Nutrition competencies for undergraduate medical education: Results of an international interdisciplinary consensus

BACKGROUND

The gap between the nutrition education provided to medical students and the nutrition competencies and attitudes needed for physicians to provide adequate nutrition care is a global concern. There is no universally accepted benchmark on nutrition competencies for doctors. The objective of this study was to establish, by expert consensus, the objectives of undergraduate nutrition medial education, the nutrition core competencies, and strategies for curriculum development in medical nutrition education.

METHODS

We administered a Delphi survey to systematically gather the opinion of a panel of Latin American experts in nutrition. The survey questionnaire was constructed considering scientific literature by using a 5-point Likert scale. Consensus was defined as >70% agreement on the importance of an item (Likert scale 4 and 5).

RESULTS

A four-round Delphi survey was conducted for this research. In the second, third, and fourth rounds, we validated a total of 130 competencies by consensus, which were distributed into four different thematic areas: (1) basic nutrition concepts, (2) public nutrition and nutrition prevention throughout the life cycle, (3) nutrition status and disease, and (4) nutrition care process.

CONCLUSION

The curricula for general physician education in medical school must include health promotion, prevention, and treatment of diseases related to nutrition. This goal can be reached by integrating ≤130 competencies into four different fundamental areas.

Are traditional screening tools adequate for monitoring the nutrition risk of in-hospital patients? An analysis of the nutritionDay database

BACKGROUND

Monitoring of adequate food intake is not a priority in hospital patients' care. The present study aimed to examine selective data from the nutritionDay survey to determine the impact of food intake during hospitalization on outcomes according to the nutrition risk status.

METHODS

We conducted a descriptive analysis of selected data from 7 consecutive, annual, and cross-sectional nutritionDay samples from 2009 to 2015. The impact of food intake on outcomes was assessed by univariate and multivariate Cox models controlling for PANDORA scores.

RESULTS

A total of 7994 adult patients from Colombia, 7243 patients from 9 Latin American countries, and 155,524 patients worldwid were included. Less than half of the patients worldwide consumed their entire meal on nutritionDay (41%). The number of reduced eaters is larger in the "no nutrition risk group" than in the "nutrition risk group" (30% vs 25%). Reduced eating is associated with higher mortality and delayed discharge in patients, regardless of the nutrition risk status. Patients without nutrition risk at the screening who ate "nothing, but were allowed to eat" had 6 times more risk of mortality (hazard ratio, 6.48; 95% CI, 3.5311.87).

CONCLUSIONS

This is the first large-scale study evaluating the relationship of food intake on clinical outcomes showing an increase of in-hospital mortality rates and a reduction in the probability of being discharged home regardless of the nutrition risk status. Traditional screening tools may not identify a group of patients who will become at risk because of reduced intake while in the hospital.

Discovery of the acetyl cation, CH3CO+, in space and in the laboratory

Using the Yebes 40m and IRAM 30m radiotelescopes, we detected two series of harmonically related lines in space that can be fitted to a symmetric rotor. The lines have been seen towards the cold dense cores TMC-1, L483, L1527, and L1544. High level of theory ab initio calculations indicate that the best possible candidate is the acetyl cation, CH3CO+, which is the most stable product resulting from the protonation of ketene. We have produced this species in the laboratory and observed its rotational transitions Ju = 10 up to Ju = 27. Hence, we report the discovery of CH3CO+ in space based on our observations, theoretical calculations, and laboratory experiments. The derived rotational and distortion constants allow us to predict the spectrum of CH3CO+ with high accuracy up to 500 GHz. We derive an abundance ratio N(H2CCO)/N(CH3CO+)~44. The high abundance of the protonated form of H2CCO is due to the high proton affinity of the neutral species. The other isomer, H2CCOH+, is found to be 178.9 kJ mol-1 above CH3CO+. The observed intensity ratio between the K=0 and K=1 lines, ~2.2, strongly suggests that the A and E symmetry states have suffered interconversion processes due to collisions with H and/or H2, or during their formation through the reaction of H 3 + with H2CCO.

Comprehensive rotational study and astronomical search for cyclopropanecarboxaldehyde

CONTEXT

At least a dozen molecules with a formyl group (HCO) have been observed to date in the interstellar medium (ISM), suggesting that other such species exist and remain to be discovered. However, there is still a lack of high-resolution spectroscopic data for simple molecular species of this type that could provide a basis for their detection.

AIMS

Cyclopropanecarboxaldehyde, c-C3H5CHO, is a small molecule containing a formyl group and is therefore an interesting candidate for astrophysical detection. The rotational spectrum of cyclopropanecarboxaldehyde has been observed before, but its experimental rotational parameters are not precise enough to allow its detection in the millimetre-wave domain.

METHODS

We measured the rotational spectrum of cyclopropanecarboxaldehyde in the frequency ranges 31.5-50 GHz and 72-116.5 GHz using the GACELA (GAS CEll for Laboratory Astrophysics) broadband high-resolution rotational spectrometer constructed at the Yebes Observatory. The spectroscopic study was supported by high-level theoretical calculations which were used in the identification of the vibrational excited states of cyclopropanecarboxaldehyde.

RESULTS

Our analysis of the rotational spectrum of cyclopropanecarboxaldehyde allowed us to obtain accurate rotational parameters for the ground state of both cis and trans isomers, which were used to derive sufficiently reliable predictions up to 300 GHz. In addition to the ground states, we identified 12 and 6 vibrationally excited states for the trans and cis isomers, respectively, including fundamental modes, multiple excitation quanta, and combination states. We find that the gas phase concentration of the trans isomer is almost 1.2 times larger than that of the cis one. These new experimental rotational parameters were employed to search for cyclopropanecarboxaldehyde in the warm molecular clouds Orion KL and Sgr B2(N) using the spectral surveys captured by ALMA (Orion) and IRAM 30 m (Sgr) at 1 mm and 3 mm, respectively.

Tentative detection of HC5NH+ in TMC-1

Using the Yebes 40m radio telescope, we report the detection of a series of seven lines harmonically related with a rotational constant B 0=1295.81581 ± 0.00026 MHz and a distortion constant D 0 = 27.3 ± 0.5 Hz towards the cold dense cloud TMC-1. Ab initio calculations indicate that the best possible candidates are the cations HC5NH+ and NC4NH+. From a comparison between calculated and observed rotational constants and other arguments based on proton affinities and dipole moments, we conclude that the best candidate for a carrier of the observed lines is the protonated cyanodiacetylene cation, HC5NH+. The HC5N/HC5NH+ ratio derived in TMC-1 is 240, which is very similar to the HC3N/HC3NH+ ratio. Results are discussed in the framework of a chemical model for protonated molecules in cold dense clouds.

Discovery of HC4NC in TMC-1: A study of the isomers of HC3N, HC5N, and HC7N

We present a study of the isocyano isomers of the cyanopolyynes HC₃N, HC₅N, and HC₇N in TMC-1 and IRC+10216 carried out with the Yebes 40m radio telescope. This study has enabled us to report the detection, for the first time in space, of HCCCCNC in TMC-1 and to give upper limits for HC₆NC in the same source. In addition, the deuterated isotopologues of HCCNC and HNCCC were detected, along with all ¹³C substitutions of HCCNC, also for the first time in space. The abundance ratios of HC₃N and HC₅N, with their isomers, are very different in TMC-1 and IRC+10216, namely, N(HC₅N)/N(HC₄NC) is ~300 and ≥2100, respectively. We discuss the chemistry of the metastable isomers of cyanopolyynes in terms of the most likely formation pathways and by comparing observational abundance ratios between different sources.

Discovery of HC3O+ in space: The chemistry of O-bearing species in TMC-1

Using the Yebes 40m and IRAM 30m radio telescopes, we detected a series of harmonically related lines with a rotational constant B 0=4460.590±0.001 MHz and a distortion constant D 0=0.511 ±0.005 kHz towards the cold dense core TMC-1. High-level-of-theory ab initio calculations indicate that the best possible candidate is protonated tricarbon monoxide, HC3O+. We have succeeded in producing this species in the laboratory and observed its J u -J l = 2-1 and 3-2 rotational transitions. Hence, we report the discovery of HC3O+ in space based on our observations, theoretical calculations, and laboratory experiments. We derive an abundance ratio N(C3O)/N(HC3O+)~7. The high abundance of the protonated form of C3O is due to the high proton affinity of the neutral species. The chemistry of O-bearing species is modelled, and predictions are compared to the derived abundances from our data for the most prominent O-bearing species in TMC-1.

Lessons Learned in Nutrition Therapy in Patients With Severe COVID-19

The coronavirus disease 2019 (COVID‐19) pandemic has reached worldwide, and until a vaccine is found, it will continue to cause significant morbidity and mortality. The clinical presentation of COVID‐19 ranges from that of being asymptomatic to developing a fatal illness characterized by multiple organ involvement. Approximately 20% of the patients will require hospitalization; one‐quarter of hospitalized patients will develop severe COVID‐19 requiring admission to the intensive care unit, most frequently, with acute respiratory failure. An ongoing effort is being made to identify the patients that will develop severe COVID‐19. Overall, patients present with 3 different phenotypes of nutrition risk: (1) the frail older patient, (2) the patient with severe ongoing chronic illness, and (3) the patient with severe and morbid obesity. These 3 phenotypes represent different nutrition risks and diverse nutrition interventions. This article explores the different potential approaches to nutrition intervention in patients with COVID‐19, evaluating, in this process, the challenges faced in the implementation of guidelines written by different societies.

Interstellar nitrile anions: Detection of C3N- and C5N- in TMC-1. Astron Astrophys 2020;641:L9. [PMID: 33173234 PMCID: PMC7116340 DOI: 10.1051/0004-6361/202039231]

We report on the first detection of C3N- and C5N- towards the cold dark core TMC-1 in the Taurus region, using the Yebes 40 m telescope. The observed C3N/C3N- and C5N/C5N- abundance ratios are ~140 and ~2, respectively; that is similar to those found in the circumstellar envelope of the carbon-rich star IRC +10216. Although the formation mechanisms for the neutrals are different in interstellar (ion-neutral reactions) and circumstellar clouds (photodissociation and radical-neutral reactions), the similarity of the C3N/C3N- and C5N/C5N- abundance ratios strongly suggests a common chemical path for the formation of these anions in interstellar and circumstellar clouds. We discuss the role of radiative electronic attachment, reactions between N atoms and carbon chain anions C n -, and that of H- reactions with HC3N and HC5N as possible routes to form C n N-. The detection of C5N- in TMC-1 gives strong support for assigning to this anion the lines found in IRC +10216, as it excludes the possibility of a metal-bearing species, or a vibrationally excited state. New sets of rotational parameters have been derived from the observed frequencies in TMC-1 and IRC +10216 for C5N- and the neutral radical C5N.

Detection of vibrationally excited HC7N and HC9N in IRC+10216 ⋆

Observations of IRC +10216 with the Yebes 40m telescope between 31 and 50 GHz have revealed more than 150 unidentified lines. Some of them can be grouped into a new series of 26 doublets, harmonically related with integer quantum numbers ranging from J up=54 to 80. The separation of the doublets increases systematically with J, i.e., as expected for a linear species in one of its bending modes. The rotational parameters resulting from the fit to these data are B = 290.8844 ± 0.0004 MHz, D = 0.88 ± 0.04 Hz, q = 0.1463 ± 0.0001 MHz. The rotational constant is very close to that of the ground state of HC9N. Ab initio calculations show an excellent agreement between these parameters and those predicted for the lowest energy vibrationally excited state, ν 19=1, of HC9N. This is the first detection, and complete characterization in space, of vibrationally excited HC9N. An energy of 41.5 cm-1 is estimated for the ν 19 state. In addition, 17 doublets of HC7N in the ν 15=1 state, for which laboratory spectroscopy is available, have been detected for the first time in IRC+10216. Several doublets of HC5N in its ν 11=1 state have been also observed. The column density ratio between the ground and the lowest excited vibrational states are ≈127, 9.5, and 1.5 for HC5N, HC7N, and HC9N, respectively. We find that these lowest-lying vibrational states are most probably populated via infrared pumping to vibrationally excited states lying at ≈600 cm-1. The lowest vibrationally excited states thus need to be taken into account to precisely determine absolute abundances and abundanceratios for long carbon chains. The abundance ratios N(HC5N)/N(HC7N) and N(HC7N)/N(HC9N) are 2.4 and 7.7 respectively.

The millimeter-wave spectrum and astronomical search for ethyl methyl sulfide

CONTEXT

Sulfur-containing molecules constitute only 8% of the molecules observed in the interstellar medium (ISM), in spite of the fact that sulfur has been shown to be an abundant element in the ISM. In order to understand the chemical behavior of the ISM and specific cases like the missing sulfur reservoir, a detailed chemical molecular composition in the ISM must be mapped out.

AIMS

Our goal is to investigate the rotational spectrum of ethyl methyl sulfide, CH₃CH₂SCH₃, which ms to be a potential candidate for observation in the ISM since the simpler analogs, CH₃SH and CH₃CH₂SH, have already been detected. Rotational spectrum of ethyl methyl sulfide has been observed before, but its experimental rotational parameters are not precise enough to allow its detection in the ISM.

METHODS

The rotational spectrum of ethyl methyl sulfide in the frequency range 72-116.5 GHz was measured using a broadband millimeter-wave spectrometer based on radio astronomy receivers with fast Fourier transform backends. The spectral searches and identification of the vibrational excited states of ethyl methyl sulfide was supported by high-level ab initio calculations on the harmonic and anharmonic force fields.

RESULTS

The rotational spectra for the trans and gauche conformers of ethyl methyl sulfide was analyzed, and a total of 172 and 259 rotational transitions were observed for each one, respectively. The observation of A - E internal rotation splittings allowed the experimental determination of the V ₃ hindered internal rotation barrier height for both trans and gauche species. In addition, the vibrational excited states, resulting from the lowest frequency vibrational mode ν ₃₀ were identified for both conformers. The new experimental rotational parameters were employed to search for ethyl methyl sulfide in the warm and cold molecular clouds Orion KL, Sgr B2(N), B1-b and TMC-1, using the spectral surveys captured by IRAM 30 m at 3 mm and 2 mm.

Nutritional risk is associated with an increase of in-hospital mortality and a reduction of being discharged home: Results of the 2009-2015 nutritionDay survey

BACKGROUND

Disease-related malnutrition is a known factor for poor outcomes. However, there is a lack of knowledge about the prevalence and the impact of nutritional risk on outcomes in Colombia. The aim of the present study was to determine the prevalence of nutritional risk, to know how nutrition screening is routinely performed and to determine the impact of nutritional risk on the outcomes of in-hospital mortality and being discharged home outcomes.

METHODS

We conducted a descriptive analysis of selected data from 7 consecutive, annual, and cross-sectional nutritionDay samples (2009-2015) including a total of 7,994 adult patients in 248 units in Colombia. Data is contrasted with the Latin American and worldwide results. The prevalence of nutritional risk was determined according to the malnutrition screening tool (MST). The impact of nutritional risk in Colombian patients regarding outcomes was assessed by a Fine and Gray competing risk regression model controlling for PANDORA score (age, BMI, length of stay before nutritionDay, cancer diagnosis, and mobility).

RESULTS

The prevalence of nutritional risk (MST score ≥ 2) in Colombia was 38%, 41% in Latin America, and 32% worldwide. Half of the Colombian units screened patients for malnutrition or nutritional risk on admission to hospital, compared to 80% in Latin America and 62% worldwide. Only 23% of the Colombian patients identified as being at nutritional risk in the nutritionDay survey received any nutritional therapy. The hospital mortality hazard ratio of Colombian patients at nutritional risk defined by MST was 1.94 (95% CI, 1.53,2.46; p < 0.001) and 0.82 of being discharged home (95% CI, 0.76,0.88, p < 0.001).

CONCLUSIONS

This is the first large-scale study in Colombia evaluating the impact of nutritional risk on clinical outcomes showing an increase of in-hospital mortality and a reduction of being discharged home. Moreover, the study shows that nutritional risk is still highly prevalent worldwide implying the need to promote an optimal nutritional care. The participation of Latin American countries in the nutritionDay survey is an opportunity to increase knowledge and awareness of these issues.

Rotational spectroscopy and astronomical search for glutaronitrile★

CONTEXT

Nitriles constitute almost 15% of the molecules observed in the interstellar medium (ISM), surprisingly only two dinitriles have been detected in the ISM so far. The lack of astronomical detections for dinitriles may be partly explained by the absence of laboratory rotational spectroscopic data.

AIMS

Our goal is to investigate the rotational spectrum of glutaronitrile, N≡C-CH2-CH2-CH2-C≡N, in order to allow its possible detection in the ISM.

METHODS

The rotational spectrum of glutaronitrile was measured using two different experimental setups. A Fourier transform microwave spectrometer was employed to observe the supersonic jet rotational spectrum of glutaronitrile between 6 and 20 GHz. In addition, the mmW spectrum was observed in the frequency range 72-116.5 GHz using a broadband millimetre-wave spectrometer based on radio astronomy receivers with fast Fourier transform backends. The spectral searches were supported by high-level ab initio calculations.

RESULTS

A total of 111 rotational transitions with maximum values of J and Ka quantum numbers 54 and 18, respectively, were measured for the gg conformer of glutaronitrile. The analysis allowed us to accurately determine the rotational, nuclear quadrupole coupling, quartic and sextic centrifugal distortion constants. These rotational parameters were employed to search for glutaronitrile in the cold and warm molecular clouds Orion KL, Sgr B2(N), B1-b and TMC-1, using the spectral surveys captured by IRAM 30m at 3mm. Glutaronitrile was not detected, and the upper limits' column densities were derived. Those are a factor of 1.5 and 5 lower than those obtained for the total column densities of the analogous succinonitrile in Orion KL and Sgr B2, respectively.

Discovery of two new magnesium-bearing species in IRC+10216: MgC3N and MgC4H

We report on the detection of two series of harmonically related doublets in IRC +10216. From the observed frequencies, the rotational constant of the first series is B = 1380.888 MHz and that of the second series is B = 1381.512 MHz. The two series correspond to two species with a 2Σ electronic ground state. After considering all possible candidates, and based on quantum chemical calculations, the first series is assigned to MgC3N and the second to MgC4H. For the latter species, optical spectroscopy measurements support its identification. Unlike diatomic metal-containing molecules, the line profiles of the two new molecules indicate that they are formed in the outer layers of the envelope, as occurs for MgNC and other polyatomic metal-cyanides. We also confirm the detection of MgCCH that was previously reported from the observation of two doublets. The relative abundance of MgC3N with respect to MgNC is close to one while that of MgC4H relative to MgCCH is about ten. The synthesis of these magnesium cyanides and acetylides in IRC +10216 can be explained in terms of a two-step process initiated by the radiative association of Mg+ with large cyanopolyynes and polyynes followed by the dissociative recombination of the ionic complexes.

The millimeter-wave spectrum and astronomical search of succinonitrile and its vibrational excited states ★

CONTEXT

Dinitriles with a saturated hydrocarbon skeleton and a -C≡N group at each end can have large electric dipole moments. Their formation can be related to highly reactive radicals such as CH2CN, C2N or CN. Thus, these saturated dinitriles are potential candidates to be observed in the ISM.

AIMS

Our goal is the investigation of the rotational spectrum of one of the simplest dinitriles N≡C-CH2-CH2-C≡N, succinonitrile, whose actual rotational parameters are not precise enough to allow its detection in the ISM. In addition, the rotational spectra for its vibrational exicted states will be analyzed.

METHODS

The rotational spectra of succinonitrile was measured in the frequency range 72-116.5 GHz using a new broadband millimeter-wave spectrometer based on radio astronomy receivers with Fast Fourier Transform backends. The identification of the vibrational excited states of succinonitrile was supported by high-level ab initio calculations on the harmonic and anharmonic force fields.

RESULTS

A total of 459 rotational transitions with maximum values of J and Ka quantum numbers 70 and 14, respectively, were measured for the ground vibrational state of succinonitrile. The analysis allowed us to accurately determine the rotational, quartic and sextic centrifugal distortion constants. Up to eleven vibrational excited states, resulting from the four lowest frequency vibrational modes ν 13, ν 12, ν 24 and ν 23 were identified. In addition to the four fundamental modes, we observed overtones together with some combination states. The rotational parameters for the ground state were employed to unsuccessfully search for succinonitrile in the cold and warm molecular clouds Orion KL, Sgr B2(N), B1-b and TMC-1, using the spectral surveys captured by IRAM 30m at 3mm and the Yebes 40m at 1.3cm and 7mm.

CONCLUSIONS

Discovery of the first Ca-bearing molecule in space: CaNC

We report on the detection of calcium isocyanide, CaNC, in the carbon-rich evolved star IRC+10216. We derived a column density for this species of (2±0.5)×1011 cm-2. Based on the observed line profiles and the modelling of its emission through the envelope, the molecule has to be produced in the intermediate and outer layers of the circumstellar envelope where other metal-isocyanides have previously been found in this source. The abundance ratio of CaNC relative to MgNC and FeCN is ≃1/60 and ≃1, respectively. We searched for the species CaF, CaCl, CaC, CaCCH, and CaCH3 for which accurate frequency predictions are available. Only upper limits have been obtained for these molecules.

Broad band high resolution rotational spectroscopy for Laboratory Astrophysics

We present a new experimental setup devoted to the study of gas phase molecules and processes using broad band high spectral resolution rotational spectroscopy. A reactor chamber has been equipped with radio receivers similar to those used by radio astronomers to search for molecular emission in space. The whole Q (31.5-50 GHz) and W bands (72-116.5 GHz) are available for rotational spectroscopy observations. The receivers are equipped with 16×2.5 GHz Fast Fourier Transform spectrometers with a spectral resolution of 38.14 kHz allowing the simultaneous observation of the complete Q band and one third of the W band. The whole W band can be observed in three settings in which the Q band is always observed. Species such as CH3CN, OCS, and SO2 are detected, together with many of their isotopologues and vibrationally excited states, in very short observing times. The system permits automatic overnight observations and integration times as long as 2.4×105 seconds have been reached. The chamber is equipped with a radiofrequency source to produce cold plasmas and with four ultraviolet lamps to study photochemical processes. Plasmas of CH4, N2, CH3CN, NH3, O2, and H2, among other species, have been generated and the molecular products easily identified by their rotational spectrum, and mass spectrometry and optical spectroscopy. Finally, the rotational spectrum of the lowest energy conformer of CH3CH2NHCHO (N-Ethylformamide), a molecule previously characterized in microwave rotational spectroscopy, has been measured up to 116.5 GHz allowing the accurate determination of its rotational and distortion constants and its search in space.

The millimeter-wave spectrum of methyl ketene and the astronomical search for it

CONTEXT

The analysis of isomeric species of a compound observed in the interstellar medium (ISM) is a useful tool to understand the chemistry of complex organic molecules. It could, likewise, assist in the detection of new species.

AIMS

Our goal consists in analyzing one of the two most stable species of the C3H4O family, methyl ketene, whose actual rotational parameters are not precise enough to allow its detection in the ISM. The obtained parameters will be used to search for it in the high-mass star-forming regions Orion KL and Sagittarius B2, as well as in the cold dark clouds TMC-1 in the Taurus Molecular Cloud and Barnard 1 (B1-b).

METHODS

A millimeter-wave room-temperature rotational spectrum of methyl ketene was recorded from 50 to 330 GHz. The internal rotation analysis of its ground state and first torsional excited state was performed with the rho-axis method employing the RAM36 program.

RESULTS

More than 3000 transitions of the rotational spectrum of the ground state (Kamax = 18) and first torsional excited state (Kamax = 13) of methyl ketene were fitted using a Hamiltonian that contains 41 parameters with an RMS (root mean square) of 41 kHz. Column density limits were calculated but no lines were detected in the ISM belonging to methyl ketene.

The millimeter wave spectrum of methyl cyanate: a laboratory study and astronomical search in space<sup/>

AIMS

The recent discovery of methyl isocyanate (CH3NCO) in Sgr B2(N) and Orion KL makes methyl cyanate (CH3OCN) a potential molecule in the interstellar medium. The aim of this work is to fulfill the first requirement for its unequivocal identification in space, i.e. the availability of transition frequencies with high accuracy.

METHODS

The room-temperature rotational spectrum of methyl cyanate was recorded in the millimeter wave domain from 130 to 350 GHz. All rotational transitions revealed A-E splitting owing to methyl internal rotation and were globally analyzed using the ERHAM program.

RESULTS

The data set for the ground torsional state of methyl cyanate exceeds 700 transitions within J″ = 10 - 35 and [Formula: see text] and newly derived spectroscopic constants reproduce the spectrum close to the experimental uncertainty. Spectral features of methyl cyanate were then searched for in Orion KL, Sgr B2(N), B1-b, and TMC-1 molecular clouds. Upper limits to the column density of methyl cyanate are provided.

[Abdominal aneurism screening in Primary Care]

OBJECTIVES

To obtain the percentage of abdominal aortic aneurism (AAA) determined in men between 65-74 years old in a health centre using ultrasound, and to describe the distribution of risk factors in the whole sample and in patients with aneurism, as well as determining how many AAA are confirmed at the hospital and those cases of uncertain diagnosis.

PATIENTS AND METHOD

A cross-sectional study conducted on patients included from September 2014 to February 2015. From a total of 212 randomised patients, a clinical interview and abdominal ultrasound were performed on 115 men, aged 65 to 74, telephone-recruited from a total of 171 that fulfilled inclusion criteria.

RESULTS

An infra-renal AAA was found in 2.6% of the sample (95% CI 0.54-7.4). Just over half (51.3%) of the sample had arterial hypertension, and 76.1% were smokers or former smokers. The 3 AAA found, one of which had an initial doubtful diagnosis, were confirmed by the Hospital Universitario Fundación Jiménez Díaz. There were no losses. All of the patients with AAA were active smokers and had at least one other risk factor.

CONCLUSION

The percentage of infra-renal AAA in the sample was lower than expected, but higher than the percentage found in other studies that did not consider smoking in the inclusion criteria.

[Analysis of factors for conversion of laparoscopic to open cholecystectomy: a prospective study of 703 patients with acute cholecystitis]

AIMS

Conversions to open surgery during laparoscopic cholecystectomy are performed in 20% of patients with acute cholecystitis, and are associated with increased morbidity and costs. The aim of this study was to identify predictive factors for conversion and to evaluate morbidity, mortality and hospital stay.

METHODS

A prospective cohort of patients admitted to the emergency department with acute cholecystitis. We evaluated the statistical significance of the demographic, clinical, biochemical, imaging and surgical factors at admission, associated with conversion to open surgery using a univariate model. The associated factors evaluated during initial analysis were then included in a multivariate analysis. Finally a comparative analysis was made of the morbidity and mortality in both models.

RESULTS

A total of 703 patients were included. Conversion rate was 13.8%. Univariate analysis identified as factors: male gender, previous ERCP, leucocytes>12,000 mm(3), age>70 years, hypertension, jaundice, cholangitis, total bilirubin>2mg/dl, ASA III-IV, gallbladder wall enlargement and choledocholithiasis. Logistic regression identified as predictive factors: previous ERCP, leucocytes, age>70 years and male gender. Converted patients had a higher morbidity rate, further operations and longer hospital stays (P<.001). No difference was seen in mortality.

DISCUSSION

It is important to recognise patients with a higher risk of conversion in order to optimise planning and performing of the surgical procedure, and to decrease the morbidity associated with laparotomy, given that the independent factors identified are not modifiable.

Umbilical cord transection in twin-reverse arterial perfusion syndrome with the use of a coaxial bipolar electrode (Versapoint®)

Umbilical-cord occlusion has been proposed for the treatment of twin-reverse arterial perfusion syndrome (TRAP). Transection of the umbilical cord is necessary in patients with monoamniotic or 'pseudomonoamniotic' TRAP to avoid subsequent cord entanglement and demise of the pump twin. We present a case of TRAP in which the umbilical cord was successfully ligated with suture and transected with the Versapoint electrode.

[Evaluation of diagnostic scales for appendicitis in patients with lower abdominal pain]

INTRODUCTION

Diagnosis of apendicitis is difficult; however several clinical scales have been developed that attempt to improve diagnostic accuracy.

OBJECTIVE

The operational characteristics of Alvarado and Fenyö scales were defined in patients with abdominal pain suggestive of appendicitis and were compare with clinical and pathological diagnoses.

MATERIAL AND METHODS

A prospective trial assessed the diagnostic tests. Sign, symptoms, and laboratory tests were included in scales selected. Surgeon decision was maintained independent from the results of the scales. Sensitivity, specificity, positive and negative predictive value and positive and negative likelihood ratio for each scale was compared with the surgeon evaluation.

RESULTS

The sample included 374 patients with approximately equal sexes. Of these 269 patients underwent surgery. Howeve, 16.9% of the male and 31.4% of female patients did not have appendicitis. For men, a diagnosis made by the surgeon had better sensitivity than scales (86.2% vs. 73% for Alvarado and 67.2% for Fenyö) without significant differences in specificity. For women, surgeon and Alvarado scale diagnoses were similar, and better than Fenyö scale (77.1% vs. 79.5% for Alvarado and 47% for Fenyö), but specificity was higher for Fenyö scale (92.9% vs. 71.4% for Alvarado and 75.9% for surgeon). Accuracy in diagnosis of appendicitis increases with a higher Alvarado score.

CONCLUSION

For men with abdominal pain on right lower quadrant, surgeon diagnosis is more accurate than scales. For women, Fenyö scale offers a better sensitivity. Alvarado score can facilitate decision-making in patients with these abdominal symptoms.

Percutaneous ultrasound-guided sclerotherapy for complicated fetal intralobar bronchopulmonary sequestration

Bronchopulmonary sequestration (BPS), which can be intralobar or extralobar, is a rare developmental anomaly of the lung characterized by nonfunctional pulmonary tissue without communication with the tracheobronchial tree and with an aberrant systemic arterial blood supply. The intralobar type is typically within the pleural cavity with an arterial feeding vessel generally arising from the thoracic aorta and with venous drainage into the left atrium. The prognosis is poor in cases diagnosed before 26 weeks' gestation and when there is mediastinal shift, polyhydramnios and fetal hydrops. The ideal prenatal management option remains undefined. We present a series of three complicated cases of intralobar BPS treated prenatally with percutaneous ultrasound-guided fetal sclerotherapy (FST). The feeding vessel was successfully accessed percutaneously under ultrasound guidance in all cases. FST with polidocanol resulted in complete obliteration of the blood flow to the mass. Abnormal Doppler findings, ascites, hydrops and polyhydramnios resolved and all patients were delivered at term. Antenatal treatment of patients with complicated BPS can be successfully achieved with FST, which is a simple and inexpensive technique. Comparison of risks and benefits of this approach with other techniques is warranted.

First case of simultaneous heart plus kidney transplantation in Chile: case report

Advanced renal disease is a formal contraindication to heart transplantation, and heart failure may make a patient ineligible for kidney transplantation. The International Society of Heart and Lung Transplantation has reported 336 simultaneous heart and kidney transplantations with a 70% rate of 5 year survival. Herein we have presented the first case of simultaneous heart plus kidney transplantation in Chile. The patient is a 62-year-old man with diabetes mellitus and arterial hypertension who in 1997 had a myocardial infarction with cardiogenic shock and acute renal failure. He underwent a coronary bypass but developed progressive heart failure, with an ejection fraction less than 20% and moderate mitral regurgitation. He required chronic hemodialysis and survived a cardiac arrest, receiving an implantable cardioverter defibrillator. Transplantation was performed in 2004 in 2 phases: initially a heart, followed by a kidney transplantation. Immunosuppression included Daclizumab, cyclosporine, mycophenolate mofetil (MMF) and steroids. He developed acute renal failure but did not receive dialysis. He left the hospital at 25 days posttransplantation. Two years following double transplantation, he has not shown acute rejection episodes of either the cardiac or the kidney graft. Both cardiac and renal functions are normal. In conclusion, simultaneous heart plus kidney transplantations offer a good alternative treatment for patients with advanced disease of both organs.

The role of Doppler studies in predicting individual intrauterine fetal demise after laser therapy for twin-twin transfusion syndrome

OBJECTIVE

To investigate the role of Doppler studies in predicting individual fetal demise in patients scheduled for selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS).

METHODS

Doppler studies of the umbilical artery, umbilical vein, ductus venosus, tricuspid valve regurgitation and middle cerebral artery were performed in the donor and recipient twins before and 24 hours after SLPCV. Results were analyzed cross-sectionally and longitudinally. As multiple comparisons were made, an a priori alpha rejection was set at P < 0.001.

RESULTS

One hundred and ten consecutive patients were available for analysis. Overall fetal survival was 68.6% (151/220) with at least one survivor in 88.2% (97/110) of cases. Absent or reversed end-diastolic velocity in the umbilical artery of the donor twin was the only preoperative Doppler result predictive of intrauterine fetal demise (IUFD) (10/15, 66.7%, P < 0.001). Postoperatively, reversed flow during atrial contraction in the ductus venosus of the donor twin showed a trend towards prediction of IUFD of this fetus (4/5, 80%, P = 0.007). No other Doppler studies, including the longitudinal analyses, were predictive of IUFD.

CONCLUSIONS

Our data suggest that preoperative absent or reversed end-diastolic velocity in the umbilical artery may be useful in predicting individual fetal demise of the donor twin in TTTS patients scheduled for SLPCV. This may reflect the role of decreased individual placental mass that may be associated with some donor twins. The inability of other Doppler studies to predict individual IUFD may be explained preoperatively by the effect of the interfetal vascular connections on the individual Doppler signals and postoperatively by the effect of surgery or the timing of the assessment. Our findings may be important in patient counseling, in furthering understanding of the disease, and perhaps in improving surgical technique.

Twin-twin transfusion syndrome with only superficial placental anastomoses: endoscopic and pathological evidence

Deep arteriovenous placental anastomoses in monochorionic placentas have been considered an essential etiological factor in twin-twin transfusion syndrome (TTTS). Moreover, some investigators have suggested that superficial anastomoses have a protective role. We report on confirmed cases of TTTS with only superficial anastomoses.

[A new method to evaluate xerostomia in Sjögren's syndrome]

The extension of wetting in a standardized piece of filter paper was used to evaluate saliva output in 26 patients with Sjogren syndrome and 101 control subjects. The mean value for normals was 33.6 +/- 6.8 mm/5 min without significant differences for age and sex. Corresponding value for patients with Sjogren syndrome was 11.8 +/- 13.9 Accordingly, this is a simple and sensitive method to quantify xerostomia.