Mortality in patients with severe COVID-19 who underwent tracheostomy due to prolonged mechanical ventilation.

BACKGROUND: The usefulness of tracheostomy has been questioned in patients with COVID-19 and prolonged invasive mechanical ventilation (IMV). AIM: To compare the 90-day mortality rate of patients who underwent a tracheostomy due prolonged IMV with those that did not receive this procedure. MATERIAL AND METHODS: We studied a historical cohort of 92 patients with COVID-19 and prolonged IMV (> 10 days). The primary outcome was the 90-day mortality rate. Secondary outcomes included days on IMV, hospital/intensive care unit (ICU) length of stay, frequency of nosocomial infections, and thrombotic complications demonstrated by images. A logistic regression was performed to adjust the effect of tracheostomy by SOFA score and days on IMV. RESULTS: Forty six patients aged 54 to 66 years (72% males) underwent tracheostomy. They had a median of two comorbidities, and received the procedure after a median of 20.5 days on IMV (interquartile range: 17-26). 90-day mortality was lower in patients who were tracheostomized than in the control group (6.5% vs. 32.6%, p-value < 0.01). However, after controlling for confounding factors, no differences were found in mortality between both groups (relative risk = 0.303, p-value = 0.233). Healthcare-associated infections and hospital/ICU length of stay were higher in patients with tracheostomy than in controls. Thrombotic complications occurred in 42.4% of the patients, without differences between both groups. No cases of COVID-19 were registered in the healthcare personnel who performed tracheostomies. CONCLUSIONS: In patients with COVID-19 undergoing prolonged IMV, performing a tracheostomy is not associated with excess mortality, and it is a safe procedure for healthcare personnel.

[Negative effects of the patients' rights law and neuro-rights bill in Chile]. / Efectos negativos en la investigación y el quehacer médico en Chile de la Ley 20.584 y la Ley de Neuroderechos en discusión: la urgente necesidad de aprender de nuestros errores.

Recently, the Chilean Senate approved the main ideas of a constitutional reform and a Neuro-rights bill. This bill aims to protect people from the potential abusive use of "neuro-technologies". Unfortunately, a literal interpretation of this law can produce severe negative effects both in the development of neuroscience research and medical practice in Chile, interfering with current treatments in countless patients suffering from neuropsychiatric diseases. This fear stems from the observation of the negative effects that recent Chilean legislations have produced, which share with the Neuro-Rights Law the attempt to protect vulnerable populations from potential abuse from certain medical interventions. In fact, Law 20,584 promulgated in 2012, instead of protecting the most vulnerable patients "incapacitated to consent", produced enormous, and even possibly irreversible, damage to research in Chile in pathologies that require urgent attention, such as many neuropsychiatric diseases. This article details the effects that Law 20.584 had on research in Chile, how it relates to the Neuro-Rights Law, and the potential negative effects that the latter could have on research and medical practice, if it is not formulated correcting its errors.

Risk factors of early adverse drug reactions with phenytoin: A prospective inpatient cohort.

INTRODUCTION: Phenytoin (PHT) is an effective and inexpensive antiepileptic drug (AED). However, its use has been limited for fear of adverse drug reactions (ADRs) and is being replaced by newer AED, increasing the costs and causing major budget problems, particularly for developing countries. OBJECTIVE: The objective of this study was to determine ADR frequency, explore, and establish related risk factors. METHODS: Prospective data were collected from a cohort of inpatients using PHT for the first time. Pharmacovigilance was performed during hospitalization and after one month from the discharge. Clinical variables, plasma levels, and concomitant medications were collected and their association with the occurrence of different ADRs was explored. RESULTS: One hundred patients were included: 59 were women, and mean age was 59±21years. Thirty-three patients presented ADR, all moderate and idiosyncratic. The most frequent were rash (17%), fever (10%), and elevated transaminases (10%). Female gender (85% vs 52%, p=0.029), younger age (mean age: 49 vs 62years, p=0.032), and higher PHT plasmatic levels after IV-PO load (mean plasmatic levels: 18.6 vs 13.9µg/mL, p=0.040) were found to be associated with rash. A higher number of concomitant medications were also found to be associated with the risk for developing any ADR. The multivariate analysis revealed an association between rash and younger age (cut-off: 35years old; relative risk (RR)=11.7; p=0.026), and higher PHT plasmatic levels (cut-off: 16µg/mL; RR=12.5; p=0.021); and increased risk of elevated transaminases with use of PHT inductors (RR=18; p=0.006). A longer hospital stay was found in patients who developed fever (mean: 43days, p<0.0001) and elevated transaminases (mean: 26days, p=0.041) compared with patients without ADR (mean: 17days). CONCLUSIONS: Phenytoin is a widely used AED associated with easily detectable ADR through structured pharmacovigilance. The development of ADR is associated with longer hospital stays. Recognition of local risk factors may lead to ADR prevention in a near future. Larger studies are needed to better define PHT-related ADR risk profile and to individualize treatment regimens.

Proposal: different types of alteration and loss of consciousness in epilepsy.

There are at least five types of alterations of consciousness that occur during epileptic seizures: auras with illusions or hallucinations, dyscognitive seizures, epileptic delirium, dialeptic seizures, and epileptic coma. Each of these types of alterations of consciousness has a specific semiology and a distinct pathophysiologic mechanism. In this proposal we emphasize the need to clearly define each of these alterations/loss of consciousness and to apply this terminology in semiologic descriptions and classifications of epileptic seizures. The proposal is a consensus opinion of experienced epileptologists, and it is hoped that it will lead to systematic studies that will allow a scientific characterization of the different types of alterations/loss of consciousness described in this article.

Effects of intraoperative adrenergic administration on postoperative hyperlactatemia in open colon surgery: an observational study.

BACKGROUND: Postoperative Hyperlactatemia (PO-HL) is a frequent condition associated with poor prognosis. In recent years, there has been growing evidence that adrenergic stimulation may contribute to increased lactate levels. The use of adrenergic agonists for the control of intraoperative hypotension is frequent, and its impact on the development of PO-HL is unknown. OBJECTIVE: To evaluate whether the use of intraoperative adrenergic agents is associated with the occurrence of PO-HL. METHODS: This was a prospective observational study. The inclusion criteria were undergoing elective open colon surgery, being ≥60 years old and signing informed consent. The exclusion criteria were cognitive impairment, unplanned surgery, and anticipated need for postoperative mechanical ventilation. Baseline and intraoperative variables were collected, and arterial lactate data were collected at baseline and every 6 hours postoperatively for 24 hours. Hyperlactatemia was defined as lactate >2.1 mEq.L-1. RESULTS: We studied 28 patients, 61% of whom developed hyperlactatemia. The variables associated with PO-HL in the univariate analysis were anesthetic time, the total dose of intraoperative ephedrine, and lower intraoperative central venous oxygen saturation (ScvO2). Multivariate analysis confirmed the association between the use of ephedrine (p = 0.004), intraoperative hypotension (p = 0.026), and use of phenylephrine (p = 0.001) with PO-HL. CONCLUSIONS: The use of intraoperative ephedrine, phenylephrine and intraoperative hypotension were independently associated with the development of PO-HL. This finding should lead to new studies in this field, as well as a judicious interpretation of the finding of a postoperative increase in lactate levels.

Obstructive sleep apnea as an independent stroke risk factor: possible mechanisms.

Obstructive Sleep Apnea (OSA) is a prevalent disease that has emerged as a new cerebrovascular disease (CVD) risk factor, which is independent of its association to hypertension, age and other known conditions that increase CVD. The mechanisms involved in this relation are most likely induced by the periodic hypoxia/reoxygenation that characteristically occurs in OSA, which results in oxidative stress, endothelial dysfunction and activation of the inflammatory cascade, all of which favor atherogenesis. Numerous markers of these changes have been reported in OSA patients, including increased circulating free radicals, increased lipid peroxidation, decreased antioxidant capacity, elevation of tumor necrosis factor and interleukines, increased levels of proinflammatory nuclear transcription factor kappa B, decreased circulating nitric oxide, elevation of vascular adhesion molecules and vascular endothelial growth factor. In addition, several authors have described that Continuous Positive Airway Pressure, the standard OSA therapy, reverts these abnormalities. Further research is needed in order to better clarify the complex mechanisms that underlie the relation between OSA, atherogenesis and CVD which most likely will have significant clinical impact.

Randomized comparison between epidural waveform analysis through the needle versus the catheter for thoracic epidural blocks.

BACKGROUND: Epidural waveform analysis (EWA) provides a simple confirmatory adjunct for loss of resistance (LOR): when the needle/catheter tip is correctly positioned inside the epidural space, pressure measurement results in a pulsatile waveform. Epidural waveform analysis can be carried out through the tip of the needle (EWA-N) or the catheter (EWA-C). In this randomized trial, we compared the two methods. We hypothesized that, compared with EWA-C, EWA-N would result in a shorter performance time. METHODS: One hundred and twenty patients undergoing thoracic epidural blocks for thoracic or abdominal surgery were randomized to EWA-N or EWA-C. In the EWA-N group, LOR was confirmed by connecting the epidural needle to a pressure transducer. After obtaining a satisfactory waveform, the epidural catheter was advanced 5 cm beyond the needle tip. In the EWA-C group, the epidural catheter was first advanced 5 cm beyond the needle tip after the occurrence of LOR. Subsequently, the catheter was connected to the pressure transducer to detect the presence of waveforms. In both study groups, the block procedure was repeated at different intervertebral levels until positive waveforms could be obtained (through the needle or catheter as per the allocation) or until a predefined maximum of three intervertebral levels had been reached. Subsequently, the operator administered a 4 mL test dose of lidocaine 2% with epinephrine 5 µg/mL through the catheter. An investigator present during the performance of the block recorded the performance time (defined as the temporal interval between skin infiltration and local anesthetic administration through the epidural catheter). Fifteen minutes after the test dose, a blinded investigator assessed the patient for sensory block to ice. Success was defined as a bilateral block in at least two dermatomes. Furthermore, postoperative pain scores, local anesthetic consumption, and breakthrough analgesic consumption were recorded. RESULTS: No intergroup differences were found in terms of performance time, success rate, postoperative pain, local anesthetic requirement, and breakthrough analgesic consumption. CONCLUSION: EWA can be carried out through the needle or through the catheter with similar efficiency (performance time) and efficacy (success rate, postoperative analgesia). TRIAL REGISTRATION NUMBER: NCT03603574.

Assessing the state of lean and six sigma practices in healthcare in Mexico.

PURPOSE: The purpose of this study is to assess the state at which lean and six sigma (LSS) are used as a management system to improve the national health system national health system of Mexico. DESIGN/METHODOLOGY/APPROACH: Cross-sectional survey-research. The survey was administered at 30 different hospitals across six states in Mexico. These were selected using convenience sampling and participants (N = 258) were selected through random/snowball sampling procedures, including from top managers down to front-line staff. FINDINGS: Only 16 per cent of respondents reported participation in LSS projects. Still, these implementations are limited to using isolated tools, mainly 5s, failure mode and effects analysis (FMEA) and Fishbone diagram, with the lack of training/knowledge and financial resources as the top disabling factors. Overall, LSS has not become systematic in daily management and operations. RESEARCH LIMITATIONS/IMPLICATIONS: The sampling procedure was by convenience; however, every attempt was made to ensure a lack of bias in the individual responses. If still there was a bias, it is conjectured that this would likely be in overestimating the penetration of LSS. PRACTICAL IMPLICATIONS: The penetration of LSS management practices into the Mexican health system is in its infancy, and the sustainability of current projects is jeopardized given the lack of systematic integration. Hence, LSS should be better spread and communicated across healthcare organizations in Mexico. ORIGINALITY/VALUE: This is the first research work that evaluates the use of LSS management practices in a Latin American country, and the first journal paper that focuses on LSS in healthcare in Mexico.

Corpus callosum atrophy and post-surgical seizures in temporal lobe epilepsy associated with hippocampal sclerosis.

OBJECTIVE: Our aim in this retrospective study was to explore whether corpus callosum atrophy could predict the post-surgical seizure control in patients with temporal lobe epilepsy associated with Hippocampal Sclerosis (HS). METHODS: We used the Corpus Callosum Index (CCI) obtained from best mid-sagittal T2/FLAIR or T1-weighted MRI at two time-points, more than one year apart. CCI has been mainly used in Multiple Sclerosis (MS), but not in epilepsy, so we tested the validity of our results performing a proof of concept cohort, incorporating MS patients with and without epilepsy. Then, we explored this measurement in a well-characterized and long-term cohort of patients with temporal lobe epilepsy associated with HS. RESULTS: In the proof of concept cohort (MS without epilepsy n:40, and MS with epilepsy, n:15), we found a larger CCI atrophy rate in MS patients with poor epilepsy control vs. MS without epilepsy (p:0.01). Then, in HS patients (n:74), annualized CCI atrophy rate was correlated with the long-term Engel scale (Rho:0.31, p:0.007). In patients with post-surgical seizure recurrence, a larger CCI atrophy rate was found one year before any seizure relapse. Univariate analysis showed an increased risk of seizure recurrence in males, higher pre-surgical seizure frequency, necessity of invasive EEG monitoring, and higher CCI atrophy rate. Two of these variables were independent predictors in the multivariate analysis, male gender (HR:4.87, p:0.002) and CCI atrophy rate (HR:1.21, p:0.001). CONCLUSION: We demonstrated that atrophy of the corpus callosum, using the CCI, is related with poor seizure control in two different neurological disorders presenting with epilepsy, which might suggest that corpus callosum atrophy obtained in early post-surgical follow-up, could be a biomarker for predicting recurrences and guiding treatment plans.

[Impact of hypotension and global hypoperfusion in postoperative delirium: a pilot study in older adults undergoing open colon surgery]. / Impacto da hipotensão e hipoperfusão global sobre o delírio pós­operatório: um estudo piloto com idosos submetidos à cirurgia aberta do cólon.

BACKGROUND: Post-operative delirium is a serious complication in patients undergoing major abdominal surgery. It remains unclear whether peri-operative hemodynamic and perfusion variables affect the risk for postoperative delirium. The objective of this pilot study was to evaluate the association between perfusion and hemodynamics peri-operative with the appearance of post-operative delirium. METHODS: Prospective cohort study of adults 60 years or older undergoing elective open colon surgery. Multimodal hemodynamic and perfusion variables were monitored, including central venous oxygenation (ScvO2), lactate levels, and non-invasive cerebral oxygenation (rSO2), according to a standard anesthesia protocol. Fisher's exact test or Student's t-test were used to compare patients who developed post-operative delirium with those who did not (p<0.05). RESULTS: We studied 28 patients, age 73±7 years, 60.7% female. Two patients developed post-operative delirium (7.1%). These two patients had fewer years of education than those without delirium (p=0.031). None of the peri-operative blood pressure variables were associated with incidence of post-operative delirium. In terms of perfusion parameters, postoperative ScvO2 was lower in the delirium than the non-delirium group, without reaching statistical significance (65±10% vs. 74±5%; p=0.08), but the delta-ScvO2 (the difference between means post-operative and intra-operative) was associated with post-operative delirium (p=0.043). Post-operative lactate and rSO2 variables were not associated with delirium. CONCLUSIONS: Our pilot study suggests an association between delta ScvO2 and post-operative delirium, and a tendency to lower post-operative ScvO2 in patients who developed delirium. Further studies are necessary to elucidate this association.

Mortality in patients with severe COVID-19 who underwent tracheostomy due to prolonged mechanical ventilation / Mortalidad en pacientes con COVID-19 grave sometidos a traqueostomía por ventilación mecánica prolongada

BACKGROUND: The usefulness of tracheostomy has been questioned in patients with COVID-19 and prolonged invasive mechanical ventilation (IMV). AIM: To compare the 90-day mortality rate of patients who underwent a tracheostomy due prolonged IMV with those that did not receive this procedure. MATERIAL AND METHODS: We studied a historical cohort of 92 patients with COVID-19 and prolonged IMV (> 10 days). The primary outcome was the 90-day mortality rate. Secondary outcomes included days on IMV, hospital/intensive care unit (ICU) length of stay, frequency of nosocomial infections, and thrombotic complications demonstrated by images. A logistic regression was performed to adjust the effect of tracheostomy by SOFA score and days on IMV. RESULTS: Forty six patients aged 54 to 66 years (72% males) underwent tracheostomy. They had a median of two comorbidities, and received the procedure after a median of 20.5 days on IMV (interquartile range: 17-26). 90-day mortality was lower in patients who were tracheostomized than in the control group (6.5% vs. 32.6%, p-value < 0.01). However, after controlling for confounding factors, no differences were found in mortality between both groups (relative risk = 0.303, p-value = 0.233). Healthcare-associated infections and hospital/ICU length of stay were higher in patients with tracheostomy than in controls. Thrombotic complications occurred in 42.4% of the patients, without differences between both groups. No cases of COVID-19 were registered in the healthcare personnel who performed tracheostomies. CONCLUSIONS: In patients with COVID-19 undergoing prolonged IMV, performing a tracheostomy is not associated with excess mortality, and it is a safe procedure for healthcare personnel.

ANTECEDENTES: La utilidad de la traqueostomía en pacientes COVID-19 sometidos a ventilación mecánica invasiva (VMI) prolongada ha sido cuestionada. OBJETIVO: Comparar la mortalidad a 90 días en estos pacientes, con y sin traqueostomía. MATERIAL Y MÉTODOS: Estudiamos una cohorte histórica de 92 pacientes COVID-19 con VMI prolongada (>10 días). El desenlace prima-rio fue mortalidad a 90 días. Se consideraron desenlaces secundarios los días en VMI, estadía hospitalaria/UCI, frecuencia de infecciones nosocomiales, y eventos trombóticos. Mediante regresión logística se ajustó el efecto de la traqueostomía en la mortalidad, por SOFA y días de VMI. RESULTADOS: Cuarenta y seis pacientes de 54 a 66 años (72% hombres) fueron traqueostomizados. Ellos tenían una mediana de dos comorbilidades, y recibieron el procedimiento luego de una mediana de 20,5 días en VMI (rango intercuartílico: 17-26). En el análisis crudo, la mortalidad a 90 días fue menor en los pacientes con traqueostomía que en el grupo control (6,5% vs. 32,6%; p < 0,001). No obstante, luego de controlar por factores de confusión, no se encontraron diferencias en mortalidad (riesgo relativo 0,303; p = 0,233). Las infecciones asociadas a la atención de salud y la estadía en hospital/UCI fueron mayores en los pacientes traqueostomizados que en los controles. Los eventos trombóticos ocurrieron en el 42,4% de los pacientes, sin diferencias entre grupos. No hubo casos de COVID-19 en el personal de salud que realizó las traqueostomías. CONCLUSIONES: En pacientes con COVID-19 sometidos a VMI prolongada, la realización de una traqueostomía no se asocia a un exceso de mortalidad, y es un procedimiento seguro para el personal sanitario.

Epilepsy and celiac disease: favorable outcome with a gluten-free diet in a patient refractory to antiepileptic drugs.

BACKGROUND: There is a well-documented relationship between epilepsy and celiac disease, including a syndrome characterized by epilepsy, occipital calcifications, and celiac disease. REVIEW SUMMARY: We report the case of a 23-year-old woman with an 11-year history of refractory epileptic seizures and newly diagnosed biopsy-proven celiac disease with increased antiendomysium immunoglobulin A antibodies. The patient showed a dramatic improvement after starting a gluten-free diet. CONCLUSION: This case emphasizes the need to include celiac disease in the differential diagnosis when investigating the etiology of epilepsy in refractory patients.

Efectos negativos en la investigación y el quehacer médico en Chile de la Ley 20.584 y la Ley de Neuroderechos en discusión: la urgente necesidad de aprender de nuestros errores / Negative effects of the patients' rights law and neuro-rights bill in Chile

Recently, the Chilean Senate approved the main ideas of a constitutional reform and a Neuro-rights bill. This bill aims to protect people from the potential abusive use of "neuro-technologies". Unfortunately, a literal interpretation of this law can produce severe negative effects both in the development of neuroscience research and medical practice in Chile, interfering with current treatments in countless patients suffering from neuropsychiatric diseases. This fear stems from the observation of the negative effects that recent Chilean legislations have produced, which share with the Neuro-Rights Law the attempt to protect vulnerable populations from potential abuse from certain medical interventions. In fact, Law 20,584 promulgated in 2012, instead of protecting the most vulnerable patients "incapacitated to consent", produced enormous, and even possibly irreversible, damage to research in Chile in pathologies that require urgent attention, such as many neuropsychiatric diseases. This article details the effects that Law 20.584 had on research in Chile, how it relates to the Neuro-Rights Law, and the potential negative effects that the latter could have on research and medical practice, if it is not formulated correcting its errors.

Sleep-related eating disorder: a descriptive study in Chilean patients.

OBJECTIVES: We aimed to describe a group of adults diagnosed with sleep-related eating disorder (SRED) at the Sleep Medicine Center of the Pontificia Universidad Catolica de Chile. METHODS: We performed a descriptive study of 34 consecutive patients who met the criteria of the International Classification of Sleep Disorders for SRED evaluated during a 3-year period who did not have an eating disorder according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. All patients had a structured clinical interview performed by a sleep specialist and completed the Beck Depression Inventory (BDI). Polysomnography (PSG) was performed when clinically indicated for ruling out other sleep-related disorders (18 patients; 52.9%). Patients' demographic and clinical data, comorbidities, and treatment response also were analyzed. RESULTS: Most patients were women (n=23; 67.6%). The average age at the time of diagnosis was 39±13.8 (17-67 years) and the latency since symptom onset was 8.3±8.8 years. Most patients had several episodes per night (average, 2.6±1.6; 1-8) and all except one patient had partial or total amnesia of these events (n=33; 97%). Comorbidities were frequent and included insomnia (n=20; 58.8%), restless legs syndrome (RLS) (n=16; 47%), sleep-disordered breathing (SDB) (n=9; 26%), psychiatric disorders (n=13; 38.2%), and overweight or obesity (n=14; 41.1%). Most patients were hypnotic users (n=21; 61.7%) and reported weight-centered anxiety (n=23; 67.6%). Twenty patients (58.8%) were treated with topiramate, 17 of whom had adequate symptomatic responses. CONCLUSION: Our SRED patients showed female preponderance, amnesia during the episodes, association with other sleep disorders, use of hypnotics, weight-centered anxiety, and positive response to topiramate. The presence of anxiety focused on weight in most patients may be an important element in the emergence of this behavior during sleep.

[Refractory status epilepticus in children: characterisation of epilepsies, continuous electroencephalographic monitoring and response to treatment]. / Estado epileptico refractario en ninos: caracterizacion de las epilepsias, monitorizacion electroencefalografica continua y respuesta al tratamiento.

INTRODUCTION: Patients with refractory status epilepticus (RSE) have high morbidity and mortality rates, are hospitalised for longer periods of time, suffer greater neurological damage and progress to symptomatic epilepsy. Continuous electroencephalogram (cEEG) monitoring is a valuable aid in the early detection of RSE, especially in the case of non-convulsive status epilepticus (NCSE). In this study we describe the clinical characteristics, treatment and use of cEEG in paediatric patients with RSE. PATIENTS AND METHODS: A retrospective study was conducted at the Hospital Clinico de la Pontificia Universidad Catolica de Chile between November 2005 and March 2011 in patients aged between 1 month and 15 years diagnosed with RSE and cEEG. Demographic characteristics, baseline and final conditions, and therapy were recorded. RESULTS: A total of 15 patients, 12 of whom were males, with a mean age of 4 years (1.5 months-13 years) were identified. Eight patients had a history of epilepsy. The most frequent aetiologies were progressive symptomatic and acute symptomatic. Convulsive epileptic status (CSE) was present in 11 patients and NCSE in the other four. During the cEEG, six of the 11 patients with CSE later progressed to NCSE. The mean amount of time with RSE was 10.2 days. Of the 15 patients, 13 responded to anticonvulsive drugs and the main secondary complications were respiratory depression and hypotension. Patients with CSE tended to evolve in a more torpid manner than patients with NCSE. On discharge from hospital, 13 patients (86.6%) presented new neurological deficit or difficult-to-manage epilepsy, one still had RSE and one died (6%). CONCLUSIONS: The aggregate neurological morbidity and mortality rates of RSE were high. The use of cEEG monitoring should be considered for use in the management of such cases of status epilepticus.

Impact of hypotension and global hypoperfusion in postoperative delirium: a pilot study in older adults undergoing open colon surgery / Impacto da hipotensão e hipoperfusão global sobre o delírio pós-operatório: um estudo piloto com idosos submetidos à cirurgia aberta do cólon

Abstract Background: Post-operative delirium is a serious complication in patients undergoing major abdominal surgery. It remains unclear whether peri-operative hemodynamic and perfusion variables affect the risk for postoperative delirium. The objective of this pilot study was to evaluate the association between perfusion and hemodynamics peri-operative with the appearance of post-operative delirium. Methods: Prospective cohort study of adults 60 years or older undergoing elective open colon surgery. Multimodal hemodynamic and perfusion variables were monitored, including central venous oxygenation (ScvO2), lactate levels, and non-invasive cerebral oxygenation (rSO2), according to a standard anesthesia protocol. Fisher's exact test or Student's t-test were used to compare patients who developed post-operative delirium with those who did not (p < 0.05). Results: We studied 28 patients, age 73 ± 7 years, 60.7% female. Two patients developed post-operative delirium (7.1%). These two patients had fewer years of education than those without delirium (p = 0.031). None of the peri-operative blood pressure variables were associated with incidence of post-operative delirium. In terms of perfusion parameters, postoperative ScvO2 was lower in the delirium than the non-delirium group, without reaching statistical significance (65 ± 10% vs. 74 ± 5%; p = 0.08), but the delta-ScvO2 (the difference between means post-operative and intra-operative) was associated with post-operative delirium (p = 0.043). Post-operative lactate and rSO2 variables were not associated with delirium. Conclusions: Our pilot study suggests an association between delta ScvO2 and post-operative delirium, and a tendency to lower post-operative ScvO2 in patients who developed delirium. Further studies are necessary to elucidate this association.

Resumo Justificativa: O delírio pós-operatório é uma complicação séria em pacientes submetidos à cirurgia abdominal de grande porte. Ainda não está claro se as variáveis hemodinâmicas e de perfusão no período perioperatório afetam o risco de delírio pós-operatório. O objetivo deste estudo piloto foi avaliar a associação entre perfusão e hemodinâmica no perioperatório com o surgimento de delírio pós-operatório. Métodos: Estudo prospectivo de coorte de adultos com 60 anos ou mais, submetidos à cirurgia eletiva aberta do cólon. As variáveis multimodais de hemodinâmica e perfusão foram monitoradas, inclusive oxigenação venosa central (ScvO2), níveis de lactato e oxigenação cerebral não invasiva (rSO2), de acordo com um protocolo-padrão de anestesia. O teste exato de Fisher ou o teste t de Student foram usados para comparar os pacientes que desenvolveram delírio pós-operatório com aqueles que não desenvolveram p < 0,05. Resultados: Avaliamos 28 pacientes, 73 ± 7 anos, 60,7% do sexo feminino. Dois pacientes desenvolveram delírio pós-operatório (7,1%). Esses dois pacientes tinham menos anos de escolaridade do que aqueles sem delírio pós-operatório (p = 0,031). Nenhuma das variáveis de pressão arterial no perioperatório foi associada à incidência de delírio. Quanto aos parâmetros de perfusão, ScvO2 foi menor no grupo que apresentou delírio pós-operatório do que no grupo que não apresentou delírio, sem atingir significância estatística (65 ± 10% vs. 74 ± 5%; p = 0,08), mas o delta-ScvO2 (a diferença entre as médias no pós-operatório e intraoperatório) foi associado ao delírio (p = 0,043). As variáveis de lactato e rSO2 no pós-operatório não foram associadas ao delírio. Conclusões: Nosso estudo piloto sugere uma associação entre delta-ScvO2 e delírio e uma tendência à diminuição da ScvO2 no pós-operatório de pacientes com delírio. Estudos adicionais são necessários para elucidar essa associação.

[Limbic encephalitis associated to voltage dependent potassium channel antibodies: report of one case]. / Encefalitis límbica por anticuerpos anticanales de potasio dependientes de voltaje: Caso clínico.

Limbic encephalitis (LE) can be associated to cancer, viral infection or be idiopathic. One form is associated to voltage dependent potassium channel (VKC) antibodies. The clinical presentation includes impairment of consciousness, amnesia and temporal lobe seizures; typical abnormalities are also found in brain magnetic resonance. We report a 68 year-old male who had LE associated to VKC antibodies. The patient was treated with steroids with a partial response. At the moment of the report he is asymptomatic and continues with prednisone treatment .

[Treatment of refractory status epilepticus with topiramate. Report of three cases]. / Tratamiento del estado epiléptico refractario con topiramato oral.

Refractory status epilepticus is a catastrophic illness of the central nervous system, with a mortality rate that reaches 50%. We report three patients admitted with refractory status epilepticus: a 24 year-old male that discontinued antiepileptic medications, a 46 year-old male with a focal epilepsy secondary to an encephalitis that discontinued medications due to gastrointestinal problems and a 59 year-old male with an ischemic encephalopathy AH were treated with topiramate, delivered through a nasogastric tube with a good response.

[Split night polysomnography to titrate continuous positive airway pressure therapy in adult patients with obstructive sleep apnea]. / La polisomnografía en noche dividida es eficaz para titular la presión en la ventilación con presión positiva continua ("CPAP") en pacientes con apnea obstructiva del sueño.

BACKGROUND: Nasal continuous positive airway pressure therapy (CPAP) in the treatment of choice for adult obstructive sleep apnea (OSA). The diagnosis is established with polysomnography, but this study is expensive and must be repeated in those patients that require CPAP, to titrate the pressure of the therapy. Split polysomnography during one night to establish the diagnosis and titrate the pressure has been proposed to reduce costs. AIM: To assess if CPAP pressure can be adequately titrated in patients with OSA using a split-night polysomnography. MATERIAL AND METHODS: One hundred fifty six patients with OSA were studied with split night polysomnography. CPAP pressure titration was considered adequate when there were less than five apnea/hypopnea episodes per hour, the registry time was more than 30 min, REM sleep occurred in more than 15% of the time and measurements were made in supine position. RESULTS: An adequate titration was achieved in 80% of patients. The variables associated with an adequate titration were a higher registry time during the titration period, a higher percentage of stage III/IV or REM sleep during such period and the comfort experienced by the patient during the study. On the other hand, patients with an inadequate titration had a longer basal registry period. CONCLUSIONS: An adequate CPAP pressure can be prescribed to 80% of patients subjected to a split-night polysomnography. The basal registry period should not be longer than three hours, to allow an adequate titration lapse.

[Malignant neuroleptic syndrome and polyserositis associated to clozapine use: report of one case]. / Síndrome neuroléptico maligno y poliserositis en paciente usuaria de clozapina: una asociación infrecuente.

Malignant neuroleptic syndrome is a complication of antipsychotic medication use. Clozapine use is also associated with polyserositis and eosinophilia. We report a 17 years old female treated with clozapine, valproic acid, lithium carbonate and lorazepam that consulted in the emergency room for confusion, lethargy, catatonia, rigidity, myalgya and fever. Complete blood count showed eosinophilia. An abdominal CAT scan showed ascites and pleural effusion. Clozapine was discontinued and bromocriptine was started. One week after admission, the patient remained febrile and liver enzymes were elevated. Valproic acid was discontinued. Inflammatory parameters stated to subside and the patient was discharged afebrile days after admission.