Attenuation of the physiological response to infection on adults over 65 years old admitted to the emergency room (ER).

It has been considered that the elderly have clinical manifestations different from the ones observed in middle-age adults during an injury event. This hypothesis has not been extensively explored in sepsis and bacterial infections. Secondary analysis of two prospective studies including 2611 patients over 18 years of age admitted to the emergency room with confirmed or probable bacterial infections and sepsis. The outcome measures were heart rate, respiratory rate, systolic blood pressure, temperature, Glasgow Coma Scale, creatinine, PaO2/FiO2 and platelets daily during the first week. Compared to survivors younger than 65, the deceased under 65 had an average heart rate of 12.5 beats per minute per day higher (95% CI 9.32; 15.61), while patients over 65 who died barely had an average 5.7 beats per minute per day higher than the same reference group (95% CI 3.45; 8.06). The systolic blood pressure had a significant decreased in those who died younger than 65, compared to survivors with the same age, in both cohorts (-5.2 mmHg, 95% CI -8.17; -2.23 and -8.5 mmHg, 95% CI -13.48; -3.54, respectively), while those older than 65 who died had a nonsignificant increase (+1.6 mmHg, 95% CI -1.33; 4.62 and +0.1, 95% CI -6.48; 6.72, respectively) compared to the same reference group. The behavior of most clinical and laboratory variables suggests a less pronounced response of subjects above 65 years of age who died 28 days after being diagnosed with sepsis.

Clinical course of sepsis, severe sepsis, and septic shock in a cohort of infected patients from ten Colombian hospitals.

BACKGROUND: Sepsis has several clinical stages, and mortality rates are different for each stage. Our goal was to establish the evolution and the determinants of the progression of clinical stages, from infection to septic shock, over the first week, as well as their relationship to 7-day and 28-day mortality. METHODS: This is a secondary analysis of a multicenter cohort of inpatients hospitalized in general wards or intensive care units (ICUs). The general estimating equations (GEE) model was used to estimate the risk of progression and the determinants of stages of infection over the first week. Cox regression with time-dependent covariates and fixed covariates was used to determine the factors related with 7-day and 28-day mortality, respectively. RESULTS: In 2681 patients we show that progression to severe sepsis and septic shock increases with intraabdominal and respiratory sources of infection [OR = 1,32; 95%IC = 1,20-1,46 and OR = 1.21, 95%CI = 1,11-1,33 respectively], as well as according to Acute Physiology and Chronic Health Evaluation II (APACHE II) [OR = 1,03; 95%CI = 1,02-1,03] and Sequential Organ Failure Assessment (SOFA) [OR = 1,16; 95%CI = 1,14-1,17] scores. The variables related with first-week mortality were progression to severe sepsis [HR = 2,13; 95%CI = 1,13-4,03] and septic shock [HR = 3,00; 95%CI = 1,50-5.98], respiratory source of infection [HR = 1,76; 95%IC = 1,12-2,77], APACHE II [HR = 1,07; 95% CI = 1,04-1,10] and SOFA [HR = 1,09; 95%IC = 1,04-1,15] scores. CONCLUSIONS: Intraabdominal and respiratory sources of infection, independently of SOFA and APACHE II scores, increase the risk of clinical progression to more severe stages of sepsis; and these factors, together with progression of the infection itself, are the main determinants of 7-day and 28-day mortality.

[Evidence-based medicine: an epistemological approach]. / Medicina basada en la evidencia: una aproximación epistemológica.

Evidence-based medicine gathers physician's experience and the best scientific evidence to make medical decisions. This proposal has been widely promulgated by medical opinion leaders. Despite a large literature supporting this practice, a formal discussion has not been established regarding its epistemological consequences in daily medical work. The main proposal of evidence-based medicine consists of choosing the best medical decision according to the best available results from scientific studies. Herein, the goal was to highlight inappropriate application of the scientific method used by physics to clinical science. The inaccuracy resides in describing health and disease in strictly numeric equivalents that can be homogenized on a continuous scale. Finally, the authors consider each diseased human being as a complex system, unique and particular, and that this being is defined by an historical background as well as current actual context. Therefore, evidence-based medicine possesses certain limitations that must be recognized in order to to provide better health care to patients.

TIMP1 and MMP9 are predictors of mortality in septic patients in the emergency department and intensive care unit unlike MMP9/TIMP1 ratio: Multivariate model.

INTRODUCTION: Matrix metalloproteinases and tissue inhibitors of metalloproteinases could be promising biomarkers for establishing prognosis during the development of sepsis. It is necessary to clarify the relationship between matrix metalloproteinases and their tissue inhibitors. We conducted a cohort study with 563 septic patients, in order to elucidate the biological role and significance of these inflammatory biomarkers and their relationship to the severity and mortality of patients with sepsis. MATERIALS AND METHODS: A multicentric prospective cohort was performed. The sample was composed of patients who had sepsis as defined by the International Conference 2001. Serum procalcitonin, creatinine, urea nitrogen, C-Reactive protein, TIMP1, TIMP2, MMP2 and MMP9 were quantified; each patient was followed until death or up to 30 days. A descriptive analysis was performed by calculating the mean and the 95% confidence interval for continuous variables and proportions for categorical variables. A multivariate logistic regression model was constructed by the method of intentional selection of covariates with mortality at 30 days as dependent variable and all the other variables as predictors. RESULTS: Of the 563 patients, 68 patients (12.1%) died within the first 30 days of hospitalization in the ICU. The mean values for TIMP1, TIMP2 and MMP2 were lower in survivors, MMP9 was higher in survivors. Multivariate logistic regression showed that age, SOFA and Charlson scores, along with TIMP1 concentration, were statistically associated with mortality at 30 days of septic patients; serum MMP9 was not statistically associated with mortality of patients, but was a confounder of the TIMP1 variable. CONCLUSION: It could be argued that plasma levels of TIMP1 should be considered as a promising prognostic biomarker in the setting of sepsis. Additionally, this study, like other studies with large numbers of septic patients does not support the predictive value of TIMP1 / MMP9.

Evaluation of Differences in Metabolic and Immunologic Markers and Cardiovascular Risk in HIV-1 Patients / Evaluación de la relación entre marcadores metabólicos, inmunológicos y de riesgo cardiovascular en pacientes con VIH-1 / Avaliação da relação entre marcadores metabólicos, imunológicos e de risco cardiovascular em pacientes com HIV-1

Introduction:hiv infection induces an exacerbated chronic inflammatory response, which triggers met-abolic disorders and cardiovascular diseases; however, there are individuals, known as hiv controllers, who do not have typical progression markers. As cardiovascular risk tests are not accurate on hiv-1 infected patients, the study of metabolic and inflammatory parameters in individuals with different patterns of progression could contribute to the definition of predictors of cardiovascular disease in this population. The aim of this study was to compare hiv controllers and hiv progressors (with and without antiretroviral therapy) as well as with healthy controls in order to explore differences and correlations in metabolic and inflammatory biomarkers associated with cardiovascular risk. Materials and methods:This was a cross-sectional analytical study which included 63 individuals infected with hiv-1 classified as hiv controllers or progressors (with or without antiretroviral therapy), and a healthy control group. The following parameters were determined: carotid intima-media thickness (cimt); cardiovascular risk scores; lipid profile, fasting glucose, high-sensitivity crp, D-dimer, sCD14, sCD163, il-6, and il-18. Data were compared with Anova or Kruskal­Wallis, and correlations were evaluated by the Spearman coef-ficient. Results: While there were no significant differences in Framingham, dad or cimt values, hiv con-trollers exhibited lower triglycerides levels when compared with hiv progressors. No differences were observed in markers, such as high-sensitivity crp, il-6, il-18, and sCD163, among the groups. The median hdl value was higher in hiv progressors on antiretroviral therapy, and cimt in hiv controllers was nega-tively correlated with sCD14. Conclusion:hiv controllers have a different cardiovascular profile than hivprogressors according to their values in metabolic and immunological biomarkers

Introducción: la infección por vih-1 induce una respuesta inflamatoria crónica exacerbada que desencadena alteraciones metabólicas y cardiovasculares; sin embargo, algunos individuos "controladores" no presentan los marcadores de progresión típicos. Dado que las pruebas que evaluan el riesgo cardiovascular carecen de precisión en pacientes con vih-1, el estudio de parámetros inflamatorios en individuos con diferente progresión podría aportar a la definición de predictores de enfermedad cardiovascular en esta población. El objetivo es explorar diferencias y correlaciones en biomarcadores metabólicos e inflamatorios asociados con riesgo cardiovascular, comparando individuos controladores y progresores con y sin terapia antiviral. Materiales y métodos: estudio analítico transversal con 63 individuos infectados por vih-1, clasificados en controladores y progresores (con terapia antiviral y sin esta), y controles sanos. Se midió el grosor de la íntima media carotidea (cimt), puntajes de riesgo cardiovascular y cuantificación de perfil lipídico, glucemia en ayunas, pcr ultrasensible, dímero D, sCD14, sCD163, il-6 e il-18. Se realizó comparación por Anova o Kruskal-Wallis y correlación por coeficiente de Spearman. Resultados: no hubo diferencias significativas en índices de Framingham, dad o cimt, pero los individuos controladores presen-taron menores valores de triglicéridos, comparados con los progresores. No se observaron diferencias en pcr ultrasensible, il-6, il-18, y sCD163, entre los grupos estudiados. La mediana del hdl fue mayor en los progresores con terapia antiviral y el cimt en los controladores se correlacionó negativamente con sCD14. Conclusión: los individuos controladores presentan un perfil cardiovascular diferente a los individuos progresores, de acuerdo con los biomarcadores metabólicos e inmunológicos evaluados

Introdução: a infecção pelo hiv-1 induz resposta inflamatória crônica exacerbada, que desencadeia alte-rações metabólicas e doenças cardiovasculares; no entanto, existem indivíduos, chamados controlado-res, que não possuem os marcadores de progressão típicos. Tendo em vista que os testes que avaliam o risco cardiovascular carecem de precisão em pacientes com hiv-1, o estudo de parâmetros metabólicos e inflamatórios em indivíduos com diferentes padrões de progressão pode contribuir para a definição de preditores de doença cardiovascular nessa população. O objetivo é explorar diferenças e correlações em biomarcadores metabólicos e inflamatórios associados ao risco cardiovascular, comparando indiví-duos controladores e progressores submetidos ou não à terapia antiviral. Materiais e métodos: Estudo analítico transversal que incluiu 63 indivíduos infectados pelo hiv-1, classificados como controladores e progressores (com e sem terapia antiviral), além de grupos controle saudáveis. Realizou-se a medição da espessura da íntima média da carótida (cimt), pontuações de risco cardiovascular; e quantificação do perfil lipídico, glicemia em jejum, pcr ultrassensível, dímero d, sCD14, sCD163, il-6 e il-18. A comparação foi feita por Anova ou teste de Kruskal-Wallis e a correlação pelo coeficiente de Spearman. Resultados.Embora não tenha havido diferenças significativas nos índices de Framingham, dad ou cimt, os indivíduos controladores apresentaram valores de triglicerídeos mais baixos, em comparação com os progressores. Não foram observadas diferenças em marcadores como pcr ultrassensível, il-6, il-18 e sCD163, entre os grupos estudados. O hdl médio foi maior em indivíduos progressores em terapia antiviral, e o cimtem indivíduos controladores foi negativamente correlacionado com o sCD14. Conclusão: os indivíduos controladores apresentam um perfil cardiovascular diferente dos indivíduos progressores, de acordo com os biomarcadores metabólicos e imunológicos avaliados

The potential impact of admission insulin levels on patient outcome in the intensive care unit.

BACKGROUND: Blood levels of insulin in patients with critical illness at admission to the intensive care unit (ICU) and its association with in-hospital mortality are not fully defined. Our objective was to determine this association in a cohort of patients with critical illness who attended in a mixed ICU. METHODS: Prospective cohort was nested in a randomized clinical trial conducted in a 12-bed mixed ICU in a tertiary hospital in Medellin (Colombia). One hundred sixty consecutively admitted patients, 15 years or older, were analyzed. Blood insulin and blood glucose levels were measured at admission to the ICU, as well as Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores. A logistic regression model was created with in-hospital mortality as the outcome. RESULTS: In-hospital mortality was 57 (35.6%) of 160. Survivors had lower Acute Physiology and Chronic Health Evaluation II (median, 13 vs. 17) and lower insulin levels (median, 6.5 vs. 9 µU/mL) than did nonsurvivors. More women than men died (27 [48.2%] of 56 vs. 30 [28.8%] of 104), and 39% of the deaths (n = 22) occurred in patients with sepsis. Patients with insulin levels greater than 15 µU/mL had a higher mortality rate compared with patients with values of 5 µU/mL to 15 µU/mL (odds ratio, 3.57; 95% confidence interval, 1.18-10.8). CONCLUSION: At admission to the ICU, patients with critical illness showed hyperglycemia and relatively decreased insulin levels. High levels of insulin were independently associated with in-hospital mortality in this study population. LEVEL OF EVIDENCE: Prognostic study, level II.

Características inmunológicas claves en la fisiopatología de la sepsis / Key immunological characteristics in the pathophysiology of sepsis

A pesar del conocimiento actual de la fisiopatología de la sepsis, esta enfermedad sigue siendo una de las principales causas de muerte a nivel mundial. Alrededor del 40% de los pacientes admitidos a la unidades de cuidado intensivo desarrollan esta enfermedad, y del 20 al 50% de los pacientes sépticos mueren por complicaciones asociadas. La investigación actual busca comprender mejor los mecanismos celulares y moleculares de esta enfermedad, y extrapolar estos hallazgos en aplicaciones clínicas que mejoren el pronóstico de estos pacientes. Actualmente, se cree que un hospedero susceptible desarrolla una respuesta inflamatoria sistémica (SIRS) en respuesta a un patógeno; sin embargo, algunos individuos progresan hacia un estado de inmunoparálisis denominado síndrome de respuesta antiinflamatoria compensatoria (CARS), asociado a infecciones secundarias. El objetivo de esta revisión es resaltar las principales características de la fisiopatología de la sepsis, destacando las implicaciones clínicas de la investigación básica, desde una perspectiva inmunológica.

Despite our current understanding of sepsis pathophysiology, this disease is still a leading cause of death worldwide. Forty percent of patients admitted to intensive care units develop this illness, and 20 to 50% of septic patients die due to its associated complications. Current research aims to improve our understanding of the cellular and molecular mechanisms of this disease and translate these findings into clinical applications that provide a better prognosis for these patients. Currently, it is believed that a susceptible host develops a systemic inflammatory response syndrome (SIRS) after an encounter with a pathogen; however, some individuals progress to a state of immunoparalysis known as compensatory anti-inflammatory response syndrome (CARS), which has been associated with secondary infections. The purpose of the present review is to highlight the main features of sepsis pathophysiology and to highlight the clinical implications of basic research from an immunological perspective.

Increased frequency of NK and gamma delta 1 T cells in a cohort of patients with sepsis * / Incremento en la frecuencia de células NK y células T gamma delta 1 en una cohorte de pacientes con sepsis

Introduction: The mechanisms involved in the immunopathogenesis of sepsis are not well established. The clinical and therapeutic relevance of several soluble mediators has been described and the contribution of cellular components with immunoregulatory roles has begun to be elucidated. Objective: To describe changes in the frequency and production of IFN- γ and IL-10 occurring in NK cells and γδ T lymphocytes in a cohort of patients with different manifestations of septic syndrome. Materials and methods: This was a prospective cohort study. Patients with sepsis (n=26), and severe sepsis (n=83) from adult emergency rooms and intensive care units, as well as healthy volunteers (n=8), were included. For all participants, the frequency and phenotype of NK cells and γδ T lymphocytes and the percentage of IFN- γ and IL-10 positive NK and γδ T cells were evaluated by flow cytometry. The NK cells were phenotyped based on the expression of CD56 and CD16 and the γδ T cells on the expression of d 1 and d 2 chains. Results: Patients with sepsis and severe sepsis exhibited an increase in the frequency of NK cells with changes in the proportion of the CD56 bright /CD16¯, CD56 bright /CD16 dim and CD56 dim CD16¯ subpopulations; these cells showed a proinflammatory cytokine profile. A decrease in the V d 2 subset of γδ T lymphocyte s was also observed. Conclusions: Our results indicate a role for NK and γδ T cells during sepsis, however, their exact contribution in the pathogenesis of sepsis syndrome requires further studies.

Introducción: Los mecanimos involucrados en la inmunopatogénesis de las sepsis no han sido claramente establecidos. La importancia clínica y terapéutica de diferentes mediadores solubles ha sido descrita y la contribución de componentes celulares con propiedades inmunorreguladoras ha empezado a dilucidarse. Objetivo: Describir los cambios en la frecuencia y en la producción de IFN- γ e IL-10 que se observa en células NK y linfocitos T γδ en una cohorte de pacientes con diferentes manifestaciones del síndrome séptico. Materiales y métodos: Estudio de cohorte prospectiva, donde pacientes con sepsis (n = 26) y sepsis grave (n = 83) provenientes de las salas de emergencias y unidades de cuidado intensivo, y controles sanos (n = 8) fueron incluidos. Tanto la frecuencia y fenotipo de las células NK y T γδ como el porcentaje de células IFN- γ+ e IL-10+ fueron evaluados mediante citometría de flujo. Las células NK fueron fenotipificadas con base en la expresión de las moléculas CD56 y CD 16 y los T γδ con base en la expresión de las cadenas δ1 y δ2. Resultados: En los pacientes con sepsis y sepsis grave se observó un incremento en la frecuencia de las células NK con cambios en las proporciones de las subpoblaciones CD56 bright /CD 16 ¯, CD56 bright /CD16 dim y CD56 dim CD16¯; en estas células se observó un perfil de citocinas proinflamarias. Se observó una reducción en el porcentaje de células Vδ2. Conclusiones: Los resultados sugieren un papel de las células NK y linfocitos T γδ durante la sepsis; sin embargo, su contribución en la patogénesis de este síndrome requiere estudios adicionales.

Fetal-maternal HLA-A and -B discordance is associated with placental RNase expression and anti-HIV-1 activity.

The incidence of maternal-to-fetal human immunodeficiency virus type 1 (HIV-1) transmission is 25-30% in absence of antiretroviral therapy, and is inversely associated with Human leukocyte antigens (HLA) class-I discordance. Based on our earlier report that mixed lymphocyte reactions (MLR) induce a ribonuclease (RNase) that inhibits HIV-1 replication, we proposed that maternal-fetal alloantigen stimulation activates factors that protect the fetus against vertically-transmitted infections. We investigate here whether the degree of mother-infant HLA discordance associates with the ability to produce anti-HIV-1 alloantigen-stimulated factor (ASF), and affects placental RNases. We also determine whether such HLA association is influenced by the mother's HIV-1 status. Paired maternal and cord blood leukocytes were tested for the induction of ASF by MLR, and typed for HLA-A and -B. The placentas were tested for mRNA expression of three RNases. Neonate anti-mother, but not mother anti-neonate MLR generated supernatants with anti-HIV-1 activity, that was associated with HLA class I discordance. This HLA association was not seen in the HIV-infected cohort. HLA class I discordance was also associated with expression of placental RNase 1. Our findings are consistent with the hypothesis that HLA class I discordance induces expression of RNases in the placenta that contribute to innate host resistance to HIV-1 and other viral infections.

Ronda Clínica y Epidemiológica Desenlaces sustitutos en investigación médica / Clinical and Epidemiological Round: Substitute outcomes in medical research

El éxito de la investigación parte desde su anatomía básica, y esta incluye una adecuada pregunta con un desenlace que represente el fenómeno que se quiere evaluar en la población de interés. La selección de un desenlace relevante está íntimamente ligada al diseño del estudio, es la base para calcular el tamaño de la muestra y determina la variable para la cual se deben maximizar los esfuerzos de evitar la pérdida de datos durante la conducción de la investigación (1). Es usual en los ensayos clínicos (EC) seleccionar varios desenlaces, algunos de los cuales pueden considerarse secundarios o exploratorios, con el fin de no desaprovechar la oportunidad excepcional para medirlos y encontrar resultados importantes que puedan guiar futuras investigaciones.

Efectos de la infección y la enfermedad por citomegalovirus en receptores de trasplante renal / Effects of cytomegalovirus infection and disease in renal transplant recipients

La infección por citomegalovirus (CMV) es una de las más importantes causas de morbilidad en pacientes con trasplante renal. Objetivo: revisar las manifestaciones de la enfermedad aguda por este virus y sus efectos directos e indirectos sobre injerto y receptor en pacientes con trasplante renal. Material y métodos: se hizo una revisión sistemática de la literatura en la que se encontraron 40 publicaciones completas relacionadas con el tema. Conclusiones: además de la enfermedad aguda que se manifiesta con síndrome de mononucleosis o daño tisular, el CMV produce efectos indirectos sobre el injerto y el sistema vascular del receptor que parecen aumentar el riesgo de enfermedad cardiovascular y acortan la supervivencia del trasplante y el receptor. Las estrategias utilizadas en los últimos años han logrado disminuir el efecto nocivo de la enfermedad aguda por CMV, pero se desconoce su impacto sobre los efectos indirectos de la infección latente.(Acta Med Colomb 2012; 37: 131-137).

Citomegalovirus infection (CMV) is one of the major causes of morbidity in renal transplant patients. Objective: to review the manifestations of the acute viral illness and its direct and indirect effects on graft and recipient in transplant patients. Material and methods: we conducted a systematic review of the literature in which we found 40 complete publications related to the topic. Conclusions: in addition to the acute illness that manifests with mononucleosis syndrome or tissue damage, CMV has indirect effects on the graft and the receptor’s vascular system that appear to increase the risk of cardiovascular disease and shorten both graft and receiver survival. The strategies used in recent years have reduced the deleterious effect of acute CMV disease, but its impact on the indirect effects of the latent infection is unknown. (Acta Med Colomb 2012; 37: 131-137).

Medicina basada en la evidencia: una aproximación epistemológica / Evidence-based medicine: an epistemological approach

La propuesta de la medicina basada en la evidencia conjuga la experiencia del clínico con el análisis juicioso de los resultados de investigaciones clínicas de excelente calidad metodológica para la toma de decisiones médicas. Esta propuesta ha sido ampliamente divulgada por los líderes de opinión médica. Sin embargo, contrario al gran número de publicaciones que promueven esta práctica, no se evidencia en la literatura médica un espacio de discusión acerca de las implicaciones epistemológicas que ha tenido la implementación de esta práctica en el acontecer cotidiano del acto médico. La propuesta novedosa de la medicina basada en la evidencia consiste en priorizar las decisiones médicas de acuerdo con la disponibilidad del conocimiento como resultado de los estudios científicos. Presentamos en este ensayo algunas reflexiones sobre la inconveniencia de la importación “ciega” del método científico de las ciencias exactas a la ciencia clínica, que es la principal fuente de evidencia para el médico, además de lo inadecuado de definir los estados de salud y enfermedad como continuos numéricos homogenizados por una escala de medición. Finalmente, proponemos que el reconocimiento del ser humano enfermo como sistema complejo, único e irrepetible, definido a su vez por su devenir y su contexto, nos obliga a reconocer que la propuesta de la medicina basada en la evidencia no es universal ni absoluta. Sólo en la medida en que dichas particularidades se tengan en cuenta, estaremos en capacidad de brindar una atención más idónea a nuestros pacientes.

to make medical decisions. This proposal has been widely promulgated by medical opinion leaders. Despite a large literature supporting this practice, a formal discussion has not been established regarding its epistemological consequences in daily medical work. The main proposal of evidence-based medicine consists of choosing the best medical decision according to the best available results from scientific studies. Herein, the goal was to highlight inappropriate application of the scientific method used by physics to clinical science. The inaccuracy resides in describing health and disease in strictly numeric equivalents that can be homogenized on a continuous scale. Finally, the authors consider each diseased human being as a complex system, unique and particular, and that this being is defined by an historical background as well as current actual context. Therefore, evidence-based medicine possesses certain limitations that must be recognized in order to to provide better health care to patients.

Guía de práctica clínica para el diagnóstico y tratamiento de la sepsis en el servicio de urgencias de adultos / Clinical guidelines for diagnosis and treatment of sepsis in adults' emergency room

La respuesta que desarrolla un hospedero frente a una infección puede llevar a un espectro de manifestaciones que incluye desde la sepsis hasta laL disfunción orgánica múltiple y la muerte. Dada la complejidad del fenómeno fisiopatológico, las manifestaciones clínicas son muy variadas y, en ocasiones, tan sutiles que para detectarlas se requiere un alto índice de sospecha por parte del médico tratante. El juicio clínico se debe complementar con los exámenes de laboratorio pertinentes para lograr el diagnóstico oportuno, lo que permite iniciar las medidas de tratamiento adecuadas: la optimización hemodinámica temprana, la terapia antimicrobiana y las medidas de soporte.

Origen no infeccioso del sida: ¿mito o realidad? / The non-infectious aetiology of AIDS: Myth or reality?

El síndrome de inmunodeficiencia adquirida, o sida,fue reconocido al principio de la década de los ochenta y hasta el momento ha causado más de 20 millones de muertes, por lo que se ha convertido en la peor pandemia de todos los siglos. Inicialmente se postularon varias hipótesis etiológicas pero en 1983, con el descubrimiento del virus de inmunodeficiencia humana (VIH), se creyó que la polémica llegaría a su fin y que este virus sería reconocido mundialmentecomo el agente etiológico del sida. Sin embargo hoy, después de muchos años de investigación, aún se promueve el origen no infeccioso del sida, negando la existencia del VIH-1 y postulando como agente causal una variedad de factores tóxico-nutricionales que pueden actuar solos o en conjunto para ®estresar¼ el sistema inmune y producir la inmunodeficiencia grave, característica del sida. La existencia del VIH-1 y su asociación causal con el sida han sido corroboradas a lo largo de estos veinte años por diferentes grupos de investigación independientes. Además de satisfacer los postulados de Koch y los postulados clásicos de causalidad, los más de veinte millones de muertes, 42 millones de infectados,14 millones de huérfanos y 15 mil nuevos infectados diariamente hablan por sí solos, demostrando una vez más el origen infectocontagioso del sida. Este artículo se propone evaluar, con la información científica disponible, cada uno de los puntos que soportan la hipótesis no infecciosa del sida y mostrar cómo, el conocimiento actual del VIH-1 y de la enfermedad permite satisfacer los postulados clásicos de causalidad.

Utilidad y aplicación de los criterios para el Síndrome de Respuesta Inflamatoria Sistémica (SIRS) en pacientes con infección severa admitidos en urgencias / Sistemic inflammatory response syndrome criteria usefulness and aplication in emergency patients with severe infección

Objetivo: evaluación de la utilidad de los criterios para SIRS comparados con el diagnóstico final de infección en pacientes admitidos en urgencias de dos hospitales universitarios. Diseño: estudio de cohorte longitudinal. Sitio: Hospital Universitario San Vicente de Paúl y Hospital General de Medellín, Medellín, Colombia. Pacientes: 734 pacientes con sospecha de infección como diagnóstico principal para la admisión en urgencias. Mediciones: la sensibilidad, la especificidad, los valores predictivos y las razones de probabilidad (RP) de los criterios de SIRS en la admisión, fueron determinados usando como estándares de oro el diagnóstico en el momento del alta basado en la historia clínica y la evolución, y la confirmación microbiológica de la infección. Resultados: se encontraron criterios para SIRS en 503 pacientes (68.5 por ciento), el diagnóstico de infección fue encontrado en 657 (89.4 por ciento) y 276 (37 por ciento) tenían confirmación microbiológica. Los criterios para SIRS mostraron una sensibilidad de 69 por ciento, una especificidad de 35 por ciento, un valor predictivo positivo (VPP) de 90 por ciento, un valor predictivo negativo (VPN) de 12 por ciento y un RP positivo de 1.06. No hubo diferencias entre ambos estándares de oro. Conclusiones: el hallazgo de dos o más criterios para SIRS fue de poca utilidad para el diagnóstico de infección. Es necesario evaluar nuevos criterios para obtener una definición simple, precisa y operativa del fenómeno de la sepsis