Revisión sobre métodos en el manejo de úlceras tórpidas / Review on treatment methods of torpid ulcers

Las dos grandes técnicas de curación de úlceras y heridas son las curas secas y la cura húmeda. Independientemente del tipo de práctica utilizada el objetivo sigue siendo el mismo: favorecer la proliferación del tejido granular, evitar la infección, y favorecer el desbridamiento. La exposición al aire de las heridas cura más lentamente que tras oclusión. En heridas de larga evolución, en úlceras de piernas, 18 de 39 (46%) curaban completamente desarrollando tejido de granulación en respuesta a la oclusión en todas ellas. Mediante apósitos se propicia un ambiente húmedo y condiciones de temperatura más óptimas para la regeneración tisular. Un apósito, según protocolo Goldman (1992), debe cumplir los siguientes requisitos: absorber el exudado, provocar un microambiente húmedo, ser estéril y de fácil manejo, no causar reacciones alérgicas ni traumas y provocar una temperatura favorable para la cicatrización reduciendo el dolor. A continuación vamos exponer un compendio de los protocolos existentes revisados desde el Agency for Health Care Policy and Research (1992), también los realizados por Anderson RM en el congreso europeo en avances sobre el manejo de heridas; otros de autores como Elorriaga Ameyugo, con su manual del Instituto Nacional de la Salud, Bregstrom, Díaz González (1995) y protocolos para lesiones venosas en extremidades inferiores de Palfreyman. Asimismo, revisamos extractos de los protocolos de Nelson para úlceras arteriales en extremidades inferiores y los de Bradley para escaras, los de Argüello y el American Family Physician, entre otros

The two important techniques to cure ulcers and wounds are dry cures and humid cures. Regardless of the type used, the objective continues to be the same: favor proliferation of granular tissue, avoid infection and favor debridement. Exposure of the wounds to air leads to slower cure after occlusion. In long course wounds, in leg ulcers, 18 of 39 (46%) cured completely, granulation tissue being developed in response to occlusion in all of them. By dressings, a human setting is favored and the best temperature conditions for tissue regeneration. A dressing according to the Goldman protocol (1992) should fulfill the following requirements: absorb the exudate, cause a humid microenvironment, be sterile and easy to manage, not cause allergic reactions or traumas and cause a favorable temperature for scarring, reducing pain. In the following, we present a synopsis of the existing protocols reviewed from the Agency for Health Care Policy and Research (1992), and those conducted by Anderson RM, in the European Congress on advances on the treatment of wounds, others from authors such as Elorriaga Ameyuga, with his manual from the National Health Institute, Bregstrom, Díaz Gonzalez (1995), protocols for venous lesions in lower limbs of Palfreyman. We also present extracts of the protocols of Nelson for arterial ulcers in lower limbs and those of Bradley for scars, Argüello and the American Family Physician, among others

Tratamiento con ciprofloxacino tópico en solución acuosa estéril sobre úlceras de evolución tórpida / Treatment with topical ciprofloxacin in sterile aqueous solution on poorly evolving ulcers

OBJETIVO: Determinar la eficacia de la aplicación de solución tópica estéril de ciprofloxacino como tratamiento local de úlceras de piel considerando las diferentes etiologías y el perfil de la población que las presentaba. DISEÑO: Ensayo terapéutico. SUJETOS: Se incluyeron 46 úlceras, 32 en mujeres de 78ñ 13 años y 14 en varones de entre 69ñ 17 años. MATERIAL Y MÉTODO: Se clasificaron las úlceras según etiología en varicosa, diabética, traumáticas, postquirúrgicas y de presión. Para cada una se recogieron las siguientes variables: tiempo de evolución antes y después del estudio, localización y estadio según la NPUAP, tamaño medido en cm2 y velocidad media de curación (Sf-Si/T), siendo Sf y Si las superficies final e inicial entre cada observación y T el tiempo entre cada dos observaciones. Consideramos la presencia de enfermedades sistémicas y el apoyo social con que contaban. En cada úlcera se realizó cultivo instaurándose tratamiento con ciprofloxacino tópico, analizando en el seguimiento la reducción de superficie semanal del lecho ulceroso y el tiempo hasta su completa epitelización. RESULTADOS: la distribución según su etiología fue: 34,7 por ciento varicosas, 8,6 por ciento diabéticas, 45,6 por ciento de presión, 6,5 por ciento traumáticas, 4,3 por ciento postquirúrgicas. Los cultivos obtenidos demostraban la existencia de colonias en el 82,6 por ciento; el 56,5 por ciento presentaban colonización mixta, siendo el germen más frecuentemente cultivado el estafilococo aureus, seguido de estreptococo grupo D, pseudomona y E. coli. Las curaciones globales fueron del 79 por ciento y por grupos etiológicos: 93,75 por ciento en UV, 25 por ciento UD, 50 por ciento UP, 100 por ciento UT, 50 por ciento PQ, encontrándose un mayor porcentaje de curación con diferencias estadísticamente significativas en UV y UT respecto a UD y UP. Se observó una correlación no lineal cúbica entre la disminución superficial semanal y la velocidad media de curación con el tiempo que duraba el tratamiento con ciprofloxacino. CONCLUSIONES: La mayor parte de los pacientes con úlceras presentan patología de base sistémica. Existe colonización bacteriana en un alto porcentaje. La terapia con ciprofloxacino tópico en solución acuosa estéril puede ofrecer una nueva alternativa para cualquier tipo de lesión ulcerosa con escaso riesgo de efectos colaterales (AU)

[Ductus closure in adults with the Rashkind device: comparative results]. / Cierre de ductus en adultos mediante dispositivo de Rashkind: resultados comparativos.

INTRODUCTION: Catheter occlusion of the persistent ductus arteriosus with Rashkind device is an alternative to the surgical closure demonstrated in children, however a few results have been reported of occlusion in adults. METHOD: From 1990 to 1996 in 127 patients with persistent ductus arteriosus undergoing occlusion by Raskind device. Two groups according age: 105 children (< 14 years) and 22 adults (> 14 years), were studied retrospectively. The results were analysed by immediate aortogram and follow-up at 24 hours, 6 and 12 months by color-Doppler echocardiograms. RESULTS: The adults were frequently asymptomatic (86%) and with high incidence (59%) of silent ductus. Similar QP/QS (1.61 +/- 0.47 in adults vs 1.49 +/- 0.51) was calculated although pulmonary pressure was superior in children (12.50 +/- 2.97 vs 16.84 +/- 5.88 mmHg; p = 0.003). In group > 14 years the ductal anatomy favorable (Krichenko type A or B) was more frequent (91% vs 73%; p = 0.06) and ductal diameter significantly higher (3.03 +/- 1.50 vs 2.41 +/- 0.96 mm; p = 0.009). In adults 17 mm umbrella were used more frequently (91 vs 61%; p = 0.02). Absence complications (embolization, bacteremia, haemolysis, proximal stenosis of the left pulmonary artery) were found in adults against 4.72% in children. The occlusion were more effective in adults specially in early controls: 55% vs 34% (p = 0.09), 82% vs 69%, 91% vs 77% and 95% vs 83% (p > 0.10). Multivariate analysis identified age as an independent predictor of complete occlusion. CONCLUSION: Our experience in transcatheter occlusion of persistent ductus arteriosus with Rashkind device in adults support the efficacy, safety and excellent early results despite higher incidence of silent asymptomatic ductus.

[A simplified method of continuous-wave Doppler noninvasive assessment of ventricular relaxation in mitral insufficiency]. / Método simplificado para el análisis no invasivo de la relajación ventricular mediante Doppler continuo en la insufficiencia mitral.

INTRODUCTION AND OBJECTIVES: The minimum value of dP/dT is a parameter of diastolic function that can be estimated noninvasively by analyzing the profile of velocity of the mitral regurgitant jet, recorded by continuous-wave Doppler. This estimation requires a complex analysis of the curves that impedes its practical use. Our objective was to validate a simplified method to estimate noninvasively the value of dP/dTmin when mitral regurgitation exists. We calculated the pendient of the profile of velocity of the curve of mitral regurgitation during its deceleration, between 3 and 1.5 m/s, an interval that defines a difference in pressure using the formula delta p = (4v2(1) - 4v2(2)). We divided this interval by the time needed by the jet to decelerate from 3 to 1.5 m/s, obtaining the rate of pressure decay, in mmHg/s. METHODS: We provoked mitral regurgitation in five pigs and registered dP/dT and the curve velocity of mitral regurgitation simultaneously, by micromanometer-tipped catheter and continuous-wave Doppler, respectively. The rate of pressure decay was calculated on the mitral regurgitation curve. RESULTS: We obtained 29 simultaneous registers. The coefficient for the correlationship between dP/dT and the rate of pressure decay was with an r value of 0.62 (p < 0.0001). The rate of pressure decay underestimated systematically the value of dP/dT. Intra and interobserver variability of TDP was 9 and 11%, respectively. CONCLUSIONS: This study validates a simplified method to estimate dP/dT noninvasively, with acceptable correlation with invasive measurements and adequate reproducibility.

[Penetrating trauma by foreign body in the left heart ventricle]. / Traumatismo penetrante con cuerpo extraño en el ventrículo izquierdo.

We present the case of a patient who suffered a cardiac penetrating trauma due to a 6-cm long steel splinter. He was self-admitted to the emergency room and was asymptomatic. Cardiac trauma was diagnosed by the presence of a foreign body in his chest X-ray. Transthoracic and transesophageal echocardiography showed pericardial effusion and a dense foreign body that crossed the left ventricle from upside down and forward to back. The patient underwent cardiac surgery under extracorporal circulation. A shooting wound was seen on the left ventricular free wall. Transesophageal echocardiography was performed during surgery in order to define the position of the foreign body and to discard lesions due to multidirectional injury. Lesions were repaired and the patient was discharged with no complications. This case report illustrates the possibility of survival after cardiac penetrating trauma, and the role of echocardiography in the diagnosis and surgical repair of this type of trauma.