Coledocolitiasis gigante, factores predictores de éxito, fracaso del manejo endosópico. Hospital de la Samaritana 2009-2011

La prevalencia de coledocolitiasis es de un 10 a 20%. 10-20% tienen coledocolitiasis gigante, es decir presencia de cálculos mayores de 15 mm, aumentando la morbimortalidad por complicaciones. El objetivo principal fue determinar la frecuencia de coledocolitiasis gigante, la presencia de factores predictores del éxito o fracaso del manejo endoscópico. El éxito en el manejo endoscópico está entre 80 y 90%, un 20% requieren cirugía de exploración biliar. Se realizó la búsqueda de las variables utilizando el instrumento para la recolección de la información. Se realizó un análisis univariado y bivariado de las variables medidas y se utilizo STATA versión 10. Como principal resultado, se encontró que la frecuencia de coledocolitiasis gigante en nuestra población fue del 10%, el éxito del manejo endoscopio fue del 89.23% y el factor predictor mas fuerte para el éxito fue el diámetro del cálculo, siendo mayor para cálculos de menos de 19.09 mm. Como conclusión, en nuestro estudio, la frecuencia de coledocolitiasis gigante es cercana a la conocida en la literatura mundial. El manejo endoscópico en nuestro estudio es el pilar en estos casos, teniendo probabilidad de éxito en el manejo que es igual a la publicada en los estudios mundiales, que existe la probabilidad que el tamaño del cálculo mayor a 19 mm de diámetro indique mayor tasa de fracaso y requerimiento de técnicas endoscópicas avanzadas para su éxito. Se requieren estudios, con mayor número de pacientes para determinar la validez estadística de estos resultados.

Factores que influyen en la actividad de trasplantes en Colombia año 2013. Desde la perspectiva de pacientes renales y de expertos en trasplante de riñón, hígado y corazón

Antecedentes: Se encuentran datos oficiales sobre trasplante de órganos en Colombia desde 2005 del Instituto Nacional de Salud y desde 2008 para riñón por la Cuenta de Alto Costo. Los datos no ofrecen explicación del número de inscritos en lista de espera para trasplante renal, al comparar con otros países: Colombia 4,68% vs. Argentina 27,58% o Estados Unidos 21,73%. Por otra parte no existen datos acerca de factores que influyen en el seguimiento pos-trasplante y no se tienen de sobrevida del receptor y del injerto. Metodología: Investigación de metodología mixta cuantitativa y cualitativa a partir de la información disponible en los informes oficiales y teniendo como fuente primaria pacientes y expertos en el cuidado de paciente antes y después del trasplante. Resultados: Los factores para acceder o no a lista de espera y seguimiento más mencionados son sistema de salud, aspectos éticos en cuanto remisión y autorización. Emerge como categoría la necesidad de un sistema de vigilancia en trasplantes. En la parte cuantitativa se trasplantan más personas si viven en una ciudad con grupo de trasplante 17,6 vs. 8,05%, si pertenecen al régimen contributivo O.R 3,37 p<0,00001, si no tienen diabetes O.R 3,22 p<0,0001 ni hipertensión arterial O.R 2,42 p<0,0001. No se encontró diferencia en cuanto a género O.R 1,01 p 0,57. Conclusiones: Se proponen ajustes al sistema de salud, de la normatividad, de la educación de la promoción de la donación y trasplante en todos los niveles del público y del personal de salud.

[177Lu – DOTA – Tyr3] – OCTREOTATE para el tratamiento de tumores neuroendocrinos gastroenteropancreáticos. Revisión sistemática de la literatura.

Introducción: los tumores neuroendocrinos gastroenteropancreáticos se diagnostican en estadio avanzado en 60 - 80% de los pacientes y las opciones terapéuticas son limitadas. Se realizó una revisión sobre el beneficio clínico del tratamiento con [177Lu - DOTA - Tyr3] - Octreotate en pacientes con enfermedad metastásica o inoperable. Objetivos: evaluar la eficacia, impacto en calidad de vida y toxicidad de la terapia con 177Lu DOTATE en pacientes con tumores neuroendocrinos gastroenteropancreáticos avanzados. Materiales y Métodos: se condujo una revisión sistemática de la literatura mediante la búsqueda de estudios clínicos prospectivos y retrospectivos en bases electrónicas (MEDLINE, EMBASE, LILACS, SCIELO, OVID y la Biblioteca Cochrane) de cualquier idioma, año y estado de publicación. Se incluyeron 5 estudios, por la heterogeneidad existente entre los estudios no se realizó un metaanálisis. Resultados: la respuesta tumoral global fue del 45 - 57%, la enfermedad permaneció estable en 27% - 38% y progresó en 6% - 21% de casos en las series incluidas. El tiempo libre de progresión osciló entre 31 - 40 meses y la sobrevida global de 31– 51 meses. Se observó toxicidad hematológica grado 3-4 hasta en 9.5% de pacientes. Hubo mejoría significativa en la calidad de vida de pacientes tratados con 177LuDOTATATE. Conclusiones: la terapia con 177Lu- DOTATATE ofrece un beneficio clínico a los pacientes con tumores neuroendocrinos bien diferenciados avanzados por su impacto positivo en calidad de vida, control de síntomas, ralentiza la progresión tumoral y su toxicidad es baja.

Caracterización de las reacciones adversas a medicamentos como causa de ingreso a una unidad de cuidado intermedio en un hospital de tercer nivel de atención

Objetivo: Determinar la ocurrencia de reacciones adversas a medicamentos (RAM) como causa de ingreso a una unidad de cuidado intermedio de un hospital universitario. Materiales y Métodos: Se revisaron las historias clínicas de los pacientes admitidos a la Sala de Emergencias – Cuidado Intermedio (SALEM) entre septiembre y diciembre de 2012 que cumplieron los criterios de inclusión y se detectaron los casos sospechosos de reacción adversa a medicamento (RAM) que posteriormente fueron evaluados por cuatro investigadores respecto a la causalidad a través del Algoritmo de Naranjo, prevenibilidad usando los criterios de Shumock y Thornton y la clasificación clínica mediante el empleo del sistema DoTS. Resultados: Se encontraron 96 pacientes que presentaron 108 casos de RAM. Las RAM más frecuentes fueron las arritmias y la hemorragia de vías digestivas altas (12.04%), 20.3% de los casos correspondieron a fallos terapéuticos, y, los medicamentos mayormente asociados fueron el ácido acetil salicílico (15.74%) y el losartán (10.19%). 46 casos fueron catalogados como posibles y uno solo como definitivo. Usando la clasificación DoTS se estableció que en el 82.4% de los casos la dosis era colateral (dentro del rango de dosis terapéutica), 89.8% fueron independientes del tiempo, y entre los factores mayormente asociados a susceptibilidad a la RAM estuvieron las comorbilidades (41.7%) y la edad (49%). 44% de las RAM fueron prevenibles. Conclusión: Las RAM son una causa de ingreso no despreciable en una unidad de cuidado intermedio para las cuales existen diferentes sistemas de evaluación, y una cantidad significativa de ellas es prevenible. Se requieren más estudios a nivel nacional para evaluar la incidencia de estas y establecer estándares de clasificación y medidas para mitigar su efecto.

Riesgo de hipertensión arterial por ruido laboral: revisión sistemática

Introducción: la pérdida auditiva inducida por ruido es el efecto nocivo del ruido más comúnmente estudiado, sin embargo, el ruido también produce trastornos digestivos y del sueño, cambios en los niveles de cortisol, efectos cardiovasculares e hipertensión arterial (HTA), entre otros. Objetivo: determinar si la exposición laboral a ruido induce hipertensión arterial. Materiales y métodos: se siguieron las recomendaciones del método PRISMA para revisiones sistemáticas. Se hizo una búsqueda de estudios en PUBMED utilizando los términos “occupational and noise and hypertension” y aplicando los filtros: 1) publicaciones incluidas entre 2005-2015; 2) estudios publicados en inglés; 3) revisión de títulos y resúmenes; 4) revisión completa de los textos para un total final de 32 estudios. Se hizo la revisión, análisis y resumen de todos los estudios. Resultados: los estudios concluyeron que aquellos portadores de los polimorfismos de la enzima convertidora de angiotensina expuestos a ruido, tuvieron una mayor susceptibilidad genética a tener HTA. Los estudios reportaron una asociación positiva entre ruido e HTA. Hay controversia acerca de la relación que existe entre HTA, ruido y coexposición a otros factores como calor, trabajo por turnos, presencia de solventes o plomo en el lugar de trabajo y carga física. Conclusiones: Se presume que solo los niveles de ruido ≥ 85 dBA tienen efectos negativos sobre la salud, pero se ha encontrado que los efectos no auditivos del ruido se producen por debajo de este parámetro. Recomendaciones: se sugiere el uso de la pérdida auditiva inducida por ruido entre población trabajadora como un método de tamizaje para detectar personas prehipertensas, con el fin prevenir la generación de HTA.

Pulsioximetría de pacientes en hemodiálisis, de la unidad de terapia renal – fundación cardioinfantil, análisis para establecer recomendaciones

Introducción. En Colombia, el 80% de los pacientes con enfermedad renal crónica en hemodiálisis tienen fístula arteriovenosa periférica (FAV) que asegura el flujo de sangre durante la hemodiálisis (1), la variabilidad en el flujo de sangre en el brazo de la FAV hacia la parte distal, puede afectar la lectura de la oximetría de pulso (SpO2) (2), llevando a la toma de decisiones equivocadas por el personal de salud. El objetivo de este estudio es aclarar si existe diferencia entre la SpO2 del brazo de la FAV y el brazo contralateral. Materiales y métodos. Se realizó un estudio de correlación entre los valores de SpO2 del brazo con FAV contra el brazo sin FAV, de 40 pacientes que asistieron a hemodiálisis. La recolección de los datos se llevó a cabo, con un formato que incluyó el resultado de la pulsioximetria y variables asociadas, antes, durante y después de la hemodiálisis. Se comparó la mediana de los deltas de las diferencias con pruebas estadísticas T Student – Mann Whitney, aceptando un valor significativo de p < 0,05. Resultados. No se encontraron diferencias estadísticamente significativas de la SpO2 entre el brazo con FAV y el brazo sin FAV, antes, durante y después de la diálisis, sin embargo si se apreció una correlación positiva estadísticamente significativa. Conclusiones. Se encontró correlación positiva estadísticamente significativa, donde no hubo diferencias en el resultado la pulsioximetría entre el brazo con FAV y brazo sin FAV, por lo tanto es válido tomar la pulsioximetría en cualquiera de los brazos.

Some biological data on cetaceans populations present in the western coasts of Ireland

Ireland’s waters constitute one of the richest habitats for cetaceans in Europe. Marine mammals, particularly cetaceans, are known to be definitive hosts of digestive parasites from the Fm.Anisakidae. The main aim of this study is to collect and compile all the information available out there regarding parasites of the Fm. Anisakidae and their definitive hosts. Secondary objectives are to relate the presence of cetacean species with the presence of parasites of the Fm. Anisakidae and to determine whether this greater number of cetaceans relates to a greater level of parasitism. Prevalence and burdens of anisakids in definitive hosts vary widely with host species, geographic location, and season. Results from several post-mortem exams are given. However, they cannot be compared due to differences in collecting techniques. Anisakis simplex is the most commonly and widespread parasite found in the majority of the samples and in a major number of hosts, which include harbour porpoise, short-beaked common dolphin and bottlenose dolphin. Studies on harbour porpoise obtained prevalences of Anisakis spp. of 46% (n=26) and of 100% (n= 12). Another study in common dolphin reported a prevalence of 68% (n=25). Several reasons could influence the variations in the presence of Anisakis. Studies on commercially exploited fish have reported prevalences of Anisakis simplex ranging from 65-100% in wild Atlantic salmon and from 42-53.4% in Atlantic cod

Effect of magnesium sulphate and L-tryptophan and genotype on the feed intake, behaviour and meat quality of pigs

Sixty-nine entire male pigs with different halothane genotype (homozygous halothane positive – nn-, n=36; and homozygous halothane negative – NN-, n=33) were fed with a supplementation of magnesium sulphate (Mg) and/or L-tryptophan (Trp) in the diet for 5 days before slaughter. Animals were housed individually and were submitted to stressful ante mortem conditions (mixed in the lorry according to treatments and transported 1h on rough roads). Individual feed intake was recorded during the 5-day treatment. At the abattoir, pig behaviour was assessed in the raceway to the stunning system and during the stunning period by exposure to CO2. Muscle pH, colour, water holding capacity, texture and cathepsin activities were determined to assess meat quality. The number of pigs with an individual feed intake lower than 2kg/day was significantly different among diets (P<0.05; Control: 8.7%; Mg&Trp: 43.5%; Trp: 17.4%) and they were considered to have inadequate supplement intake. During the ante mortem period, 15.2% of pigs included in the experiment died, and this percentage decreased to 8.7% in those pigs with a feed intake > 2kg/day, all of them from the stress-sensitive pigs (nn). In general, no differences were observed in the behaviour of pigs along the corridor leading to the stunning system and inside the CO2 stunning system. During the stunning procedure, Trp diet showed shorter periods of muscular excitation than control and Mg&Trp diets. The combination of a stressful ante mortem treatment and Mg&Trp supplementation led to carcasses with high incidence of severe skin lesions. Different meat quality results were found when considering all pigs or considering only those with adequate supplement intake. In this later case, Trp increased pH45 (6.15) vs Control diet (5.96) in the Longissimus thoracis (LT) muscle (P<0.05) and pH at 24h (Trp: 5.59 vs C: 5.47) led to a higher incidence of dark, firm and dry (DFD) traits in SM muscle (P<0.05). Genotype affected negatively all the meat quality traits. Seventy-five percent of LT and 60.0% of the SM muscles from nn pigs were classified as pale, soft and exudative (PSE), while none of the NN pigs showed these traits (P<0.0001). No significant differences were found between genotypes on the incidence of DFD meat. Due to the negative effects observed in the Mg&Trp group in feed intake and carcass quality, the utilization of a mixture of magnesium sulphate and tryptophan is not recommended

Estenose pilórica congénita num bulldog francês : caso clínico

A estenose pilórica congénita é uma patologia que afecta cachorros, cujo principal sintoma é o vómito. Neste trabalho, descrevemos um caso de estenose congénita do piloro num Bulldog Francês, com 2,5 meses de idade e do sexo masculino. O diagnóstico foi obtido através da história, apresentação clínica e alterações ecográficas compatíveis. O paciente foi tratado com sucesso com recurso à piloroplastia em Y-U e terapia de suporte.

Intervenção Farmacêutica em Patologias Digestivas com Indicação Terapêutica de Medicamentos Não Sujeitos a Receita Médica

Cada vez mais o dia a dia do indivíduo é um stress constante, não tendo normalmente tempo para realizar de forma adequada e correcta os seus hábitos diários. Por vezes, essa falta de rotina diária, nomeadamente nas mudanças horárias constantes para efectuar as refeições, a fraca qualidade de alimentos que ingere, a escassez de líquidos, bem como a diminuta reserva de tempo para realizar as suas necessidades fisiológicas, leva a que perturbações digestivas se desenvolvam e ocorram. No surgimento de tais perturbações, maioritariamente, o indivíduo afectado desloca-se a uma farmácia com o objectivo de lhe resolver o problema em questão. Cabe assim, ao farmacêutico avaliar e indicar qual será a melhor opção para os sinais e sintomas que cada utente poderá apresentar. Desta forma, o farmacêutico irá seguir os vários passos que um correcto atendimento perante o utente deverá conter, colocando diversas questões a este com o intuito de averiguar e assegurar qual a patologia que poderá estar iminente, bem como certificar-se que a indicação farmacêutica e a respectiva dispensa, será a mais correcta para tal situação. As várias etapas em que o farmacêutico se rege, encontram-se normalmente em protocolos de intervenção farmacêutica, indicando todos os aspectos a ter em conta em cada patologia, as medidas não farmacológicas e farmacológicas e os aspectos aquando de referenciação ao médico. Direccionado através de todos estes tópicos, o farmacêutico irá realizar a indicação terapêutica mais adequada a cada situação, melhorando o estado patológico do utente. Pretende-se com esta revisão bibliográfica demonstrar como o farmacêutico deverá actuar perante o utente, proporcionar um maior conhecimento e entendimento de algumas perturbações digestivas, de forma a que a informação prestada ao doente seja a mais correcta, e demonstrar ao farmacêutico quais as opções terapêuticas de não prescrição médica disponíveis na sua farmácia, de modo a encontrar e indicar a melhor solução para cada situação específica.

Diet digestibility, rate of passage, and eating and rumination behavior of Jersey and Holstein cows

Diet digestibility and rate of passage, eating and rumination behavior, dry matter intake (DMI), and lactation performance were compared in 6 Jersey and 6 Holstein multiparous cows. Cows were fed gestation diets according to body weight (BW) beginning 7 wk before expected calving and ad libitum amounts of a lactation diet postpartum. Diet digestibility and rate of passage were measured in 5-d periods at wk 5 prepartum and wk 6 and 14 of lactation. Eating and ruminating behavior was measured over 5-d periods at wk 5 and 2 prepartum and wk 2, 6, 10, and 14 of lactation. Milk yield and DMI were higher in Holsteins, but milk energy output per kilogram of metabolic BW (BW0.75) and intake capacity (DMI/kg of BW) did not differ between breeds. Holsteins spent longer ruminating per day compared with Jerseys, but daily eating time did not differ between breeds. Jerseys spent more time eating and ruminating per unit of ingested feed. The duration and number of meals consumed did not differ between breeds, but the meals consumed by Jerseys were distributed more evenly throughout each 24-h period, providing a more regular supply of feed to the rumen. Feed passed through the digestive tract more quickly in Jerseys compared with Holsteins, suggesting particle breakdown and rumen outflow were faster in Jerseys, but this may also reflect the relative size of their digestive tract. Neutral detergent fiber digestibility was greater in Jerseys, despite the shorter rumen retention time, but digestibility of dry matter, organic matter, starch, and N did not differ between breeds. Utilization of digested N for tissue retention was higher at wk 5 prepartum and lower at wk 14 of lactation in Jerseys. In contrast to numerous published studies, intake capacity of Jerseys was not higher than that of Holsteins, but in the present study, cows were selected on the basis of equal expected milk energy yield per kilogram of metabolic BW. Digestibility of neutral detergent fiber and rate of digesta passage were higher in Jerseys, probably as a consequence of increased mastication per unit of feed consumed in Jerseys and their smaller size.

Major advances in fundamental dairy cattle nutrition

Fundamental nutrition seeks to describe the complex biochemical reactions involved in assimilation and processing of nutrients by various tissues and organs, and to quantify nutrient movement (flux) through those processes. Over the last 25 yr, considerable progress has been made in increasing our understanding of metabolism in dairy cattle. Major advances have been made at all levels of biological organization, including the whole animal, organ systems, tissues, cells, and molecules. At the whole-animal level, progress has been made in delineating metabolism during late pregnancy and the transition to lactation, as well as in whole-body use of energy-yielding substrates and amino acids for growth in young calves. An explosion of research using multicatheterization techniques has led to better quantitative descriptions of nutrient use by tissues of the portal-drained viscera (digestive tract, pancreas, and associated adipose tissues) and liver. Isolated tissue preparations have provided important information on the interrelationships among glucose, fatty acid, and amino acid metabolism in liver, adipose tissue, and mammary gland, as well as the regulation of these pathways during different physiological states. Finally, the last 25 yr has witnessed the birth of "molecular biology" approaches to understanding fundamental nutrition. Although measurements of mRNA abundance for proteins of interest already have provided new insights into regulation of metabolism, the next 25 yr will likely see remarkable advances as these techniques continue to be applied to problems of dairy cattle biology. Integration of the "omics" technologies (functional genomics, proteomics, and metabolomics) with measurements of tissue metabolism obtained by other methods is a particularly exciting prospect for the future. The result should be improved animal health and well being, more efficient dairy production, and better models to predict nutritional requirements and provide rations to meet those requirements.

The dispersal of traditionally managed hay meadow plants via farmyard manure application

The dispersal of plants within botanically rich grassland is an important area of study if such swards are to be maintained. The application of farmyard manure provides a possible mechanism by which seeds contained within hay can be returned/introduced to grasslands. In this study, hay, dung and manure samples taken from farms with botanically rich meadows contained very limited quantities of seeds of desirable species. Digestion by cattle, and storage within a manure heap for 6 months or longer, further reduced seed germination. Samples were characterized by an abundance of the grass, Poa trivialis, with few forbs present. Confirmation of the negative effect of the digestive processes of cattle on seed viability was achieved using an in vitro laboratory experiment. However, this experiment did show that the perennial herbs, Filipendula ulmaria and Sanguisorba officinalis, were able to survive digestion at least as well as P. trivialis. The burial of known quantities of seeds in a manure heap also showed these perennial herbs to be at least as resistant to damage as P. trivialis. The results demonstrate that, given appropriate timing of the hay cut, seeds of species with high conservation value could become incorporated into manure for subsequent dispersal. However, manure dispersal would appear to be of limited value for many species desirable from a conservation viewpoint.

Dry matter intake is decreased more by abomasal infusion of unsaturated free fatty acids than by unsaturated Triglycerides

Previous experiments from our group have demonstrated that abomasal infusion of unsaturated free fatty acids (FFA) markedly decreases dry matter intake (DMI) in dairy cows. In contrast, experiments from other groups have noted smaller decreases in DMI when unsaturated triglycerides (TG) were infused postruminally. Our hypothesis was that unsaturated FFA would be more potent inhibitors of DMI than an equivalent amount of unsaturated TG. Four Holstein cows in late lactation were used in a single reversal design. Cows were fed a total mixed ration containing (DM basis) 23% alfalfa silage, 23% corn silage, 40.3% ground shelled corn, and 10.5% soybean meal. Two cows received soy FFA (UFA; 0, 200, 400, 600 g/d) and 2 received soy oil (TG) in the same amounts; cows then were switched to the other lipid source. Cows were abomasally infused with each amount for 5-d periods. The daily amount of lipid was pulse-dosed in 4 equal portions at 0600, 1000, 1700, and 2200 h; no emulsifiers were used and there was no sign of digestive disturbance. Both lipid sources linearly decreased DMI, with a significant interaction between lipid source and amount. Slope-ratio analysis indicated that UFA were about 2 times more potent in decreasing DMI than were TG. Decreased DMI led to decreased milk production. Milk fat content was increased linearly by lipid infusion. Milk fat yield decreased markedly for UFA infusion but was relatively unaffected by infusion of TG. Contents of short- and medium-chain fatty acids in milk fat decreased as the amount of either infusate increased. Contents of C-18:2 and C18: 3 in milk fat were increased linearly by abomasal infusion of either fat source; cis-9 C-18:1 was unaffected. Transfer of infused C18: 2 to milk fat was 35.6, 42.5, and 27.8% for 200, 400, and 600 g/d of UFA, and 34.3, 39.6, and 34.0% for respective amounts of TG. Glucagon-like peptide-1 (7-36) amide (GLP-1) concentration in plasma significantly increased as DMI decreased with increasing infusion amount of UFA or TG. Plasma concentration of cholecystokinin-octapeptide (CCK-8) was unaffected by lipid infusion. These results indicate that unsaturated FFA reaching the duodenum are more potent inhibitors of DMI than are unsaturated TG; the effect may be at least partially mediated by GLP-1.