Guía de práctica clínica de hipotermia perioperatoria no intencionada

The importance of the safety of our patients in the surgical theatre, has driven many projects. The majority of them aimed at better control and clinical performance; mainly of the variables that intervene or modulate the results of surgical procedures, and have a direct relationship with them.The Spanish Society of Anesthesiology, Critical Care and Therapeutic Pain (SEDAR), maintains a constant concern for a variable that clearly determines the outcomes of our clinical processes, “unintentional hypothermia” that develops in all patients undergoing an anesthetic or surgical procedure.SEDAR has promoted, in collaboration with other scientific Societies and patient Associations, the elaboration of this clinical practice guideline, which aims to answer clinical questions not yet resolved and for which, up to now, there are no documents based in the best scientific evidence available.With GRADE methodology and technical assistance from the Ibero-American Cochrane Collaboration office, this clinical practice guideline presents three recommendations (weak in favor) for active heating methods for the prevention of hypothermia (skin, fluid or gas); three for the prioritization of strategies for the prevention of hypothermia (too weak in favor and one strongly in favor); two of preheating strategies prior to anesthetic induction (both weak in favor); and two for research.     

Intravenous sildenafil and inhaled nitric oxide: a randomised trial in infants after cardiac surgery

Objective To investigate the acute effects of intravenous sildenafil on haemodynamics and oxygenation, and its interaction with inhaled nitric oxide (iNO) in infants at risk of pulmonary hypertension early after cardiac surgery.Design Prospective, randomised trial. Setting Paediatric intensive care unit of a childrens hospital.Patients and participants Sixteen ventilated infants early after closure of ventricular or atrioventricular septal defects, were randomly assigned to one of two groups. The study was completed in 15 infants.Interventions Studies were commenced within 7 h of separation from bypass. Seven infants received iNO (20 ppm) first, with the addition of intravenous sildenafil (0.35 mg/kg over 20 min) after 20 min. Eight infants received sildenafil first, iNO was added after 20 min. Vascular pressures, cardiac output and a blood gas were recorded at 0, 20 and 40 min.Measurements and results In infants receiving iNO first, iNO lowered the pulmonary vascular resistance index (PVRI) from 3.45 to 2.95 units (p=0.01); sildenafil further reduced PVRI to 2.45 units (p<0.05). In those receiving sildenafil first, PVRI was reduced from 2.84 to 2.35 units (p<0.05) with sildenafil, and fell to 2.15 units (p=0.01) with the addition of iNO. In both groups, sildenafil reduced the systemic blood pressure and systemic vascular resistance (p<0.01) and worsened arterial oxygenation and the alveolar-arterial gradient (p<0.05).Conclusion Intravenous sildenafil augmented the pulmonary vasodilator effects of iNO in infants early after cardiac surgery. However, sildenafil produced systemic hypotension and impaired oxygenation, which was not improved by iNO.     

Periovarian adhesions following ovarian wedge resection or laparoscopic biopsy

The purpose of this paper is to describe the formation of periovarian adhesions after ovarian bilateral wedge resection or laparoscopic biopsy. Twelve patients with polycystic ovaries and infertility had bilateral ovarian wedge resection and second-look laparoscopy after a mean of 33 months. On the other hand, twenty-four patients with various menstrual disorders had laparoscopic ovarian biopsy and subsequent second-look after a mean of 8.8 months. Ninety-two per cent of the patients who had wedge resection had some periovarian adhesions, and in three cases the adhesions were extensive enough to produce mechanical infertility. Pregnancy occurred in four patients despite the presence of filmy or moderate adhesions. The patients who had laparoscopic ovarian biopsy were found to be free of periovarian adhesions during the second-look ovarian visualization. We conclude that ovarian resection should be reserved for nonresponders to a nonsurgical approach of anovulation, and ovarian biopsy when properly done is not followed by periovarian adhesions.     

Class 1 integron-borne gene cassettes in multidrug-resistant Yersinia enterocolitica strains of different phenotypic and genetic types

Seventy nine strains of Yersinia enterocolitica resistant to one or more antimicrobials were analyzed for integrons. Only class 1 sul1 integrons containing aadA1a (28 strains), aadA1a-dfr1-sat1 (2 strains), and dfr1-aadA1a (1 strain) gene cassettes were found. The first two types were found in clinical isolates belonging to serotype O:3, biotypes 2 to 4, and eight combined ribotypes, and the third was found in the reference strain, CECT4054 (O:8). All screened resistance markers were found in strains with and without integrons (except for chloramphenicol resistance, encoded by catA1 gene, which was only present in strains with integrons), but in different resistance profiles (R profiles). A profile (ampicillin, streptomycin, sulfadiazine, and trimethoprim resistance, encoded by the tem1, aadA1a, sul1, and dfr1 genes, respectively) was found in strains, with and without integrons. Integrons and some of the resistance genes are located on plasmids with sizes ranging between 65 and 140 kb. This is the first report of class 1 integrons in Y. enterocolitica.     

Patient dose management in digital radiography

Purpose:

To present the experience in patient dose management and the development of an online audit tool for digital radiography.

Materials and methods:

Several tools have been developed to extract the information contained in the DICOM header of digital images, collect radiographic parameters, calculate patient entrance doses and other related parameters, and audit image quality.

Results:

The tool has been used for mammography, and includes images from over 25,000 patients, over 75,000 chest images, 100,000 computed radiography procedures and more than 1,000 interventional radiology procedures. Examples of calculation of skin dose distribution in interventional cardiology based upon information of DICOM header and the results of dosimetric parameters for cardiology procedures in 2006 are presented.

Conclusion:

Digital radiology has great advantages for imaging and patient dose management. Dose reports, QCONLINE systems and the MPPS DICOM service are good tools to optimise procedures and to manage patient dosimetry data. The implementation of the ongoing IEC-DICOM standard for patient dose structured reports will improve dose management in digital radiology.     

Ethical issues in susceptibility genetic testing for late‐onset neurodegenerative diseases

Genome‐wide association studies have revolutionized our understanding of the genetic architecture of complex traits and diseases over the last decade. This knowledge is enabling clinicians, researchers, and direct‐to‐consumer genetics companies to conduct disease susceptibility testing based on powerful methods such as polygenic risk scoring. However, these technologies raise a set of complex ethical, legal, social, and policy considerations. Here we review and discuss a series of ethical dilemmas associated with susceptibility genetic testing for the two most common late‐onset neurodegenerative diseases, Alzheimer's and Parkinson's disease, including testing in asymptomatic individuals. Among others, these include informed consent, disclosure of results and unexpected findings, mandatory screening, privacy and confidentiality, and stigma and genetic discrimination. Importantly, appropriate counseling is a deciding factor for the ethical soundness of genetic testing, which poses a challenge for the regulation of these tests and the training of healthcare professionals. As genetic knowledge about these diseases continues growing and genetic testing becomes more widespread, it is increasingly important to raise awareness among researchers, medical practitioners, genetic counselors, and decision makers about the ethical, legal, and social issues associated with genetic testing for polygenic diseases.     

Association between mannose-binding lectin deficiency and septic shock following acute pyelonephritis due to Escherichia coli

Structural and promoter MBL2 gene polymorphisms responsible for low MBL levels are associated with increased risk of infection. The objective of this study was to assess the possible association between polymorphisms of the MBL2 gene and the incidence of septic shock and bacteremia in patients with acute pyelonephritis due to Escherichia coli. The study included 62 female patients with acute pyelonephritis due to E. coli who required hospital admission, as well as 133 healthy control subjects. Six single-nucleotide polymorphisms (-550 G/C, -221 C/G, +4 C/T, codon 52 CGT/TGT, codon 54 GGC/GAC, and codon 57 GGA/GAA) in the MBL2 gene were genotyped by using a sequence-based typing technique. No significant differences were observed in the frequencies for low-expression MBL2 genotypes (O/O and LXA/O) between patients with acute pyelonephritis and healthy controls. Patients with acute pyelonephritis and septic shock had a higher incidence of low-expression MBL2 genotypes than patients with acute pyelonephritis without septic shock (odds ratio = 9.019, 95% confidence interval = 1.23 to 65.93; P = 0.03). No association was found between bacteremic acute pyelonephritis and low-expression MBL2 genotypes. We found that low-expression MBL2 genotypes predispose to septic shock but not to bacteremia in patients with E. coli-induced acute pyelonephritis. Determination of MBL2 polymorphisms could be useful for assessing the risk of septic shock in women undergoing acute pyelonephritis.     

Detailed structure of integrons and transposons carried by large conjugative plasmids responsible for multidrug resistance in diverse genomic types of Salmonella enterica serovar Brandenburg

OBJECTIVES: To evaluate the incidence, molecular basis and distribution among genomic types of antimicrobial drug resistance in Salmonella enterica (S.) serovar Brandenburg isolates recorded in the Principality of Asturias, Spain. METHODS: Thirty-seven S. Brandenburg isolates were tested for susceptibility to antimicrobial agents and typed by random amplified polymorphic DNA (RAPD) and pulsed-field gel electrophoresis (PFGE). PCR amplifications, together with DNA cloning and sequencing, were used to identify resistance genes, integrons and transposons and to establish the structure and physical associations between them. Conjugation experiments were applied to establish the location of the identified elements. RESULTS: Twenty-one isolates were resistant to one or more unrelated drugs. Resistances to streptomycin, tetracycline, kanamycin, chloramphenicol, ampicillin and trimethoprim-sulfamethoxazole, encoded by aadA1, tet(A) or tet(B), aphA1, catA1, bla(TEM) and dfrA1-sul1-sul3, respectively, were most frequently observed. Multidrug resistance (32.4%) was mainly mediated by mobile genetic elements. These included: (i) class 1 integrons (with dfrA1-aadA1 gene cassettes in their variable region), which were part of Tn21-related transposons associated with Tn9; (ii) a Tn1721-derivative containing tet(A); (iii) a defective Tn10 that carried tet(B), and was linked to an integron; and (iv) large conjugative plasmids carrying a class 1 integron-Tn21-Tn9-like structure, together with the Tn1721- or the Tn10-related element. Two-way-RAPD and XbaI-PFGE discriminated the isolates into 15 and 12 profiles, respectively. CONCLUSIONS: Complex genetic elements have apparently been responsible for the recruitment, assembly and dispersion of resistance genes among the highly diverse genomic types of S. Brandenburg, identified as causal agents of human salmonellosis in the Principality of Asturias, over recent years.