Prolapso y necrosis intestinal como complicación de un aborto

Prolapse and intestinal necrosis by uterine perforation, is a rare complication, very serious and avoidable, which occurs, usually as a result of the practice of a traumatic obstetric procedure, most of the time, by an instrumental uterine curettage, of an unsafe abortion, also known, as clandestine; in inadequate conditions, with instruments that are not correct, rather unfriendly and performed by unskilled personnel. The aim of this work is to present a clinical obstetric-surgical gynaecological case of prolapse and intestinal necrosis as a complication of an abortion and to perform a brief updated review of the literature. Materials and methods: A retrospective descriptive study was performed, presenting a clinical case. Informed consent and authorization were requested for publication of the case by the teaching and research department of the Alfredo G Paulson hospital. Case report: This was a 19-year-old female patient who underwent an unsafe abortion, where as a serious complication, she had uterine perforation, which led to evisceration of the small intestine, causing ischemia and necrosis thereof, What generated an emerging situation of high mortality, fortunately the timely intervention of a multidisciplinary team, provided good results. conclusions: Prolapse and intestinal necrosis through the vagina, is a potentially serious complication, which should be avoided, implementing control and safety measures for the patient, consider the risk factors that threaten the development of this adversity, drawing up a complete clinical history, using imaging tests, choosing an optimal location and the necessary equipment for performing surgical procedures, observation and continuous monitoring of the patient, in addition to having highly trained medical personnel, to solve an emergencyEl prolapso y necrosis intestinal por perforación uterina, es una complicación poco frecuente, muy grave y evitable, que se produce, generalmente a consecuencia de la práctica de un procedimiento obstétrico traumático, la mayoría de las veces, por un legrado uterino instrumental, de un aborto inseguro, conocido también, como clandestino; en condiciones inadecuadas, con instrumentos que no son los correctos, en lugar poco propicio y realizado por un personal no especializado. El objetivo de este trabajo es presentar un caso clínico gineco obstétrico- quirúrgico de prolapso y necrosis intestinal como complicación de un aborto y realizar una breve revisión actualizada de la literatura. Materiales y métodos: Se realizó un estudio descriptivo retrospectivo, presentación de caso clínico. Se solicitó el consentimiento informado y autorización, para publicación del caso por parte del departamento de docencia e investigación del hospital Alfredo G Paulson. Reporte de caso: Se trató de un paciente femenino, de 19 años, que se sometió, a la realización de un aborto inseguro, donde como complicación grave, tuvo perforación uterina, lo que produjo evisceración del intestino delgado, ocasionando isquemia y necrosis del mismo, lo que generó una situación emergente de alta mortalidad. Afortunadamente la intervención oportuna de un equipo multidisciplinario brindó buenos resultados. Discusión:  la importancia y relevancia de la presentación de este caso clínico, es dar a conocer las complicaciones que pueden ocurrir, si se realiza un procedimiento obstétrico en condiciones inadecuadas ; recalcar,  la necesidad de participación de un equipo multidisciplinario,  para resolver dicha eventualidad, cuya detección debe ser temprana y en un hospital que cuente con la complejidad resolutiva, tomando en consideración que, un prolapso y necrosis intestinal  a través de la vagina, no solo se puede manifestar por perforación uterina en un legrado, sino también, por otras causas; como perforación en la cúpula vaginal posterior a una histerectomía,  en pacientes que están expuestas a  radiación pélvica , por desgarro en la pared vaginal después de un parto, por hipoestrogenismo, entre otros.  conclusiones: El prolapso y necrosis intestinal a través de la vagina, es una complicación potencialmente grave,  que debe evitarse, implementando medidas de control y seguridad para el  paciente,  considerar los factores de riesgo  que amenazan el desarrollo de esta adversidad, elaborando historia clínica completa, uso de  exámenes imagenológicos,  elegir un lugar optimo y   los equipos necesarios para realización de los  procedimientos quirúrgicos, observación y monitorización continua  del paciente, además de contar con personal médico altamente  capacitado, para resolver una emergencia

Muerte materna y complicaciones de la preeclampsia. Una revisión sistemática

Introduction: Preeclampsia is a multisystem disorder of high maternal and perinatal mortality. Worldwide, it affects 3-10% of all pregnancies, in Western countries, the incidence is around 8%; of these cases, only 10-15% develop HELLP syndrome, which considerably increases maternal and perinatal mortality. Objectives:  to conduct a systematic review with an epidemiological, diagnostic, therapeutic and predictive approach for the early recognition of complications and their management due to the challenge of reducing maternal mortality. Materials and methods: A systematic review was conducted with 35 articles from the last 5 years, clinical cases, review studies, meta-analysis, literature review, guidelines, observational, descriptive and retrospective studies on the topic: complications of preeclampsia and its management. Results: The selected studies, which were obtained through a search process meeting inclusion and exclusion criteria, have shown: The prediction of preeclampsia is useful, using biomarkers. There are racial differences in occurrence, presentation, and outcomes with aspirin use. 16% of maternal mortality can be attributed to hypertensive disorders, gestational hypertension complicates 2% of pregnancies and preeclampsia 8%. Hepatic hematoma should be suspected in patients presenting with severe pre-eclampsia or HELLP syndrome and manifesting epigastralgia, right hypochondrium pain with or without hemodynamic instability. Complications related to the liver, have high morbidity and mortality, their early recognition and timely treatment is crucial HELLP Syndrome occurs in 0.2-0.8% of pregnancies, 70-80% coexists with preeclampsia, but can also occur in isolation, without preeclampsia. Factors derived from the placenta could have a significant influence, so they are used as predictors to avoid the development of preeclampsia and its complications The history of preeclampsia is a marker of future cardiovascular and cerebrovascular risk. Conclusion: The identification of high-risk pregnancies for the development of preeclampsia, through screening with biochemical markers in the first and second trimester is crucial for the implementation with aspirin and calcium supplements in order to prevent preeclampsia, which is a pathology of high morbidity and mortality, because it generates multiple complications if it is not adequately treated with strict prenatal and postnatal control in a specialized center.Introducción: La preeclampsia es un trastorno multisistémico de alta mortalidad materna y perinatal. A nivel mundial, afecta 3-10% de todas las gestaciones, en los países occidentales, la incidencia ronda el 8%; de estos casos, solo un 10-15% desarrollan, síndrome HELLP, que aumenta considerablemente la mortalidad materna y perinatal. Objetivo: realizar una revisión sistemática con un enfoque epidemiológico, diagnóstico, terapéutico y predictivo para el reconocimiento temprano de las complicaciones y su manejo por el desafío que representa reducir la mortalidad materna. Materiales y métodos: Se realizó una revisión sistemática con 35 artículos de los últimos 5 años, casos clínicos, estudios de revisión, metaanálisis, revisión de la literatura, guías, estudios observacionales, descriptivos y retrospectivos sobre el tema: complicaciones de la preeclampsia y su manejo. Resultados: Los estudios seleccionados, que fueron obtenidos mediante, proceso de búsqueda cumpliendo con criterios de inclusión y exclusión, han mostrado: La predicción de la preeclampsia es útil, mediante uso de biomarcadores. Existen diferencias raciales en ocurrencia, presentación y resultados con el uso del ácido acetilsalicílico. El 16% de la mortalidad materna, puede atribuirse a trastornos hipertensivos, la hipertensión gestacional complica el 2% de los embarazos y la preeclampsia el 8%. Se debe sospechar la presencia de un hematoma hepático en pacientes que presentan preeclampsia severa o síndrome HELLP y que manifiestan epigastralgia, dolor en hipocondrio derecho con o sin inestabilidad hemodinámica. Las complicaciones relacionadas con el hígado, tienen alta morbimortalidad, su reconocimiento temprano y tratamiento oportuno es crucial El Síndrome HELLP ocurre en el 0,2-0,8% de los embarazos, el 70-80% coexiste con la preeclampsia, pero también puede ocurrir de forma aislada, sin preeclampsia. Factores derivados de la placenta podrían tener una influencia significativa, por lo que son utilizados como predictores para evitar el desarrollo de la preeclampsia y sus complicaciones La historia de preeclampsia es un marcador de riesgo cardiovascular y cerebrovascular futuro. Conclusión: La identificación de embarazos de alto riesgo para desarrollo de preeclampsia, mediante tamizaje con marcadores bioquímicos en el primer y segundo trimestre es crucial para la implementación con suplementos con aspirina y calcio con el objeto de prevenir la preeclampsia, que es una patología de alta morbimortalidad, porque genera múltiples complicaciones si no es tratada adecuadamente con un estricto control prenatal y postnatal en un centro especializad

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Compilación de Proyectos de Investigacion de 1984-2002

Instituto Politecnico Nacional. UPIICS

Contemporary use of cefazolin for MSSA infective endocarditis: analysis of a national prospective cohort

Objectives: This study aimed to assess the real use of cefazolin for methicillin-susceptible Staphylococcus aureus (MSSA) infective endocarditis (IE) in the Spanish National Endocarditis Database (GAMES) and to compare it with antistaphylococcal penicillin (ASP). Methods: Prospective cohort study with retrospective analysis of a cohort of MSSA IE treated with cloxacillin and/or cefazolin. Outcomes assessed were relapse; intra-hospital, overall, and endocarditis-related mortality; and adverse events. Risk of renal toxicity with each treatment was evaluated separately. Results: We included 631 IE episodes caused by MSSA treated with cloxacillin and/or cefazolin. Antibiotic treatment was cloxacillin, cefazolin, or both in 537 (85%), 57 (9%), and 37 (6%) episodes, respectively. Patients treated with cefazolin had significantly higher rates of comorbidities (median Charlson Index 7, P <0.01) and previous renal failure (57.9%, P <0.01). Patients treated with cloxacillin presented higher rates of septic shock (25%, P = 0.033) and new-onset or worsening renal failure (47.3%, P = 0.024) with significantly higher rates of in-hospital mortality (38.5%, P = 0.017). One-year IE-related mortality and rate of relapses were similar between treatment groups. None of the treatments were identified as risk or protective factors. Conclusion: Our results suggest that cefazolin is a valuable option for the treatment of MSSA IE, without differences in 1-year mortality or relapses compared with cloxacillin, and might be considered equally effective

Effects of pre-operative isolation on postoperative pulmonary complications after elective surgery: an international prospective cohort study an international prospective cohort study

We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care. We aimed to determine the impact of pre-operative isolation on postoperative pulmonary complications after elective surgery during the global SARS-CoV-2 pandemic. We performed an international prospective cohort study including patients undergoing elective surgery in October 2020. Isolation was defined as the period before surgery during which patients did not leave their house or receive visitors from outside their household. The primary outcome was postoperative pulmonary complications, adjusted in multivariable models for measured confounders. Pre-defined sub-group analyses were performed for the primary outcome. A total of 96,454 patients from 114 countries were included and overall, 26,948 (27.9%) patients isolated before surgery. Postoperative pulmonary complications were recorded in 1947 (2.0%) patients of which 227 (11.7%) were associated with SARS-CoV-2 infection. Patients who isolated pre-operatively were older, had more respiratory comorbidities and were more commonly from areas of high SARS-CoV-2 incidence and high-income countries. Although the overall rates of postoperative pulmonary complications were similar in those that isolated and those that did not (2.1% vs 2.0%, respectively), isolation was associated with higher rates of postoperative pulmonary complications after adjustment (adjusted OR 1.20, 95%CI 1.05–1.36, p = 0.005). Sensitivity analyses revealed no further differences when patients were categorised by: pre-operative testing; use of COVID-19-free pathways; or community SARS-CoV-2 prevalence. The rate of postoperative pulmonary complications increased with periods of isolation longer than 3 days, with an OR (95%CI) at 4–7 days or ≥ 8 days of 1.25 (1.04–1.48), p = 0.015 and 1.31 (1.11–1.55), p = 0.001, respectively. Isolation before elective surgery might be associated with a small but clinically important increased risk of postoperative pulmonary complications. Longer periods of isolation showed no reduction in the risk of postoperative pulmonary complications. These findings have significant implications for global provision of elective surgical care

Diminishing benefits of urban living for children and adolescents’ growth and development

Optimal growth and development in childhood and adolescence is crucial for lifelong health and well-being1–6. Here we used data from 2,325 population-based studies, with measurements of height and weight from 71 million participants, to report the height and body-mass index (BMI) of children and adolescents aged 5–19 years on the basis of rural and urban place of residence in 200 countries and territories from 1990 to 2020. In 1990, children and adolescents residing in cities were taller than their rural counterparts in all but a few high-income countries. By 2020, the urban height advantage became smaller in most countries, and in many high-income western countries it reversed into a small urban-based disadvantage. The exception was for boys in most countries in sub-Saharan Africa and in some countries in Oceania, south Asia and the region of central Asia, Middle East and north Africa. In these countries, successive cohorts of boys from rural places either did not gain height or possibly became shorter, and hence fell further behind their urban peers. The difference between the age-standardized mean BMI of children in urban and rural areas was <1.1 kg m–2 in the vast majority of countries. Within this small range, BMI increased slightly more in cities than in rural areas, except in south Asia, sub-Saharan Africa and some countries in central and eastern Europe. Our results show that in much of the world, the growth and developmental advantages of living in cities have diminished in the twenty-first century, whereas in much of sub-Saharan Africa they have amplified

Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults

Background: Underweight and obesity are associated with adverse health outcomes throughout the life course. We estimated the individual and combined prevalence of underweight or thinness and obesity, and their changes, from 1990 to 2022 for adults and school-aged children and adolescents in 200 countries and territories. Methods: We used data from 3663 population-based studies with 222 million participants that measured height and weight in representative samples of the general population. We used a Bayesian hierarchical model to estimate trends in the prevalence of different BMI categories, separately for adults (age ≥20 years) and school-aged children and adolescents (age 5-19 years), from 1990 to 2022 for 200 countries and territories. For adults, we report the individual and combined prevalence of underweight (BMI &lt;18·5 kg/m2) and obesity (BMI ≥30 kg/m2). For school-aged children and adolescents, we report thinness (BMI &lt;2 SD below the median of the WHO growth reference) and obesity (BMI &gt;2 SD above the median). Findings: From 1990 to 2022, the combined prevalence of underweight and obesity in adults decreased in 11 countries (6%) for women and 17 (9%) for men with a posterior probability of at least 0·80 that the observed changes were true decreases. The combined prevalence increased in 162 countries (81%) for women and 140 countries (70%) for men with a posterior probability of at least 0·80. In 2022, the combined prevalence of underweight and obesity was highest in island nations in the Caribbean and Polynesia and Micronesia, and countries in the Middle East and north Africa. Obesity prevalence was higher than underweight with posterior probability of at least 0·80 in 177 countries (89%) for women and 145 (73%) for men in 2022, whereas the converse was true in 16 countries (8%) for women, and 39 (20%) for men. From 1990 to 2022, the combined prevalence of thinness and obesity decreased among girls in five countries (3%) and among boys in 15 countries (8%) with a posterior probability of at least 0·80, and increased among girls in 140 countries (70%) and boys in 137 countries (69%) with a posterior probability of at least 0·80. The countries with highest combined prevalence of thinness and obesity in school-aged children and adolescents in 2022 were in Polynesia and Micronesia and the Caribbean for both sexes, and Chile and Qatar for boys. Combined prevalence was also high in some countries in south Asia, such as India and Pakistan, where thinness remained prevalent despite having declined. In 2022, obesity in school-aged children and adolescents was more prevalent than thinness with a posterior probability of at least 0·80 among girls in 133 countries (67%) and boys in 125 countries (63%), whereas the converse was true in 35 countries (18%) and 42 countries (21%), respectively. In almost all countries for both adults and school-aged children and adolescents, the increases in double burden were driven by increases in obesity, and decreases in double burden by declining underweight or thinness. Interpretation: The combined burden of underweight and obesity has increased in most countries, driven by an increase in obesity, while underweight and thinness remain prevalent in south Asia and parts of Africa. A healthy nutrition transition that enhances access to nutritious foods is needed to address the remaining burden of underweight while curbing and reversing the increase in obesity. Funding: UK Medical Research Council, UK Research and Innovation (Research England), UK Research and Innovation (Innovate UK), and European Union