Aplicación de los criterios RIFLE (Risk, Injury, Failure, Loss y End) para determinar la falla renal aguda en pacientes de 1 a 5 años hospitalizados en la unidad de cuidados intensivos del Hospital de Niños Benjamín Bloom en el año 2013.

La Falla Renal Aguda (FRA) es un síndrome multifactorial de etiología variada e incidencia que difiere según países y poblaciones de estudio. A nivel mundial no existe un consenso en cuanto a una definición universal. Últimamente se ha reconocido la importancia que tiene la reducción leve a moderada de la función renal en la morbimortalidad especialmente en los pacientes críticos. En 2004, la Acute Dialysis Quality Initiative, realizó un consenso para definir la falla renal aguda, a través del criterio de RIFLE (Riesgo, Injuria, Falla, Pérdida y Estado final de la falla), el cual utilizó los criterios de los adultos y lo extrapoló hacia los pacientes pediátricos. Objetivo: diagnosticar falla renal aguda de acuerdo con los criterios RIFLE en los pacientes de 1 a 5 años hospitalizados en la Unidad de Cuidados Intensivos Pediátricos del Hospital Bloom en el año 2013, identificación de la prevalencia y de las principales causas etiológicas en las cuales se presenta. Muestra: pacientes de 1 a 5 años hospitalizados en la Unidad de Cuidados Intensivos del Hospital Nacional de Niños Benjamín Bloom, los cuales no fueron sometidos a procedimientos quirúrgicos o presentaron insuficiencia renal crónica. Método: se realizó un estudio retrospectivo, descriptivo, desarrollado en la unidad de cuidados intensivos de dicho hospital, haciendo el diagnóstico de falla renal aguda mediante la aplicación los criterios RIFLE para demostrar la utilidad de ésta metodología en el diagnóstico temprano de FRA. Se analizaron los datos epidemiológicos, clínicos y analíticos de todos los pacientes con falla renal aguda. Consideraciones éticas: el presente estudio se evaluó y aprobó por el comité de ética del HNNBB considerándolo adecuado y de bajo riesgo para los pacientes. Resultados: hubo 27 episodios de FRA en 43 pacientes con edad de 1 a 5 años lo cual corresponde al 62.7% de los casos estudiados, el 52% sexo femenino. La patología primaria más frecuente fueron las patologías de origen infeccioso, más común en las neumonías; la media de edad de presentación son los 26 meses. Mediante la aplicación de los criterios RIFLE se permitió diagnosticar de forma más temprana la FRA.

Acute renal failure in critically ill patients : With special reference to prediction of outcome

Acute renal failure (ARF) is a clinical syndrome characterized by rapidly decreasing glomerular filtration rate, which results in disturbances in electrolyte- and acid-base homeostasis, derangement of extracellular fluid volume, and retention of nitrogenous waste products, and is often associated with decreased urine output. ARF affects about 5-25% of patients admitted to intensive care units (ICUs), and is linked to high mortality and morbidity rates. In this thesis outcome of critically ill patients with ARF and factors related to outcome were evaluated. A total of 1662 patients from two ICUs and one acute dialysis unit in Helsinki University Hospital were included. In study I the prevalence of ARF was calculated and classified according to two ARF-specific scoring methods, the RIFLE classification and the classification created by Bellomo et al. (2001). Study II evaluated monocyte human histocompatibility leukocyte antigen-DR (HLA-DR) expression and plasma levels of one proinflammatory (interleukin (IL) 6) and two anti-inflammatory (IL-8 and IL-10) cytokines in predicting survival of critically ill ARF patients. Study III investigated serum cystatin C as a marker of renal function in ARF and its power in predicting survival of critically ill ARF patients. Study IV evaluated the effect of intermittent hemodiafiltration (HDF) on myoglobin elimination from plasma in severe rhabdomyolysis. Study V assessed long-term survival and health-related quality of life (HRQoL) in ARF patients. Neither of the ARF-specific scoring methods presented good discriminative power regarding hospital mortality. The maximum RIFLE score for the first three days in the ICU was an independent predictor of hospital mortality. As a marker of renal dysfunction, serum cystatin C failed to show benefit compared with plasma creatinine in detecting ARF or predicting patient survival. Neither cystatin C nor plasma concentrations of IL-6, IL-8, and IL-10, nor monocyte HLA-DR expression were clinically useful in predicting mortality in ARF patients. HDF may be used to clear myoglobin from plasma in rhabdomyolysis, especially if the alkalization of diuresis does not succeed. The long-term survival of patients with ARF was found to be poor. The HRQoL of those who survive is lower than that of the age- and gender-matched general population.

Investigations of Noise-Related Tinnitus

Tinnitus is a frequent consequence of noise trauma. Usually, however, the main focus regarding the consequences of noise trauma is placed on hearing loss, instead of tinnitus. The objectives of the present study were to assess various aspects of noise-related tinnitus in Finland, such as to determine the main causes of conscript acute acoustic traumas (AAT) in the military, assess tinnitus prevalence after noise trauma, characterize long-term AAT-related tinnitus prevalence and characteristics, assess occupational tinnitus, and evaluate the efficacy of hearing protection regulations in preventing hearing loss and tinnitus. The study comprised several independent noise-exposed groups: conscripts performing their military duty, former conscripts who suffered an AAT over a decade earlier, bomb explosion victims, and retired army personnel. Tinnitus questionnaires were used to assess tinnitus prevalence and characteristics. For occupational tinnitus, occupational noise-induced hearing loss (NIHL) reports to the Finnish Institute of Occupational Health were reviewed. Tinnitus is a common result of AAT, blast exposure and long-term noise exposure. Despite hearing protection regulations, up to hundreds of AATs occur annually among conscripts in the Finnish Defence Forces (FDF). The most common cause is an accidental shot, accounting for approximately half of the cases. Conscript AATs are mainly due to accidental shots, while the ear is unprotected. Only seldom is an AAT due to negligence. The most common causative weapon of conscript AATs is the assault rifle, accounting for 81% of conscript AATs. After AAT, the majority of tinnitus cases resolve during military service and become asymptomatic. However, in one-fifth of the cases, tinnitus persists, causing problems such as sleeping and concentration difficulties in many. In Finland, occupational tinnitus often remains unreported in conjunction with NIHL reports. In a survey of occupational NIHL cases, tinnitus was mentioned in only four per cent. However, a subsequent inquiry revealed that almost 90% in fact had tinnitus, indicating that most cases remained undetected and unreported. The best way to prevent noise-related tinnitus is prevention of noise trauma. In the military, hearing protection guidelines have been revised several times over the years. These regulations have been effective in reducing hearing loss of professional soldiers. There has also been a reduction in cases with tinnitus, but the decrease was not significant. However, with improved hearing protection regulations, a significant reduction in the risk of more serious, disturbing tinnitus was observed.

Comparison-speed liquid jets

The performance of a small high-speed liquid jet apparatus is described. Water jets with velocities from 200 to 700 m/s were obtained by firing a deformable lead slug from an air rifle into a stainless steel nozzle containing water sealed with a rubber diaphragm. Nozzle devices using the impact extrusion (IE) and cumulation (CU) methods were designed to generate the jets. The effect of the nozzle diameter and the downstream distance on the jet velocity is examined. The injection sequences are visualized using both shadowgraphy and schlieren photography. The difference between the IE and CU methods of jet generation is found.

Performance of a small high-speed liquid jet apparatus

The performance of a small high-speed liquid jet apparatus is described. Water jets of 200m/s to 700m/s have been obtained by firing a deformable lead slug from an air rifle into a stainless steel nozzle containing water sealed with a rubber diaphragm. Nozzle devices of using the impact extrusion (IE) method and cumulation (CU) method are designed to generate jets. The injection sequences are visualized using schlieren photography. The difference between the IE and CU methods in the jet generation is found.

Regulation of the Gene Encoding Thrombin-Activable Fibrinolysis Inhibitor

Disequilibrium between coagulation and fibrinolysis can lead to severe haemostatic disorders such as thrombosis and hemophilia. Thrombin-activable fibrinolysis inhibitor (TAFI) is a carboxypeptidase B-like pro-enzyme that, once activated, attenuates fibrinolysis. TAFI may also mediate connections between coagulation and inflammation. Studies have associated high plasma TAFI levels with risk for thrombotic diseases. Interestingly, steroid hormones, such as estrogen and progestogens used in hormone replacement therapy or oral contraceptive preparations, have been shown to affect plasma TAFI levels. Regulation of the expression of the gene encoding TAFI, CBP2, is likely an important determinant of the role of the TAFI pathway in vivo; this concept motivated the investigations described in this thesis. In Chapter 2, the results of my research lead to the identification of key transcription factors regulating CPB2. Specifically, we described the binding of NF-Y and HNF-1 to the CPB2 promoter. NF-Y was shown to be an important factor for the basal CPB2 promoter activity. Binding of HNF-1 is essential for the activity of the promoter and is potentially responsible for the liver specific expression of CPB2. In Chapter 3, we set to investigate the effect of female sex hormone on hepatic expression of CPB2. We demonstrated that the levels of TAFI protein secreted from cultured hepatoma cells (HepG2) are decreased by 17beta-estradiol and progesterone. The change in protein expression was paralleled by decreases in CPB2 mRNA abundance and promoter activity. Deletion analysis of the CPB2 promoter indicated that the genomic effects of estrogen and progesterone are likely mediated via a non-classical mechanism. In Chapter 4, we evaluated the effects of various inflammatory mediators on expression of the gene encoding mouse TAFI (Cpb2). Our results showed that Cpb2 mRNA abundance and promoter activity are up-regulated by inflammatory mediators IL-1beta, IL-6, and TNFalpha. We also showed that TNFalpha mediates its effect via the binding of NFkB. Additionally, our results suggest that TNFalpha promotes the binding of NFkB to the promoter by increasing its translocation to the nucleus. The NFkB site is not conserved between human and mouse and may explained the different responses to inflammation observed in vivo.

Lead contamination and associated disease in captive and reintroduced red kites Milvus milvus in England

Since 1989, a red kite Milvus milvus reintroduction programme has been underway in the United Kingdom, with 4-6 week old nestlings brought into captivity and held for 6-8 weeks before reintroduction. As scavengers, red kites may consume unretrieved game, and ingest shot or lead (Pb) fragments in their prey's flesh. We evaluated exposure to Pb in captive and wild red kites by taking blood samples from 125 captive young red kites prior to release, through analysing 264 pellets (regurgitated by wild birds) collected from under a roost site, and analysing Pb concentrations in livers and/or bones of 87 red kites found dead between 1995 and 2003. Lead isotope analyses of livers were also conducted in an effort to identify Pb exposure routes. Forty-six (36.8%) kites sampled prior to release had elevated blood Pb concentrations (201-3340 microg l(-1)). The source of this Pb was probably small fragments of lead ammunition in the carcasses of birds or mammals either fed to the nestlings by their parents or, more likely, subsequently whilst in captivity. Once released, kites were also exposed to lead shot in their food, and a minimum of 1.5-2.3% of regurgitated pellets contained Pb gunshot. Seven of 44 red kites found dead or that were captured sick and died within a few days had elevated (>6 mg kg(-1) dry weight [d.w.]) liver Pb concentrations, and six of these (14%) had concentrations of >15 mg kg(-1) d.w., compatible with fatal Pb poisoning. Post-mortem analyses indicated that two of these birds had died of other causes (poisoning by rodenticide and a banned agricultural pesticide); the remaining four (9%) probably died of Pb poisoning. Bone samples from 86 red kites showed a skewed distribution of Pb concentration, and 18 samples (21%) had Pb concentrations >20 mg kg(-1) d.w., indicating elevated exposure to Pb at some stage in the birds' life. Lead isotopic signatures (Pb (208/206); Pb (206/207)) in liver samples of the majority of kites were compatible with those found in lead shot extracted from regurgitated pellets. Lead isotope ratios found in the livers of kites with very low Pb concentrations were distinct from UK petrol Pb isotopic signatures, indicating that birds were exposed to little residual petrol Pb. We conclude that the primary source of Pb to which red kites are exposed is lead ammunition (shotgun pellets or rifle bullets), or fragments thereof, in their food sources; in some cases exposure appears sufficient to be fatal. We make recommendations to reduce Pb poisoning in both captive and wild red kites and other scavenging species.

General regulations and orders, 1804

Bound with: The manual and platoon exercises, &c., &c. (51 p.) and: General orders and observations on the movement and field exercise of infantry (16 p.) Inscribed on front paste-down: L. Colonel Brock. Also inscribed: Maj. Genl T.A. Smith late of the 1st. Rifle Regt. Bookplate of Robert B. Taylor, Norfolk. On front flyleaf: lengthy, two-page transcription in ink, headed /Copy/Circular/ dated "Horse Guards, 25th May '07" and signed: "Harry Calvert Adjt. General.

General regulations and orders, 1804

Bound with: The manual and platoon exercises, &c., &c. (51 p.) and: General orders and observations on the movement and field exercise of infantry (16 p.) Inscribed on front paste-down: L. Colonel Brock. Also inscribed: Maj. Genl T.A. Smith late of the 1st. Rifle Regt. Bookplate of Robert B. Taylor, Norfolk. On front flyleaf: lengthy, two-page transcription in ink, headed /Copy/Circular/ dated "Horse Guards, 25th May '07" and signed: "Harry Calvert Adjt. General.

Broadside reporting the Fenian Invasion of Canada, June 2, 1866

The Fenians were a group intent on securing Irish independence from England. The movement had its origins in Ireland in1857, under the leadership of James Stephens, with the assistance of John O'Mahony, an American who had raised funds for the cause. The American branch of this movement was especially successful, having raised $500 000 and enlisting about 10 000 American Civil War veterans. The group split into two separate factions, one desiring an invasion of Canada and the other preferring an uprising in Ireland. It soon became apparent that an uprising in Ireland was not imminent, and a decision was made to invade Canada. In April, 1866, a raid was launched against New Brunswick. It proved unsuccessful, and another raid was attempted on June 1, 1866, this time in Ridgeway, near Fort Erie, Ontario. The Canadian militiamen were defeated, but the Fenians subsequently withdrew. A third incident occurred on June 7, this time at Missisquoi Bay in Quebec, when the Fenians crossed the border, remained there for 2 days, and withdrew. A failed uprising in Ireland in 1867 signaled the demise of the movement. The Fenian threat helped to promote a sense of union among Canadians and provided an incentive for Confederation.

Letter - Lieut A. Watson Sime to Col. F.C. McCordick

A letter from Lieut. A. Watson to Col. F.C. McCordick dated only July 3rd. The letter reads "My dear Col. McCordick, If you haven't already heard, you will be surprised to get this letter from me - in Germany. It happened at that awful slaughter - the 3rd battle of Ypres, & even now when I think of it all, I doubt my reality of existence. Everything was O.K at 730am on the 2nd - a little morning hate in the way of trench mortars, that was all. I had just visited a few of my guns & had passed Gen.s Mercer & Williams & their aides, Lyman Gooderham and Fraser (two latter at this camp) on the way to the -- C.M.R Bn. Head Quarters when the storm broke. It last for 5 hours & by the time the Germans came over there were few left to oppose them. By a miracle, the 15 yard bay of the front line, where I was with 6 others, was not levelled like all the rest of the line & we did our best with rifle & bomb. I got a crack on the head & 3 hours later I found myself in a waterfilled shell hole. By night I tried to crawl back & through, but at dawn was caught. Am very comfortable here & glad to have company of Col. Usher, Capt. Light Bourne, Capt. Frank Park M.O. -- CMR) & about 20 other Canadians. Hope all is well with you & 35 - Good luck & best regards to all. A. Watson Sime, Lieut. Haus 62-B OFFIZIER-KRIEGSGEFANGENLAGER Gutersloh.

Broadside reporting the Fenian Invasion of Canada, June 2, 1866

The Fenians were a group intent on securing Irish independence from England. The movement had its origins in Ireland in1857, under the leadership of James Stephens, with the assistance of John O'Mahony, an American who had raised funds for the cause. The American branch of this movement was especially successful, having raised $500 000 and enlisting about 10 000 American Civil War veterans. The group split into two separate factions, one desiring an invasion of Canada and the other preferring an uprising in Ireland. It soon became apparent that an uprising in Ireland was not imminent, and a decision was made to invade Canada. In April, 1866, a raid was launched against New Brunswick. It proved unsuccessful, and another raid was attempted on June 1, 1866, this time in Ridgeway, near Fort Erie, Ontario. The Canadian militiamen were defeated, but the Fenians subsequently withdrew. A third incident occurred on June 7, this time at Missisquoi Bay in Quebec, when the Fenians crossed the border, remained there for 2 days, and withdrew. A failed uprising in Ireland in 1867 signaled the demise of the movement. The Fenian threat helped to promote a sense of union among Canadians and provided an incentive for Confederation.