Informe especial: Transmisión vertical de Chagas: situación epidemiológica de Chagas en embarazo y Chagas congénito en la maternidad Sardá: Primer semestre de 2018 / Special report: Vertical transmission of Chagas: epidemiological situation of Chagas in pregnancy and congenital Chagas in Sardá Maternity: first semester of 2018

Hasta la Semana Epidemiológica 36 de 2018 se notificaron en la Ciudad de Buenos Aires 104 casos de Chagas congénito, de los cuales se confirmaron 6 (5,8%), se descartaron 6 y el 88% restante aún no cuenta con el cierre de caso. Las comunas del sur de la Ciudad acumulan el 56% de los casos. Durante el primer semestre de 2018 se diagnosticaron en la Maternidad Sardá 67 mujeres con Chagas en el embarazo, de un total de 2972 partos realizados en la institución en ese periodo, lo que representa una prevalencia de 22,54 por cada mil embarazadas En este informe se busca describir la situación de la transmisión vertical de la enfermedad de Chagas en el primer semestre de 2018, entre SE 1 y 26; describir la modalidad de notificación de los casos por la Unidad de Promoción y Protección de la Salud (P y P); y reforzar la importancia de la notificación de Enfermedades de Notificación Obligatoria debido a su relevancia en la Salud Pública. Se presentan los casos de Chagas en embarazo por grupo etario, y según provincia de residencia, y se detallan propuestas para la optimización de resultados.

Pharmacokinetics of free ertapenem in critically ill septic patients: intermittent versus continuous infusion.

BACKGROUND: The aim of this paper was to compare the pharmacokinetic and pharmacodynamic (PK/PD) parameters of continuous (CI) and intermittent infusion (ITI) of ertapenem into critically ill patients with severe abdominal infections. METHODS: Twenty septic patients hospitalized in a university hospital intensive care unit were enrolled in the study. Half of the patients received ertapenem as an ITI 1 g bolus once daily, and the other half of the patients received the same dose via CI over 24 h following a 1-g loading dose. Blood was drawn 1, 12 and 24 h after terminating ITI or on days 2, 3 and 5 after starting CI for each patient. After centrifugation, the drawn blood was frozen at -80 °C until being examined by high-performance liquid-chromatography analysis. RESULTS: Median serum-free ertapenem concentrations were as follows: ƒCmax = 98.9 mg/L and ƒCmin = 2.5 mg/L for ITI, and ƒCss=15.9 mg/L for CI. The ITI and CI median total clearance and volumes of distribution were 2.2 L/h vs. 2.5 L/h and 15.4 L vs. 21.0 L, respectively. The ertapenem MIC ranges were as follows: Escherichia coli (0.006 to 0.5 mg/L), Enterobacter cloacae (0.023 to 0.5 mg/L), Klebsiella oxytoca (0.023 to 0.5 mg/L), Staphylococcus aureus (0.38 to 3 mg/L), Streptococcus viridians (0.38 to 3 mg/L) and Enterococcus faecalis (0.38 to 3 mg/L). ITI and CI provided steady-state serum-free ertapenem concentrations constantly above the MIC for all bacteria. CONCLUSION: Ertapenem exhibited satisfactory PK/PD parameters and achieved serum-free concentrations 100% of the time, above even the high MIC of extracellular pathogens normally encountered during severe abdominal infections. CI administration resulted in equally effective PK/PD parameters as ITI in normal weight, good renal-function patients.

Incidence of congenital hypothyroidism and congenital adrenal hyperplasia at Flushing Hospital Medical Center

BACKGROUND: Newborn screening (NBS) program is a simple and inexpensive method for early detection and treatment of over forty conditions as of 2005. Most cases of congenital hypothyroidism (CH) are sporadic and occurs in 1 in 3500 live births. Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders that occurs in 1 in 1600 live births. The detection of CH is determined by either low T4 and/or elevated TSH and the detection of CAH is determined by elevated 17OH progesterone on Guthrie filter paper. Infants who meet the above criteria on NBS for either condition must undergo confirmatory testing. OBJECTIVE: Is the incidence of CH and CAH at FHMC, a community hospital in northern Queens, New York serving a multiethnic population different from theincidence of CH and CAH in New York State (NYS)? DESIGN/METHODS: We reviewed records of the infants recalled and confirmed to have CH and CAH for 2000, 2001 and 2004 and compared with reported incidence of the same conditions in NYS. RESULTS: The total number of live births in NYS was 760,112 and in FHMC 6348 for the three years studied, accounting for 0.7 to 0.8of total NYS live births. The population served by FHMC included 43White, 35Asian, 16Hispanic, 3Afro-American and 3other. A total of 5 patients were identified to have CH in the three years studied, accounting for an incidence of 0.12 (p > 0.05). Three patients were identified to have CAH in 2004 or an incidence of 1.4 (p < 0.05). [Table 1]. CONCLUSIONS: The incidence rate of CH was similar to that of NYS. However, the incidence rate of CAH at FHMC was greater than that reported by NYS. This difference in incidence rate for CAH may be related to the ethnic composition of the population that FHMC serves. Pediatricians and pediatric endocrinologists must be cognizant of the signs and symptoms of CAH in certain populations known to have higher incidence for this condition. Further follow up of incidence rate for CAH at FHMC is indicated since CAH was added to the NBS in 2003.

[Comparison of eight deep breaths and tidal volume breathing preoxygenation techniques in morbid obese patients]. / Comparaison de la technique de préoxygénation à huit capacités vitales et à volume courant chez les patientes ayant une obésité morbide.

OBJECTIVE: To compare two techniques of preoxygenation, eight deep breaths (8DB) and tidal volume breathing in obese patients by measuring end-tidal fractional oxygen concentration (FETO2) and apnea time from 100% of hemoglobin saturation to 95% (T95%). STUDY DESIGN: Prospective randomized study. METHODS: Twenty obese patients (BMI >40 kg/m2) without cardiorespiratory disease nor difficult intubation criteria were randomized into two groups of ten. One group received preoxygenation with eight deep breaths in one minute (8DB) and the other with three minutes tidal volume preoxygenation (3TV) both under FIO2 100%. FETO2 every minute of preoxygenation and T95% were measured. Data were analyzed with Mann and Whitney test. A p <0.05 was considered significant. RESULT: There was no significant difference between the groups regarding FETO2 values [84 +/- 4% (8DB) and 88 +/- 5% (3TV)] and T95% [176 +/- 23 s (8DB) and 181 +/- 35 s (3TV)]. The PETCO2 was significantly inferior in the 8DB group at the end of preoxygenation [PETCO2 =29 +/- 1 mmHg (8DB) and PETCO2 =36 +/- 5 mmHg (3TV)]. CONCLUSION: 8DB and 3TV preoxygenation techniques in morbid obese patients induce similar FETO2 and T95%. However hyperventilation effects in the 8DB group are unknown.

Early development of intractable epilepsy in children: a prospective study.

BACKGROUND: Little is known about early prediction of intractable epilepsy (IE) in children. Such information could help guide the early use of new therapies in selected patients. METHODS: Children with newly diagnosed epilepsy (n = 613) were prospectively identified from child neurology practices in Connecticut (1993--1997) and followed-up for the occurrence of IE (failure of > or = 2 drugs, > or = 1 seizure/month, over 18 months) [corrected]. Etiology and epilepsy syndromes were classified per International League Against Epilepsy guidelines. RESULTS: The median follow-up is 4.8 years, and 599 (97.7%) have been followed for more than 18 months. Sixty children (10.0%) have met the criteria for IE, including 34.6% with cryptogenic/symptomatic generalized, 2.7% with idiopathic, 10.7% with other localization-related, and 8.2% with unclassified epilepsy (p < 0.0001). After multivariable adjustment for epilepsy syndrome, initial seizure frequency (p < 0.0001), focal EEG slowing (p = 0.02), and acute symptomatic or neonatal status epilepticus (p = 0.001) were associated with an increased risk of IE, and age at onset between 5 and 9 years was associated with a lowered risk (p = 0.03). The absolute number of seizures and unprovoked or febrile status epilepticus were not associated substantially with IE. CONCLUSIONS: Approximately 10% of children meet criteria for IE early in the course of their epilepsy. Cryptogenic/symptomatic generalized syndromes carry the highest risk and idiopathic syndromes the lowest. Half of IE occurs in children with nonidiopathic localization-related syndromes. Initial seizure frequency is highly predictive of IE. By contrast, absolute number of seizures and unprovoked or febrile status epilepticus are not.

Defining early seizure outcomes in pediatric epilepsy: the good, the bad and the in-between.

PURPOSE: To examine different approaches to classifying seizure outcomes. METHODS: In a prospective cohort study of children (N=613) with newly diagnosed epilepsy, seizure outcomes at 2 years were classified as 'good' (> or =1 year remission), 'bad' or 'intractable' (> or = AED failures, > or =1 seizure/month over > or =18 months), and 'indeterminate' (neither 'good' nor 'bad'). Outcomes at 2 years were compared to outcomes in those followed 4 or more years. The associations of three commonly studied prognostic factors, etiology, age at onset, and syndromic grouping with the three-level outcome were assessed. RESULTS: 595 (97.1%) children were followed > or =2 years. A 'good', indeterminate, and 'bad' outcome was present in 314 (52.8%), 235 (38.3%), and 46 (7.7%) children. Problems with treatment were recorded in 64.7% of the indeterminate group. In 390 children followed > or =4 years, early 'good' and 'bad' outcomes persisted in approximately 80%. About half of those with indeterminate 2-year outcomes later achieved remission, 8% met criteria for intractability, and 37% remained indeterminate. Most of the associations with etiology, age, and syndrome were due to variation in the proportion that met criteria for intractability and not remission. CONCLUSIONS: Many children have indeterminate outcomes, often in association with treatment issues. Clearly 'good' and 'bad' early outcomes can be identified and persist > or =2 years later. In the absence of pharmaco-resistance, lack of early remission (indeterminate outcome) is usually not associated with a bad outcome, at least over the next few years.

Morphology and spelling among Hebrew-speaking children: from kindergarten to first grade.

This study had two major objectives: (1) to analyse the development of two morphological structures in Hebrew, one inflectional and the other derivational and (2) to examine the mutual contribution of morphological knowledge and learning the written code. In a longitudinal design, 40 children were tested twice, first in kindergarten (mean age: 5; 11) and again in first grade (mean age: 6;5), on two oral tasks--inflecting nouns for possession and deriving denominal adjectives--and one written task of writing a series of noun-adjective pairs. The derivational task was found to be harder than the inflectional task, both on the stem and the suffix level, attributable to its higher semantic opacity. In both oral tests, correct stem production when suffixed was related to the morphophonological level of stem change. Correlations were found between morphological and writing scores. Moreover, children who were more advanced in morphology in kindergarten progressed more in writing vowels from kindergarten to first grade, and those who were more advanced in writing in kindergarten improved more in derivational morphology with grade.

Two-year remission and subsequent relapse in children with newly diagnosed epilepsy.

PURPOSE: Although remission is the ultimate measure of seizure control in epilepsy, and epilepsy syndrome should largely determine this outcome, little is known about the relative importance of syndrome versus other factors traditionally examined as predictors of remission or of relapse after remission. The purpose of this study was to examine remission and relapse with respect to the epilepsy syndrome and other factors traditionally considered with respect to seizure outcome. METHODS: A prospectively identified cohort of 613 children with newly diagnosed epilepsy was assembled and is actively being followed to determine seizure outcomes. Epilepsy syndrome and etiology were classified at diagnosis and again 2 years later. Remission was defined as 2 years completely seizure-free, and relapse as the recurrence of seizures after remission. Multivariable analysis was performed with the Cox proportional hazards model. RESULTS: Five hundred ninety-four of the original 613 children were followed > or = 2 years (median follow-up, 5 years). Remission occurred in 442 (74%), of whom 107 (24%) relapsed. On multivariable analysis, idiopathic generalized syndromes and age at onset between 5 and 9 years were associated with a substantially increased remission rate, whereas remote symptomatic etiology, family history of epilepsy, seizure frequency, and slowing on the initial EEG were associated with a decreased likelihood of attaining remission. Young onset age (<1 year) and seizure type were not important after adjustment for these predictors. Relapses occurred more often in association with focal slowing on the initial EEG and with juvenile myoclonic epilepsy. Benign rolandic epilepsy and age at onset <1 year were associated with markedly lower risks of relapse. About one fourth of relapses were apparently spontaneous while the child was taking medication with good compliance, and more than half occurred in children who were tapering or had fully stopped medication. CONCLUSIONS: A large proportion of children with epilepsy remit. Symptomatic etiology, family history, EEG slowing, and initial seizure frequency negatively influence, and age 5-9 years and idiopathic generalized epilepsy positively influence the probability of entering remission. Factors that most influence relapse tend to be different from those that influence remission.

How well can epilepsy syndromes be identified at diagnosis? A reassessment 2 years after initial diagnosis.

PURPOSE: Epilepsy syndromes can be identified very early in the course of a seizure disorder. It is unclear how accurate and resilient such early classifications are. We compared the classification of epilepsy syndromes made previously on the basis of information available at diagnosis with those made 2 years later in a cohort of children with newly diagnosed epilepsy. METHODS: Children (n = 613) were prospectively identified at the time of initial diagnosis by participating physicians in Connecticut between 1993 and 1997. Classification of epilepsy syndrome according to International League Against Epilepsy guidelines was made previously based on all relevant information available at diagnosis. All cases were reclassified again after 2 years of additional evidence had accumulated. The distributions of syndromes at diagnosis and at 2 years are compared and reasons for changes examined. RESULTS: After 2 years, syndromes remained the same in 86.3% of the cohort and changes occurred in 13.7% (n = 84). Evolution of the syndrome occurred in 24 children (3.9%), and rectification to the initial diagnosis occurred in 60 children (9.8%). The most common scenario for evolution of a syndrome was from West syndrome (n = 5), undetermined (n = 4), or symptomatic localization-related epilepsy (n = 3) to the Lennox-Gastaut syndrome. The most common rectification of initial classifications involved incompletely classified syndromes (cryptogenic localization-related and undetermined syndromes; n = 36). In a few instances, a fully specified syndrome was reclassified to another apparently unrelated syndrome. In these cases, initial information at diagnosis had been difficult to interpret. CONCLUSIONS: Epilepsy syndromes can, for the most part, be identified at the time of initial diagnosis. Two years later, rectifications were made in only 9.8% of cases, and most of these involved syndromes that represented incomplete classifications in the first place. Significant changes were rare. The International League Against Epilepsy classification of the epilepsies can be meaningfully applied in epidemiological studies of newly diagnosed pediatric epilepsy.

Coagulation problems in liver disease.

Three topics are addressed in this manuscript: (1) the causes of abnormal hemostasis in cirrhosis; (2) the evaluation of hemostasis in cirrhotic patients before invasive procedures or in the presence of bleeding; and (3) the assessment of the effect of recombinant activated factor VII (rFVIIa; NovoSeven, Novo Nordisk A/S, Bagsvaerd, Denmark) on hemostatic function in cirrhotic patients. Laboratory experiments are described that could enhance the understanding of the effect of rFVIIa on blood coagulation during hemostasis in cirrhotic patients.

A novel clotting assay for quantitation of plasma prothrombin (factor II) using Echis multisquamatus venom.

Measuring plasma prothrombin activity seems useful for evaluating thrombotic risk and managing oral anticoagulant therapy as an adjunct to the international normalized ratio. Therefore, we designed a new plasma prothrombin assay based on the ability of Echis multisquamatus venom to activate prothrombin with only calcium as a cofactor. In this assay, 1 part of undiluted citrated plasma is added to 5 parts of a venom reagent and the clotting time is measured. The assay's advantages are that dilution of the test plasma is required only when prothrombin activity exceeds 100%, a single standard curve can be used over months for a given batch of stock reagent, and barium-adsorbed plasma is used for dilution of test plasma and construction of the standard curve, thus eliminating the need for prothrombin-deficient plasma. However, one should be aware of the following: (1) test samples must contain at least 200 mg/dL fibrinogen; and (2) when prothrombin concentrations were below 50%, the venom-based assay often gave values up to 10% higher than the thromboplastin-based assay. Values obtained in 262 plasma samples tested with the venom-based assay and with a thromboplastin-based prothrombin assay correlated well (r2 = 0.93).

Hemostatic factors in rabbit limb lymph: relationship to mechanisms regulating extravascular coagulation.

Mechanisms regulating extravascular coagulation in interstitial fluids of peripheral tissues are poorly understood, since measurements of hemostatic factors in these fluids are unavailable. Because lymph from a body region reflects the composition of its interstitial fluid, we measured hemostatic factors in limb lymph of rabbits both as activity and as antigen. Mean lymph-to-plasma activity ratios were the following: fibrinogen, 0.28; prothrombin, 0.26; factor X, 0.27; factor VII, 0.17; and factors V and VIII, 0.08. All lymph fibrinogen was clottable; fibrin degradation products were absent. Lymph von Willebrand factor antigen was < 10% of plasma antigen and consisted primarily of lower molecular weight multimers. Mean lymph-to-plasma activity ratio for antithrombin was 0.38 and for tissue factor pathway inhibitor the ratio was 0.40. Low levels of antithrombin-factor Xa were measurable in lymph. The data are compatible with a basal factor VIIa-tissue factor-catalyzed extravascular activation of factor X that is prevented from progressing to generation of fibrin in limb interstitial fluid and lymph by low levels of factor VIII and factor V and by the inhibitory activity of antithrombin and tissue factor pathway inhibitor.

Rapid estimation of insertional length of endotracheal intubation in newborn infants.

OBJECTIVE: To create a simple and accurate method of predicting the correct insertional length of endotracheal intubation during resuscitation of neonates. STUDY DESIGN: Phase I of the study enrolled infants that required either orotracheal or nasotracheal intubations. The endotracheal tube position was confirmed by auscultation and radiographic images. Three regression equations were then created using nasal-tragus length, sternal length, and birth weight on insertional length. In phase II of the study, the modified regression equations of nasotracheal and sternal length were used to predict endotracheal tube insertional length in 50 infants (40 orotracheal and 10 nasotracheal). RESULTS: Nasal-tragus length and sternal length are good parameters to estimate insertional length for endotracheal intubation (p < 0.005 for both the parameters). The modified prediction equation for insertional length of the endotracheal tube for the orotracheal route is NTL or STL + 1. For the nasotracheal route the equation is NTL or STL + 2. CONCLUSION: During resuscitation of the neonate when vital parameters are difficult to obtain, the insertional length of endotracheal intubation can be quickly and accurately predicted by nasal-tragus length or sternal length.

A Protac-based screening test for activated protein C-resistant factor Va and other defects of the protein C anticoagulant pathway.

We have standardized a simple screening test for abnormalities of the protein C anticoagulant system. The test is basically a modified prothrombin time in which one aliquot of a test plasma is incubated for 3 min at 37 degrees C with Protac and another is incubated with buffer. During the incubation the Protac activates both protein C and factor V. The plasmas are then clotted with thromboplastin plus Ca2+, and the clotting time difference reflects the ability of the activated protein C (APC) to inactivate factor Va. With the use of Thromboplastin C Plus as the activator, clotting time differences found in 31 normal subjects (10.4 +/- 3.5 s, mean +/- 2SD) were distinct from clotting time differences found in 57 of 58 subjects with established APC-resistant factor Va (3.6 +/- 3.0 s). In addition, the Protac-based test detected six of seven patients with isolated protein C deficiency and 20 of 28 patients with isolated protein S deficiency. Because of the reported high prevalence of heterozygous APC-resistant factor Va in Caucasian populations, it should be particularly useful in determining whether this genetic risk is present in individuals who have experienced or are at increased environmental risk of venous thrombosis.

Correction of excessive anticoagulation with low-dose oral vitamin K1.

BACKGROUND: Despite earlier acceptance of oral vitamin K1 (phytonadione) for the treatment of excessive anticoagulation, some recent guidelines do not recommend its use. OBJECTIVE: To reevaluate the efficacy of oral vitamin K1 in correcting excessive anticoagulation. DESIGN: Case series. SETTING: Anticoagulation clinics at two university medical centers. PATIENTS: 81 outpatients who had an international normalized ratio (INR) greater than 5.0 but did not have significant bleeding. INTERVENTIONS: Withholding 1 or 2 doses of warfarin, administering 2.5 mg of oral vitamin K1, measuring the INR after 24 to 48 hours, and adjusting the warfarin dose. MEASUREMENTS: INRs were obtained from a portable capillary fingerstick monitor or from an automated photooptical coagulometer. RESULTS: In 68 of 71 patients (96%), oral vitamin K1 lowered the INR from between 5.0 and 10.0 to less than 5.0 without inducing resistance to further anticoagulation. CONCLUSIONS: Withholding 1 or 2 doses of warfarin and administering 2.5 mg of oral vitamin K1 is a reliable, safe, and inexpensive way to rapidly correct excessive anticoagulation (INR > 5.0) in patients who do not have serious bleeding episodes and have an INR of less than 10.0.

Reliability of a modified tissue factor-dependent factor V assay for activated protein C resistant factor Va using a calcium-containing thromboplastin.

The original tissue factor-dependent factor V assay for activated protein C resistant factor Va (Blood 1995; 85: 1704-1711) has been modified to use a calcium containing thromboplastin and to express results as an observed to expected ratio (Obs/Exp.). The latter permits establishing a normal range independent of variations due to differences in reagents. Comparing Obs/Exp ratios with DNA analysis in 72 persons revealed that an Obs/Exp ratio of 0.6 distinguished without overlap normals from heterozygotes for FV R506Q. Three homozygotes had a ratio of < 0.1. Application of this Obs/Exp cut-off ratio of 0.6 to a total of 226 plasma samples tested to date discriminated without overlap between normals and heterozygotes. We conclude that this assay-readily adaptable to any dedicated coagulation laboratory and capable of yielding reliable results in all clinical circumstances in which testing is indicated-can distinguish between normals and heterozygotes for the FV R506Q mutation without the need for confirmatory DNA analysis.

The effect of immunodepletion of antithrombin III on the response of rabbits to Russell's viper venom-induced activation of factor X.

Many years ago it was shown that an infusion of tissue factor (TF) into rabbits causing only limited consumption of factor X and prothrombin resulted in extensive consumption of fibrinogen. More recently it was shown that an injection of a concentration of the factor X-activating fraction of Russell's viper venom (RVV-X) depleting rabbits of factor X resulted in only minimal consumption of both plasma prothrombin and fibrinogen. We report here experiments in which rabbits depleted of antithrombin III (ATIII) to different degrees were infused over 4 hours with a concentration of RVV-X, causing consumption of about 60% of plasma factor X. Similar minimal mean falls in plasma prothrombin and fibrinogen levels were observed in control rabbits given nonimmune goat IgG and in rabbits immunodepleted with goat anti-rabbit ATIII IgG to about 40% of normal plasma ATIII activity. However, if rabbits were immunodepleted to about 10% to 20% of normal plasma ATIII, then mean consumption of prothrombin was increased modestly and, more impressively, mean consumption of plasma fibrinogen was increased markedly. Whereas limited amounts of thrombin generated on the surface of phospholipid vesicles by factor VIIa/ TF can trigger extensive intravascular coagulation in rabbits with normal plasma ATIII levels, limited amounts of thrombin generated by reactions triggered by factor Xa formed in fluid phase did so only after plasma ATIII levels were markedly depleted. A possible reason for this difference is discussed.