Complicaciones asociadas al mielomeningocele: reporte de un caso

El mielomeningocele es un defecto congénito, o rara vez adquirido, en el que existe herniación de las meninges y la médula espinal a través de un defecto óseo de la columna vertebral. La mayoría de estos defectos se producen en la región lumbosacra. Las características clínicas incluyen paraplejía, pérdida de la sensibilidad en la parte inferior del cuerpo, e incontinencia especialmente urinaria. Esta condición se asocia con la malformación de Arnold‐Chiari e hidrocefalia. A continuación, presentamos el caso de un paciente de 9 años de edad, quien manifestó varias de las complicaciones asociadas al mielomeningocele. Se discuten los métodos para la prevención primaria de esta enfermedad, así como también los avances en la cirugía para la corrección intrauterina de este defecto

Insuficiencia respiratoria aguda, hipoxemia refractaria y ventilación mecánica. Una revisión sistemática.

Acute respiratory distress syndrome (ARDS) or also known as respiratory distress, is an interruption of homeostasis at the alveolar level that can promote: hypoventilation, deterioration of diffusion, shunt and mismatch between ventilation - perfusion or a combination of both. Refractory hypoxemia is defined as a partial blood oxygen pressure measured by blood gas (PaO2) 60 mmHg or a divided oxygen blood pressure ratio for the oxygen inspiratory fraction, PaO2/FiO2 or (PAFI) 100. Mechanical ventilation is a necessary life support measure in the treatment of severe acute respiratory failure. General Objective: To determine the ventilatory management of patients with acute respiratory failure and refractory hypoxemia. Specific objectives: To evaluate the use of ECMO in refractory hypoxemia 2) To determine the usefulness of non-invasive mechanical ventilation, oxygen therapy and adjuvant therapy. METHODS: a systematic review of the literature according to the PRISMA 2020 declaration was carried out with articles from the last 5 years in the vast majority. Databases such as academic Google, Pubmed, IntechOpen, Mendeley, ScienceDirect, journals: JAMA, BMJ, critical care, NEJM, respiratory care were consulted: randomized studies, multicenter studies, clinical cases, review articles, meta-analysis, systematic review, guidelines, observational, descriptive, retrospective studies and consensus documents on the topics: acute respiratory failure, refractory hypoxemia and mechanical ventilation. RESULTS: Position in a prone position is of great importance during distress, as is support with extracorporeal circulation membrane, neuromuscular block and corticosteroids in the treatment of ARDS. As for the ventilatory strategies in this group of patients, intubation is the first step, via translaringea and connection to invasive mechanical ventilation, after which, we can apply the following strategies to improve oxygenation: Use of low Vt in volume-controlled ventilatory modes, low plateau pressures <30 in controlled modes that minimize barotrauma and low FiO2, to prevent oxygen-free radical-related injuries. Current evidence supports use of tidal volume (Vt) lower 6 ml/kg. DISCUSSION: Mechanical ventilatory management of the critical patient with acute respiratory failure presenting refractory hypoxemia includes evaluating oxygenation by PaO2/FiO2. the primary objective is to achieve adequate airway pressure values, apply low Vt, maintain an adequate plateau pressure and measure the conduction pressure to titrate the PEEP at the lowest possible value. Pronation is vital to improve oxygenation and airway pressures. The results of this research showed that, there is benefit of mechanical ventilation with the use of ECMO in this group of patients, in addition, it was determined that high flow oxygen therapy only decreases hypoxemia before intubation, without altering mortality. Dexamethasone, if it provides benefit, as adjuvant therapy in the treatment of acute respiratory failure, with refractory hypoxemiaIntroducción: El síndrome de dificultad respiratoria aguda (SDRA) o también conocido como distress respiratorio, es una interrupción del homeostasis a nivel alveolar que puede promover: hipoventilación, deterioro de la difusión, derivación y desajuste entre la ventilación - perfusión o una combinación de ambas

Epidemiología molecular y análisis filogenético de la infección por el virus del papiloma humano en mujeres con lesiones cervicales y cáncer en la región litoral del Ecuador

The aim of the present study was to gather information regarding the molecular epidemiology of Human papillomavirus (HPV) and related risk factors in a group of women with low- and high-grade cervical lesions and cancer from the coastal region of Ecuador. In addition, we studied the evolution of HPV variants from the most prevalent types and provided a temporal framework for their emergence, which may help to trace the source of dissemination within the region. We analyzed 166 samples, including 57 CIN1, 95 CIN2/3 and 14 cancer cases. HPV detection and typing was done by PCR-sequencing (MY09/MY11). HPV variants and estimation of the time to most recent common ancestor (tMRCA) was assessed through phylogeny and coalescence analysis. HPV DNA was found in 54.4% of CIN1, 74.7% of CIN2/3 and 78.6% of cancer samples. HPV16 (38.9%) and HPV58 (19.5%) were the most prevalent types. Risk factors for the development of cervical lesions/cancer were the following: three or more pregnancies (OR = 4.3), HPV infection (OR = 3.7 for high-risk types; OR = 3.5 for HPV16), among others. With regard to HPV evolution, HPV16 isolates belonged to lineages A (69%) and D (31%) whereas HPV58 isolates belonged only to lineage A. The period of emergence of HPV16 was in association with human populations (tMRCA = 91. 052 years for HPV16A and 27. 000 years for HPV16D), whereas HPV58A preceded Homo sapiens evolution (322. 257 years). This study provides novel data on HPV epidemiology and evolution in Ecuador, which will be fundamental in the vaccine era.Fil: Bedoya Pilozo, Cesar H.. Escuela Superior Politécnica del Litoral; Ecuador. Instituto Nacional de Investigaciones en Salud Pública; EcuadorFil: Medina Magües, Lex G.. Escuela Superior Politécnica del Litoral; EcuadorFil: Espinosa García, Maylen. Instituto Nacional de Investigaciones en Salud Pública; EcuadorFil: Sánchez, Martha. Instituto Nacional de Investigaciones en Salud Pública; EcuadorFil: Parrales Valdiviezo, Johanna V.. Instituto Nacional de Investigaciones en Salud Pública; EcuadorFil: Molina, Denisse. Instituto Nacional de Investigaciones en Salud Pública; EcuadorFil: Ibarra, María A.. Instituto Nacional de Investigaciones en Salud Pública; EcuadorFil: Quimis Ponce, María. Instituto Nacional de Investigaciones en Salud Pública; EcuadorFil: España, Karool. Instituto Nacional de Investigaciones en Salud Pública; EcuadorFil: Párraga Macias, Karla E.. Instituto Nacional de Investigaciones en Salud Pública; EcuadorFil: Cajas Flores, Nancy V.. Instituto Nacional de Investigaciones en Salud Pública; EcuadorFil: Solon, Orlando A.. Instituto Nacional de Investigaciones en Salud Pública; Ecuador. Universidad Agraria del Ecuador; EcuadorFil: Robalino Penaherrera, Jorge A.. Instituto Nacional de Investigaciones en Salud Pública; EcuadorFil: Chedraui, Peter. Hospital Gineco-Obstétrico Enrique C. Sotomayor; EcuadorFil: Escobar, Saul. Universidad Católica de Guayaquil; EcuadorFil: Loja Chango, Rita D.. Universidad Católica de Guayaquil; EcuadorFil: Ramirez Morán, Cecibel. Universidad Católica de Guayaquil; EcuadorFil: Espinoza Caicedo, Jasson. Universidad Católica de Guayaquil; EcuadorFil: Sánchez Giler, Sunny. Universidad Especialidades Espíritu Santo. Facultad de Ciencias Médicas; EcuadorFil: Limia, Celia M.. Instituto de Medicina Tropical Pedro Kouri; CubaFil: Alemán, Yoan. Instituto de Medicina Tropical Pedro Kouri; CubaFil: Soto, Yudira. Instituto de Medicina Tropical Pedro Kouri; CubaFil: Kouri, Vivian. Instituto de Medicina Tropical Pedro Kouri; CubaFil: Culasso, Andrés Carlos Alberto. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Nordeste; Argentina. Universidad de Buenos Aires. Facultad de Farmacia y Bioquímica. Departamento de Microbiología, Inmunología y Biotecnología. Cátedra de Virología; ArgentinaFil: Badano, Ines. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Nordeste; Argentina. Secretaría de Educación Superior, Ciencia, Tecnología e Innovación; Ecuador. Universidad Nacional de Misiones. Facultad de Ciencias Exactas, Químicas y Naturales. Laboratorio de Biología Molecular Aplicada; Argentin

Hemorragia anteparto asociada a placenta succenturiata. Reporte de un caso.

Introduction: placenta succenturiata is a morphological abnormality of the placenta that can result in significant morbidity and mortality for both the fetus and the mother. Aim to describe a clinical case of antepartum hemorrhage associated with placenta succenturiata. Materials and methods: a retrospective descriptive study, clinical case presentation, informed consent of the patient to have access to the clinical history and use of images corresponding to the present investigation. Clinical case: the case of a pregnant woman of 33 weeks, who enters the emergency area, with hemorrhage of the third trimester, was observed in the ultrasound, presence of a lobe that reaches the level of the internal cervical orifice, being confused with placenta previa, patient was stable and under observation, with continuous fetal monitoring, until complete lung maturation was obtained, later I present pain and bleeding before delivery so it was operated surgically by cesarean operation where the presence of succenturiado lobe in the placenta is confirmed. Both developments were favourable. Discussion: The present article demonstrates, a rare variety of placental malformation that causes multiple complications and belongs to the differential of other pathologies that cause third trimester bleeding, being associated with placenta previa, so, we must keep in mind the placenta succenturiata as a cause of bleeding in the third trimester, also take into account that in the postpartum period is cause of retention of a placental portion and can cause bleeding or infection. Conclusions: The placenta succenturiata is an abnormality of rare presentation, which is part of the differential diagnosis of haemorrhages before delivery and must be diagnosed in the prenatal period, so that prenatal control and care of the birth can be performed properly, in addition to giving guidance to the patient and her family. Caesarean delivery is recommended in these cases, with surgical approach and type of incision of choice, according to comorbidities and clinical status of the patient.Introducción: La placenta succenturiata es una anomalía morfológica de la placenta que puede resultar en morbilidad y mortalidad significativas tanto para el feto como para la madre. Objetivo: describir un caso clínico de hemorragia anteparto asociado a placenta succenturiata.   Materiales y métodos: se realizó un estudio descriptivo retrospectivo, presentación de caso clínico, se obtuvo consentimiento informado  de  paciente para tener acceso a la historia clínica y uso de imágenes correspondientes a la presente investigación. Caso clínico:  se presenta el caso de una gestante de 33 semanas, que ingresa al area de emergencias, con hemorragia del tercer trimestre, en la ecografía se observó,  presencia de un  lóbulo que alcanza el  nivel del orificio cervical interno, confundiéndose con placenta previa,  paciente se encontraba  estable y en observación, con monitorización fetal continua,  hasta obtener maduración pulmonar completa, posteriormente presento dolor y sangrado ante parto por lo que fue intervenida quirúrgicamente mediante operación cesárea donde se constata la presencia de lóbulo succenturiado en placenta. La evolución de ambos fue favorable. Discusión: El presente artículo demuestra,  una rara variedad de malformación placentaria que provoca múltiples complicaciones y pertenece al diferencial de otras patologías que provocan hemorragia del tercer trimestre, pudiendo estar asociadas con placenta previa, por lo que,  hay que tener presente la placenta succenturiata como una causa de hemorragia del tercer trimestre, además tener en consideración que en el periodo postparto  es causa de retención de una porción placentaria y  puede ocasionar hemorragia o infección. Conclusiones: La placenta succenturiata es una anomalía de rara presentación, que forma parte del diagnóstico diferencial de las hemorragias ante parto y que debe ser diagnosticada en el periodo prenatal, para poder así, realizar un control prenatal y atención del parto de forma adecuada, además de dar una orientación a la paciente y su familia. Se recomienda en estos casos el parto por cesárea, con abordaje quirúrgico y tipo de incisión a elección, de acuerdo a comorbilidades y estado clínico de paciente

Towards the new Thematic Core Service Tsunami within the EPOS Research Infrastructure

Tsunamis constitute a significant hazard for European coastal populations, and the impact of tsunami events worldwide can extend well beyond the coastal regions directly affected. Understanding the complex mechanisms of tsunami generation, propagation, and inundation, as well as managing the tsunami risk, requires multidisciplinary research and infrastructures that cross national boundaries. Recent decades have seen both great advances in tsunami science and consolidation of the European tsunami research community. A recurring theme has been the need for a sustainable platform for coordinated tsunami community activities and a hub for tsunami services. Following about three years of preparation, in July 2021, the European tsunami community attained the status of Candidate Thematic Core Service (cTCS) within the European Plate Observing System (EPOS) Research Infrastructure. Within a transition period of three years, the Tsunami candidate TCS is anticipated to develop into a fully operational EPOS TCS. We here outline the path taken to reach this point, and the envisaged form of the future EPOS TCS Tsunami. Our cTCS is planned to be organised within four thematic pillars: (1) Support to Tsunami Service Providers, (2) Tsunami Data, (3) Numerical Models, and (4) Hazard and Risk Products. We outline how identified needs in tsunami science and tsunami risk mitigation will be addressed within this structure and how participation within EPOS will become an integration point for community development

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

Risk profiles and one-year outcomes of patients with newly diagnosed atrial fibrillation in India: Insights from the GARFIELD-AF Registry.

BACKGROUND: The Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) is an ongoing prospective noninterventional registry, which is providing important information on the baseline characteristics, treatment patterns, and 1-year outcomes in patients with newly diagnosed non-valvular atrial fibrillation (NVAF). This report describes data from Indian patients recruited in this registry. METHODS AND RESULTS: A total of 52,014 patients with newly diagnosed AF were enrolled globally; of these, 1388 patients were recruited from 26 sites within India (2012-2016). In India, the mean age was 65.8 years at diagnosis of NVAF. Hypertension was the most prevalent risk factor for AF, present in 68.5% of patients from India and in 76.3% of patients globally (P < 0.001). Diabetes and coronary artery disease (CAD) were prevalent in 36.2% and 28.1% of patients as compared with global prevalence of 22.2% and 21.6%, respectively (P < 0.001 for both). Antiplatelet therapy was the most common antithrombotic treatment in India. With increasing stroke risk, however, patients were more likely to receive oral anticoagulant therapy [mainly vitamin K antagonist (VKA)], but average international normalized ratio (INR) was lower among Indian patients [median INR value 1.6 (interquartile range {IQR}: 1.3-2.3) versus 2.3 (IQR 1.8-2.8) (P < 0.001)]. Compared with other countries, patients from India had markedly higher rates of all-cause mortality [7.68 per 100 person-years (95% confidence interval 6.32-9.35) vs 4.34 (4.16-4.53), P < 0.0001], while rates of stroke/systemic embolism and major bleeding were lower after 1 year of follow-up. CONCLUSION: Compared to previously published registries from India, the GARFIELD-AF registry describes clinical profiles and outcomes in Indian patients with AF of a different etiology. The registry data show that compared to the rest of the world, Indian AF patients are younger in age and have more diabetes and CAD. Patients with a higher stroke risk are more likely to receive anticoagulation therapy with VKA but are underdosed compared with the global average in the GARFIELD-AF. CLINICAL TRIAL REGISTRATION-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362

Nurses' perceptions of aids and obstacles to the provision of optimal end of life care in ICU

Contains fulltext : 172380.pdf (publisher's version ) (Open Access

COVID-19 symptoms at hospital admission vary with age and sex: results from the ISARIC prospective multinational observational study

Background: The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods: International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results: ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18 years: 69, 48, 23; 85%), older adults (≥ 70 years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P &lt; 0.001). The most common atypical presentations under 60 years of age were nausea and vomiting and abdominal pain, and over 60 years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation: This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30 years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60 years. Women are less likely to experience typical symptoms than men

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat