la prueba de Chicuadrado de Pearson. Se analizó la sensibilidad y especificidad y se construyó una curva ROC. Se realizó regresión logística binaria. Se utilizó el software SPSS v.22, considerando umbral de significación de 5 %. Todas las características analizadas presentaron diferencias estadísticas significativas (p<0,05). El perfil frontal, el arco superciliar y la glabela fueron las características que presentaron mayor sensibilidad, mejor equilibrio sensibilidad/especificidad y mayor area under curve. El modelo de regresión con el perfil frontal, arco superciliar y proceso mastoides fue significativo [X2(2) = 115,728 p=0.000, R2 Negelkerke=0,657], y presentó una clasificación sexual correcta de 90 % (Males; 87,4 %; Females: 83,1 %). En individuos desconocidos en los cuales esté presente el cráneo, el análisis no-métrico del perfil frontal, del arco superciliar, del proceso mastoides y de la glabela pueden ser utilizados como herramienta para identificación sexual.

Respuesta inmune y alergia a vacunas / Immune response and allergies to vaccines

Las vacunas son altamente efectivas en prevenir enfermedades infecciosas a través del desarrollo en el individuo de una respuesta inmune protectora, sin desarrollar la enfermedad. Los distintos tipos de vacunas producen diferentes tipos de respuestas inmunes y variadas estrategias se han desarrollado para mejorar esta respuesta. El sistema inmune sufre cambios con la edad y esta inmunosenecencia altera la capacidad de responder frente a ellas. Por otro lado, si bien el sistema inmune puede reconocer elementos presentes en las vacunas y montar respuestas de hipersensibilidad ante ellos, las alergias a las vacunas son raras, teniendo que distinguirlas adecuadamente de otro tipo de reacciones. En caso que un paciente presente una reacción compatible con alergia, es importante conocer todos los componentes de la vacuna para realizar un estudio adecuado.

Vaccines are highly effective in preventing infectious diseases through the development in the individual a protective immune response, without developing the disease. Different types of vaccines produce different types of immune responses, and varied strategies have been developed to improve this response. The immune system undergoes changes with age, and this inmunosenescence alters the ability to respond to them. On the other hand, although the immune system can recognize elements present in vaccines and establish hypersensitivity responses to them, vaccine allergies are rare, having to properly distinguish them from other types of reactions. In the event that a patient has an allergy-compatible reaction, it is important to know all the components of the vaccine to conduct a proper study.

[Severe combined immunodeficiency, report of chilean patients diagnosed during the 1999-2020 period]. / Inmunodeficiencia Combinada Severa, reporte de pacientes chilenos diagnosticados durante el período 1999-2020.

INTRODUCTION: Severe combined immunodeficiency (SCID) is the most severe form of primary immunodeficiency. To date, there is little local information about this disease. OBJECTIVE: To describe the epidemiology, complications, prognosis, and use of the BCG vaccine in Chilean patients with SCID. PATIENTS AND METHOD: Retrospective review of the clinical records of patients diagnosed with SCID by clinical immunologists between 1999 and 2020 throughout Chile. SCID was diagnosed according to the cri teria proposed by Shearer: T lymphocytes (CD3+) < 300 cells/µL and proliferation 10% of the limit of normality in response to phytohemagglutinin or presence of T lymphocytes of maternal origin. Data collected from the clinical records were: sex, age at diagnosis, consanguinity, region of origin, lymphocyte subpopulations, genetic diagnosis, infectious and non-infectious complications, BCG vaccination and its complications, age at referral to the bone marrow transplant (BMT) center, and cause of non-BMT-related mortality. RESULTS: Between 1999 and 2020, 25 patients were diagnosed with SCID. 78% of them were male, mean age at first manifestation of the disease was 2.3 months (0-7), while the mean age at diagnosis was 3.4 months (0-7). 16% of patients had a family history of SCID. 40% of cases were diagnosed within the Metropolitan Region. The most frequent immuno- phenotype was T-B-NK+ SCID (48%). Genetic studies were done in 69.5% of cases, mutations in the RAG2 gene were the most common etiology of SCID (39%). 88% of SCID patients received the Bacillus Calmette-Guerin (BCG) vaccine before diagnosis, including 2 cases with a known family history of SCID. 36% of those who received the vaccine had BCG-related complications. The mean age at referral to a bone marrow transplant center was 7.4 months (5-16). 11/25 patients died before being transferred to a transplant center. DISCUSSION: There is a clinically significant delay between the first manifestations and the diagnosis of SCID in Chilean patients, as well as an important time gap between the diagnosis of SCID and referral to a center for BMT. Most SCID cases in Chile receive the BCG vaccine, despite a known family history of the disease, and frequently develop vaccine-related complications.

Analgesia postoperatoria en operación cesárea / Postoperative analgesia in caesarean section

Resumen: El dolor por cesárea se caracteriza por ser moderado a severo. El manejo analgésico inicia en el preoperatorio con la evaluación de los factores de riesgo, continúa con la técnica anestésica y termina con la planificación de la analgesia postoperatoria. La técnica anestésica recomendada es el bloqueo epidural, siempre y cuando no existan signos de amenaza inminente para la vida de la mujer o el feto como: coagulopatía, choque hipovolémico, aumento de la presión intracraneal e insuficiencia respiratoria aguda. Para el bloqueo epidural se recomienda el uso de dosis combinada de anestésico local, adyuvante opioide y bicarbonato. En el postoperatorio, la analgesia debe ser multimodal, aplicando vía intravenosa AINE/COX-2 y complementar el manejo con paracetamol, continuando con analgesia epidural controlada por el paciente. Recientemente, técnicas regionales como el bloqueo TAP bilateral (plano transverso del abdomen) y el bloqueo iliohipogástrico e ilioinguinal bilateral han demostrado ser buenas estrategias analgésicas (para ver artículo completo visitehttp://www.painoutmexico.com).

Abstract: Cesarean section pain is expected from moderate to severe. The analgesic management begins in the preoperative, with the evaluation of the risk factors, continues with the definition of the anesthetic technique to be used, and finish with the planed anesthetic technique. Recommended anesthetic technique is epidural block, provided there is no imminent threat to the life of the woman or the fetus, coagulopathies, hypovolemic shock, increased intracranial pressure and acute respiratory. For epidural block the combined dose of local anesthetic, opioid adjuvant and bicarbonate is recommended. In the postoperative period, analgesia should be multimodal applying intravenously the synergy of NSAIDs/COX-2 and continuing with analgesia via epidural controlled by the patient (PCA). Regional techniques such as transverse plane blockage of the abdomen and iliohypogastric and ilioinguinal block are good analgesic strategies (for full version and recommendations visithttp://www.painoutmexico.com) .

Analgesia en histerectomía / Analgesia in hysterectomy

Resumen: El dolor por histerectomía (HTA) se espera de moderado a severo; sin embargo, la intensidad del dolor y la recuperación dependerán de la técnica quirúrgica: HTA abierta vs HTA laparoscópica. En ambas, el dolor que se presenta es de tipo visceral y de tipo somático. El manejo analgésico inicia con la valoración, la planificación de la técnica anestésica y la analgesia postoperatoria. La analgesia proporcionada por el bloqueo epidural con anestésico local y opioide es superior al bloqueo subaracnoideo en cirugía abierta, la analgesia debe ser complementada con AINE/COX-2 y/o paracetamol, con rescates de opioide débil. Sólo en caso de histerectomía laparoscópica, la técnica anestésica recomendada es la anestesia general balanceada, con analgesia intravenosa controlada por el paciente (PCA). Recientemente, la utilización de técnicas regionales como el bloqueo TAP (plano del músculo transverso del abdomen) y el bloqueo del cuadrado lumbar son estrategias analgésicas que favorecen el ahorro opioide y la recuperación temprana (para ver el artículo completo visitehttp://www.painoutmexico.com).

Abstract: Postoperative pain after hysterectomy is moderate to severe. However, the intensity of pain and recovery depends on the surgical technique: hysterectomy open vs hysterectomy laparoscopic. In both, the pain is the visceral and the somatic type. The analgesic management starts with the evaluation, the planning of the anesthetic technique and the post-operative analgesia. The analgesia provided by the epidural block with local anesthetic and opioid, is superior to the subarachnoid block in open surgery, the analgesia must be complemented with NSAID/COX-2 and/or paracetamol, plus rescue doses of a weak opioid. Only in the case of laparoscopic hysterectomy, the recommended anesthetic technique is balanced general anesthesia, in addition to patient-controlled intravenous analgesia (PCA). The use of regional techniques such as: transversus abdominis plane block (TAP) and quadratum lumborum block (QLB) are the analgesic strategies that sparing opioid and early recovery (full version visithttp://www.painoutmexico.com) .

El ABC de la analgesia controlada por el paciente / The ABCs of patient-controlled analgesia

Resumen La analgesia controlada por el paciente (PCA, por sus siglas en inglés: patient controlled analgesia) es la administración continua y/o intermitente de analgésicos opioides y no opioides a través de un dispositivo con dosis a demanda y control del paciente. Su mecanismo de acción antinociceptivo tiene efecto en la percepción del control del dolor por el propio paciente, en sinergia, con la acción de los medicamentos. Bajo el concepto de concentración mínima efectiva analgésica, las bombas PCA permiten mantener las concentraciones plasmáticas estables de los fármacos, particularmente de los opioides, disminuyendo la carga de atención al personal de enfermería y la administración de medicamentos «por razón necesaria¼. Las bombas de PCA cuentan con un intervalo de seguridad que impide la sobredosificación por intentos repetitivos de activación por el paciente de las dosis en bolos, y se ha demostrado que brindan mejores resultados en la analgesia durante las primeras 24 horas (nivel de evidencia moderada). Las rutas más utilizadas son la vía intravenosa y la vía epidural. En esta revisión se presentan los pasos básicos para el uso de estos dispositivos, preparación y programación de bolos o infusiones analgésicas, así como los pasos seguros que deben considerarse durante su empleo (visite http://www.painoutmexico.com para obtener el artículo completo y videos).

Abstract Patient-controlled analgesia (PCA) is the continuous and/or intermittent administration of opioid and non-opioid analgesics through a device with on-demand doses and patient control. Its mechanism anti-nociceptive has an effect on the perception of pain controlled by the patient himself, in synergy, with the action of the medications. Under the concept of minimum effective analgesic concentration, PCA pumps allow the stable plasma concentrations of the drugs, particularly opioids, to be maintained, reducing the nursing staff attention and the administration of drugs «for necessary reason¼. PCA pumps have a safety interval that prevents overdosing due to repetitive attempts by the patient to activate bolus and has been shown to provide better analgesia during the first 24 hours (moderate level of evidence). The most commonly routes are the intravenous and the epidural. In this review we present the basic steps for the use of these devices, preparation and programming of boluses or analgesic infusions, as well as safety steps during their use (visit http://www.painoutmexico.com to see the full article and videos).

Continuous venovenous hemofiltration in neonates with hyperammonemia. A case series. / Uso de Hemofiltración veno-venosa continua en neonatos con hiperamonemia. Serie clínica.

INTRODUCTION: Neonatal hyperammonemia secondary due to inborn errors of metabolism is a rare condition with a high rate of neurological sequelae and mortality. Initial medical management is often insufficient to stop the progressive increase of ammonia, with the consequent deterioration of the patient. For this reason, depurative techniques have been implemented, including peritoneal dialysis, intermittent hemodialysis and continuous renal replacement therapy (CRRT). OBJECTIVE: To describe our experience with continuous extracorporeal dialysis in severely ill neonates with hyperammonemia. PATIENTS AND METHODS: Retrospective review of clinical records of neonates with hyperammonemia due to congenital errors of metabolism undergoing CRRT admitted in our institution in the last 6 years. Demographic data, chronological and gestational age, gender, anthropometric and laboratory data (creatininemia, ammonemia), and severity index PIM-II where collected. It was analyzed the CRRT: modality, duration and complications. The stard of therapy depended on the response to medical management in the first 24 hours, progressive neurological involvement, or increased blood ammonia (> 400 qg/dl) at the time of admission. CRRTs were performed using the Prisma Flex system and M100 and/or HF20 filters. RESULTS: 6 neonates, 4 males, half of them with a history of prematurity, all with severe acute neurological involvement and severe ammonemias (> 1,000 qg/dl). The average age and weight at the start of the CRRT were 10 days and 2798 g, respectively, ammonia (median) 1,663 qg/dl (range 1,195 - 3,097). The PIM-II score had a median of 53 (range 13.4 - 87.4). On average, patients were 49.5 hours in continuous therapy. In four neonates, a mixed convective and diffusive technique (hemodiafiltration) was used, and only convective one (hemofiltration) in the 2 remaining. Mortality was 33%, and one of the survivors had permanent moderate neurological damage in clinical follow-up. CONCLUSIONS: The results obtained in this extremely ill group of neonates encourage us to propose this dialytic therapy as an excellent alternative in the management of this type of patients.

Uso de Hemofiltración veno-venosa continua en neonatos con hiperamonemia. Serie clínica / Continuous venovenous hemofiltration in neonates with hyperammonemia. A case series

Resumen: Introducción: La hiperamonemia neonatal secundaria a errores congénitos del metabolismo es una entidad poco frecuente pero con una alta tasa de secuelas neurológicas y mortalidad. El manejo médico inicial es en muchas ocasiones insuficiente para detener el progresivo aumento de la amonemia, con el consecuente deterioro del paciente. Por esta razón se han implementado técnicas depurativas entre las que se cuenta la diálisis peritoneal, la hemodiálisis intermitente y las terapias de reemplazo renal continuo (TRRC). Objetivo: Describir nuestra experiencia en diálisis extracorpórea continua en pacientes con hiperamonemia neonatal gravemente enfermos. Pacientes y Método: Revisión retrospectiva de fichas clínicas de neonatos con hiperamonemias secundarias a errores congénitos del metabolismo sometidos a TRRC, admitidos en nuestra institución en los últimos 6 años. Se obtuvieron datos demográficos, edad cronológica y gestacional, género; datos antropométricos y de laboratorio (creatininemia, amonemia) e índice de gravedad por PIM-II. Se analizó la TRRC utilizada: modalidad, duración y complicaciones. El inicio de la terapia dependió de la respuesta al manejo médico en las primeras 24 horas, compromiso neurológico progresivo, o cifras de amonio sanguíneo elevados (> 400 μg/dl) al momento del ingreso. Las TRRC fueron realizadas con la máquina Prisma Flex, usando filtros M100 y/o HF20. Resultados: 6 neonatos, 4 varones, la mitad con antecedentes de prematurez, todos con compromiso neurológico agudo severo y amonemias en rango grave (> 1.000 μg/dl). La edad y peso promedio al iniciar la TRRC fueron de 10 días y 2.798 g respectivamente, amonemia (mediana) 1.663 μg/dl (rango 1.195-3.097). El puntaje PIM-II tuvo una mediana de 53 (rango 13,4-87,4). En promedio, los pacientes estuvieron 49,5 h en la terapia continua. En cuatro neonatos se usó una técnica dialítica mixta convectiva y difusiva (hemodiafiltración), y solo convectiva (hemofiltración) en las 2 restantes. La mortalidad fue de 33%, y uno de los sobrevivientes quedó con daño neurológico moderado permanente en seguimiento clínico. Conclusiones: Los resultados obtenidos en este grupo de neonatos extremadamente graves nos incentivan a proponer esta terapia dialítica como una excelente alternativa en el manejo de este tipo de pacientes.

Abstract: Introduction: Neonatal hyperammonemia secondary due to inborn errors of metabolism is a rare condition with a high rate of neurological sequelae and mortality. Initial medical management is often insufficient to stop the progressive increase of ammonia, with the consequent deterioration of the patient. For this reason, depurative techniques have been implemented, including peritoneal dialysis, intermittent hemodialysis and continuous renal replacement therapy (CRRT). Objective: To describe our experience with continuous extracorporeal dialysis in severely ill neonates with hyperammonemia. Patients and Methods: Retrospective review of clinical records of neonates with hyperammonemia due to congenital errors of metabolism undergoing CRRT admitted in our institution in the last 6 years. Demographic data, chronological and gestational age, gender, anthropometric and laboratory data (creatininemia, ammonemia), and severity index PIM-II where collected. It was analyzed the CRRT: modality, duration and complications. The stard of therapy depended on the response to medical management in the first 24 hours, progressive neurological involvement, or increased blood ammonia (> 400 qg/dl) at the time of admission. CRRTs were performed using the Prisma Flex system and M100 and/or HF20 filters. Results: 6 neonates, 4 males, half of them with a history of prematurity, all with severe acute neurological involvement and severe ammonemias (> 1,000 qg/dl). The average age and weight at the start of the CRRT were 10 days and 2798 g, respectively, ammonia (median) 1,663 qg/dl (range 1,195 - 3,097). The PIM-II score had a median of 53 (range 13.4 - 87.4). On average, patients were 49.5 hours in continuous therapy. In four neonates, a mixed convective and diffusive technique (hemodiafiltration) was used, and only convective one (hemofiltration) in the 2 remaining. Mortality was 33%, and one of the survivors had permanent moderate neurological damage in clinical follow-up. Conclusions: The results obtained in this extremely ill group of neonates encourage us to propose this dialytic therapy as an excellent alternative in the management of this type of patients.

Frequency and position of the mental foramen in panoramic X-rays: literature review / Frecuencia y posición del foramen mental en radiografías panorámicas: revisión bibliográfica

The mental foramen (MF), located in the body of mandible in the region below the inferior premolars, is the anatomical structure through which the mental neurovascular bundle emerges. The MF can be seen clearly in panoramic X-rays. The object of the present study was to carry out a literature review in order to identify the frequency and position of the MF in panoramic X-rays. We looked for articles in the SCiELO, Pubmed, Scopus, LILACS, Web of Science and EBSCOhost databases, for the years 2006 to 2016. The key words used were "mental foramen", "mandibular canal", "inferior alveolar nerve", "anatomy" and "panoramic X-ray". Once the articles had been selected, an analysis was made of their methodological quality; poor-quality articles were excluded. In each article the frequency and position of the MF in each hemi-mandible was analyzed. We found 82 articles, of which 20 were retained after application of the exclusion criteria. The MF was found in 4,824 hemi-mandibles (95.2 %), with greater presence on the left side (50.29 %) than the right (49.71 %). The MF is most commonly located between the apices of the inferior premolars (42.22 %), coincident with the root of the second inferior premolar (33.98 %) or distal of the root of the second inferior premolar (10.98 %). The MF is a very frequent anatomical structure. Knowledge of its location is fundamental for reducing the risk of accidents and unexpected events during clinical and surgical manoeuvres.

El foramen mental (FM), ubicado en el cuerpo de la mandíbula, inferiormente a la región de los dientes premolares inferiores, es la estructura anatómica por donde emerge el paquete vásculonervioso mental. El FM se logra visualizar con buena precisión en una radiografía panorámica. El objetivo del presente estudio fue realizar una revisión de la literatura para identificar la frecuencia y posición del FM en radiografías panorámicas. Se buscaron artículos en las bases de datos SCiELO, Pubmed, Scopus, LILACS, Web of Science y EBSCOhost, entre los años 2006 y 2016. Las palabras clave utilizadas fueron "foramen mental", "canal mandibular", "nervio alveolar inferior", "anatomía" y "radiografía panorámica". Tras la selección de los artículos se realizó un análisis de la calidad metodológica de los mismos, donde se excluyó artículos de baja calidad. Se analizó en cada artículo la frecuencia y posición del FM en cada hemimandíbula. Se encontraron 82 artículos, de los cuales quedaron sólo 20 al aplicar criterios de exclusión. El FM fue encontrado en 4824 hemimandíbulas (95,2 %), siendo el lado izquierdo donde hubo mayor presencia de forámenes (50,29 %) en comparación al lado derecho (49,71 %). El FM se localiza entre los ápices de los premolares inferiores en 42,22 %, es coincidente con la raíz del segundo premolar inferior en 33,98 %, y es distal a la raíz del segundo premolar inferior en 10,98 %, siendo éstos los más relevantes. El FM es una estructura anatómica muy frecuente, ubicada en general inferiormente a los premolares inferiores. Es una estructura de gran importancia clínica, por ello el conocimiento detallado de sus características y variaciones anatómicas es muy importante para evitar complicaciones y disminuir el riesgo de accidentes durante procedimientos clínico-quirúrgicos en la región. Además, a pesar de que la RP presenta buena precisión en la identificación del FM hay condiciones clínicas que requieren otros métodos imagenológicos para su identificación.