Sepsis Code: dodging mortality in a tertiary hospital

Introducción

En el hospital de La Princesa comienza el “Código Sepsis” (CSP) en el año 2015, como un grupo multidisciplinar que dota al personal sanitario de herramientas clínicas, analíticas y organizativas, con el objetivo de la detección y el tratamiento precoz del paciente con sepsis. El objetivo de este estudio es evaluar el impacto de la implantación de CSP en la mortalidad y determinar las variables asociadas con un aumento de la misma.

Material y métodos

Se realizó un estudio analítico retrospectivo de los pacientes con activación de la alerta CSP de 2015 a 2018. Se recogieron variables clínico-epidemiológicas, parámetros analíticos y factores de gravedad como el ingreso en Unidades de Cuidados Críticos (UCC) y la necesidad de aminas. La significación estadística se estableció en una p < 0,05.

Resultados

Se incluyeron 1.121 pacientes. La estancia media fue de 16 días y un 32% requirieron ingreso en UCC. La mortalidad mostró una tendencia lineal descendente estadísticamente significativa del 24% en 2015 hasta el 15% en 2018. Las variables predictivas de mortalidad con asociación estadísticamente significativa fueron el lactato > 2 mmol/L, la creatinina > 1,6 mg/dL y la necesidad de aminas.

Conclusiones

La implementación de Código Sepsis disminuye la mortalidad de los pacientes con sepsis y shock séptico. La presencia de una cifra de lactato > 2 mmol/L, los niveles de creatinina > 1,6 mg/dL y/o la necesidad de administrar aminas en las primeras 24 horas, se asocian con un aumento de la mortalidad en el paciente con sepsis.

Taphonomy and chronosequence of the 709 ka Kalinga site formation (Luzon Island, Philippines)

The recently described site of Kalinga in the Philippines adds to our understanding of Early-Middle Pleistocene hominin behaviour. Yet, disentangling the natural from the anthropogenic modifications that have taken place in such an old archaeological site is challenging. In this paper we use a set of taphonomic tools at hand to rectify the distortion made by natural processes during the formation of the Kalinga site. From the description of the ribs completeness, surface damages and scattering in the excavation, one can reconstruct the butchery, transport and deposition sequence of the rhino carcass and its post-depositional disturbances and diagenetic evolution of the site. We conclude that the rhino and the stone artefacts potentially used to deflesh the carcass were transported by a mudflow from its butchery place over a few meters only and got stuck and mixed with an older faunal assemblage that was transported by a small stream.

High-mountain altitudinal gradient influences thermal ecology of the Mesquite Lizard (Sceloporus grammicus)

The thermal requirements of ectotherms may vary among species due to adaptation to different thermal environments. Nevertheless, some of these requirements are evolutionarily conserved, leading organisms to compensate behaviorally for harsh environmental conditions. High-mountain systems provide temperature gradients that allow for studies of evolutionary and plastic variation in thermal ecology under natural conditions. We evaluated the thermoregulation strategies of Sceloporus grammicus Wiegmann, 1828 at three points (2600, 3100, and 4150 m above sea level) along an altitudinal gradient. We found that the thermal quality of the site and the body temperatures of lizards are influenced by altitude and decrease with increasing elevation. However, lizards from the three different elevations have similar thermal requirements. High-altitude lizards have lower thermal accuracy and efficiency indices compared with those from the lower sites, owing to the low thermal quality of their environment. Nevertheless, they are efficient in thermoregulation, increasing their body temperature above the ambient temperature. We found that pregnant females from all three elevations had similar preferred body temperatures. Compared with nonpregnant females and males, they exhibited lower preferred temperatures and more accurate thermoregulation. The wide altitudinal distribution of S. grammicus is thus not caused by variable thermal requirements. Instead, the wide repertoire of physiological and behavioral strategies of these lizards allows this species to successfully inhabit contrasting environments.

Mothers and offspring: The rabbit as a model system in the study of mammalian maternal behavior and sibling interactions

This article is part of a Special Issue "Parental Care". Jay Rosenblatt effectively promoted research on rabbit maternal behavior through his interaction with colleagues in Mexico. Here we review the activities of pregnant and lactating rabbits (Oryctolagus cuniculus), their neuro-hormonal regulation, and the synchronization of behavior between mother and kits. Changing concentrations of estradiol, progesterone, and prolactin throughout gestation regulate nest-building (digging, straw-carrying, fur-pulling) and prime the mother's brain to respond to the newborn. Nursing is the only mother-young contact throughout lactation. It happens once/day, inside the nest, with ca. 24h periodicity, and lasts around 3min. Periodicity and duration of nursing depend on a threshold of suckling as procedures reducing the amount of nipple stimulation interfere with the temporal aspects of nursing, though not with the doe's maternal motivation. Synchronization between mother and kits, critical for nursing, relies on: a) the production of pheromonal cues which guide the young to the mother's nipples for suckling; b) an endogenous circadian rhythm of anticipatory activity in the young, present since birth. Milk intake entrains the kits' locomotor behavior, corticosterone secretion, and the activity of several brain structures. Sibling interactions within the huddle, largely determined by body mass at birth, are important for: a) maintaining body temperature; b) ensuring normal neuromotor and social development. Suckling maintains nursing behavior past the period of abundant milk production but abrupt and efficient weaning occurs in concurrently pregnant-lactating does by unknown factors.

CONCLUSION

female rabbits have evolved a reproductive strategy largely dissociating maternal care from maternal presence, whose multifactorial regulation warrants future investigations.

Abdominal cystic lymphangiomas in pediatrics: surgical approach and outcomes

BACKGROUND

Abdominal Cystic lymphangiomas (ACL) are uncommon benign masses usually presented during infancy. Although extremely rare, they may cause complications; therefore, the recommended therapy is surgical excision. The purpose of this study is to report our experience with the diagnosis and surgical treatment of ACL in pediatric population.

MATERIAL AND METHODS

From January 1994 to December 2009, 10 patients (6 females; 4 males) with diagnostic confirmation of ACL were retrospectively included in study. Children's age ranged between 9 months and 8 years (mean age at diagnosis was 2.5 years). Clinical presentation, cyst location, imaging studies employed, surgical approach and pathologic features were analyzed.

RESULTS

The most common symptom was abdominal pain but three cases were incidentally detected. One case had presented with acute abdomen after traumatic haemorrhage of the tumor. All patients were diagnosed with ultrasonography as first-line radiological study. MRI was used in last three cases. At surgery, concomitant bowel resection was necessary in 3 children. Location of the lesion (omentum, mesentery) did not influence the outcome but surgery was more difficult (operative time over three hours) in patients with lymphangioma affecting mesentery of the jejunum. Mean hospital stay after surgery was 6.7 days. Mean follow-up was 5.1 years. No recurrence of the cystic lymphangioma was noticed during follow-up. One case developed an intestinal occlusion due to bowel adhesions 1 year after surgery.

CONCLUSIONS

ACL usually affect infants and young children and may present with spectrum of symptoms from an incidental finding to an acute life-threatening abdominal obstruction. Complete excision of the tumor is a safe and effective method in the management of ACL in pediatric population. Surgery is mandatory to avoid potential complications.

Thermal benefit of sibling presence in the newborn rabbit

Newborn rabbits compete vigorously for the mother's milk, and survivors benefit from littermate deaths. Here we report that rabbit pups also may benefit from littermate presence in terms of increased thermal efficiency. Pups nursed normally once a day by their mother but otherwise raised alone had a lower probability of survival, lower body temperature, and lower efficiency of converting milk into body mass than their siblings raised with littermates. The contribution of a more favorable thermal environment to the better growth and survival of group-raised pups was supported by the finding that single pups raised at higher ambient temperatures grew more rapidly than single pups raised at lower temperatures. These effects were most clearly seen across Days 2 to 5, after which time differences between treatment groups were no longer significant. Thus, the results of this study suggest that the benefits as well as costs of having siblings must be weighed against each other when considering the manner in which sibling presence influences individual development and survival.

[Maze technique for the treatment of auricular fibrillation: initial experience]

INTRODUCTION AND OBJECTIVES

The MAZE procedure was developed as a surgical approach to the management of patients with atrial fibrillation refractory to medical treatment. This study seeks to identify the risk and benefits of adding the MAZE procedure in patients with atrial fibrillation undergoing surgery for underlying organic cardiac disorders.

MATERIAL AND METHODS

Since november 1993, we have performed 10 interventions with the MAZE procedure, for the treatment of refractory atrial fibrillation. The indication to perform the technique was systemic embolism in 5 patients, contraindication for the anticoagulant treatment in two cases and no response to antiarrhythmic treatment in 5 cases. Two patients had more than one indication. In all the cases another surgical procedure was performed, 5 replacements of mitral valve, a mitral repair, one tricuspid repair and tree repairs of an atrial septal defect.

RESULTS

Soon after surgery 9 patients were in sinus rhythm, and one in atrial fibrillation. Four patients needed atrial pacing during the first days. One patient required a pacemaker due to symptomatic sinus bradycardia. During the first 3 months, 4 patients had episodes of paroxysmal atrial fibrillation and flutter. One patient died suddenly one month after surgery. Seven patients have completed two years of follow-up, and are in stable sinus rhythm, in functional class I and free of antiarrhythmic drugs. All of them have echocardiographic evidence of mechanical activity in both atria. Left atrium had been reduced from 5.3 +/- 0.7 cm to 4.5 +/- 0.7 cm (p < 0.05). No patient has presented new embolic events.

CONCLUSIONS

The MAZE procedure is a good choice in selected patients with atrial fibrillation refractory to medical treatment, or a precedent of systemic embolism. However, several problems can complicate the patient's course.

[The absence of interference between GSM mobile telephones and implantable defibrillators: an in-vivo study. Groupe Systèmes Mobiles]

INTRODUCTION AND OBJECTIVES

The electromagnetic field created by mobile telephones can cause pacemaker dysfunction. Although implantable cardioverter defibrillators are also susceptible to electromagnetic interference, few studies have addressed this issue and compatibility with the GSM mode has not been tested. This study was developed to detect possible "in vivo" interference between GSM mobile telephones and implantable cardioverter defibrillators.

MATERIAL AND METHODS

The study group is composed of 30 patients with 8 different models of defibrillators. Twenty six had endocardial leads and 4 epicardial. Three GSM mobile phones were used: Siemens S3 COM and Motorola 6200 in all cases and Ericsson GA 318 in one. The tests were performed under continuous electrocardiographic monitoring. All therapies were deactivated and sensitivities were set to maximal parameters. The telephones were positioned in close contact to the defibrillator can and precordium, in two different angles. Three situations were evaluated: calling, established contact for 15 seconds and ringing. The protocol was repeated during pacing to assess the possibility of pacemaker mode inhibition.

RESULTS

No cases of electromagnetic interference were observed. One patient presented non-sustained ventricular tachycardia episodes during the tests that were detected by the defibrillator.

CONCLUSIONS

These results suggest that electromagnetic interference by GSM mobile phones are not a probable cause of implantable defibrillators dysfunction.

Motor function of the esophagus after caustic burn

During the subacute and chronic phases of esophagitis due to ingestion of a caustic substance, the patient commonly displays stricture, esophageal rigidity and dysphagia. We used esophageal manometry, radiology, pH monitoring and 99mTc scintigraphy to investigate esophageal motor function in 25 children (mean age 24 +/- 7 months) with chronic esophagitis after second- and/or third-degree caustic burns. The results were compared with those for a control group of 12 children (mean age 32 +/- 19 months) under surveillance for suspected gastroesophageal reflux (GER) but for whom this pathology was later ruled out. Seventeen (68%) of the lesioned-group children showed esophageal dysfunction as revealed by monitoring of pH over a 24-hour period. Over this period, the mean percentage of time with pH below 4 was 19 +/- 10%, the mean number of reflux episodes was 48 +/- 52, the mean number of reflux episodes lasting longer than 5 min was 10 +/- 5, and the mean duration of the longest reflux episode was 51 +/- 21 min. Manometry indicated that, in the lesioned group, an average of 77 +/- 18% of peristaltic waves were nonpropulsive, while the mean Esophageal Work Index (number of propulsive waves per hour x mean maximum pressure developed during propulsive waves) was 227 +/- 192 units. All of the above means were significantly different (p < 0.01) from the corresponding control-group means. Esophageal strictures were observed in 60% (15) of the children. In 2 cases it was minimal, 2 cases moderate and 11 cases had severe strictures. 99mTc scintigraphy indicated that esophageal transit was slightly delayed in four, moderately delayed in five and severely delayed in 16 of the lesioned-group subjects. There was close correspondence between the results of manometry and scintigraphy as regards severity of esophageal dysfunction. These results indicate that motility disturbances and GER are very frequent sequelae of caustic burns of the esophagus, and should be taken into account when evaluating symptoms and deciding on the therapeutic strategy (including diet) to be followed.

Effects of prednisolone and dexamethasone in children with alkali burns of the oesophagus

We compared the efficacies of prednisolone and dexamethasone for treatment of children with oesophageal burns due to ingestion of caustic substances. The criteria of efficacy used were a) stricture severity by 3 weeks post-ingestion, b) reduction in burn severity by 3 weeks post-ingestion and c) number of dilatations required over the first year post-ingestion. Thirty-six children (24 boys and 12 girls; mean age 23.6 +/- 7.4 months) were selected from a total of 63 patients admitted over a ten-year period to the General Hospital of Galicia with second- or third-degree oesophageal burns due to accidental ingestion of liquid alkali preparations. The patients were divided into two groups of 18, one group for treatment with prednisolone (2 mg/kg/day) and the other for treatment with dexamethasone (1 mg/kg/day). Strictures developed in 12 (66.7%) of the children in the prednisolone-treated group and only 7 (38.9%) of the children in the dexamethasone-treated group. Severe strictures developed in 10 (55.6%) of the children in the prednisolone-treated group and only 5 (27.8%) of the children in the dexamethasone treated group. However, there was no significant difference between the groups in the posttreatment distribution of stricture-severity ratings. Burn healing was significantly better in the dexamethasone-treated group. Similarly, the number of dilatations necessary during the first year of treatment was significantly lower in the dexamethasone-treated group. Our results thus indicate that, by comparison with prednisolone, dexamethasone leads to improved burn healing and reduced need for dialatations during the first year post-injury.

Effects of prednisolone and dexamethasone on alkali burns of the esophagus in rabbit

Steroids have been widely used to prevent the severe secondary strictures that inevitably follow accidental ingestion of caustic substances by children, though with controversial results. To confirm the efficacy of large early doses of dexamethasone, we conducted an experimental study in rabbits. A cotton swab soaked in sodium hydroxide was placed on the esophageal mucosa of 30 rabbits. The rabbits were then treated with antibiotics and randomly allocated to one of three groups. One group received no steroids; the second group was treated with prednisolone; and the third was given dexamethasone. After 21 days, the rabbits were killed and the severity of the lesion was evaluated by radiological, anatomical, and histological examination. Rabbits with moderate or severe stricture, as defined on the basis of radiological examination, made up 80% of the control group, 70% of the prednisolone-treated group, and 40% of the dexamethasone-treated group. Rabbits with third-degree burns, with or without macroscopic ulcers, made up 60% of the control group, 40% of the prednisolone-treated group, and 30% of the dexamethasone-treated group. On histological examination, rabbits with third-degree lesions made up 70% of the control group, 40% of the prednisolone-treated group, and only 20% of the dexamethasone-treated group. Only the difference between the control and dexamethasone-treated group was statistically significant. Taken together, our results clearly indicate that, in rabbits, rapid postburn administration of dexamethasone leads to significant reductions in the frequency and severity of strictures and in the severity of burns.

Intrapartum suctioning of meconium: comparative efficacy of bulb syringe and De Lee catheter

Intrapartum suctioning of the newborn's pharynx with a De Lee catheter (DL) has reduced the incidence of meconium aspiration syndrome (MAS) in neonates born with meconium staining of the amniotic fluid. However, the bulb syringe (BLB) is used more often for this purpose because of greater technical convenience. In a prospective study, 60 offspring of such deliveries received intrapartum pharyngeal suctioning either by BLB (29 cases) or by DL (31 cases), according to random selection. The presence and amount of meconium in the trachea, incidence and severity of MAS, and mortality from the disease were similar between the two groups. This study suggests that the BLB is as effective as the DL for intrapartum removal of nasopharyngeal meconium in deliveries with meconium staining of the amniotic fluid. Since the BLB is easier to use, less expensive and probably safer, our results suggest that it may be the preferable method.

Absorption and tolerance of lactose in infants recovering from severe diarrhea

Nineteen infants were challenged during their convalescence from severe diarrhea with a lactose-containing meal. Twenty-four hour intake, pre- and post-challenge breath H2 levels, clinical responses, and growth were measured at approximately biweekly intervals for 3 months beginning 1 month after hospital discharge. Ten lactose-tolerant infants were assigned randomly to receive one of two formulas similar in composition except for carbohydrates: lactose (Group L) (n = 6) and sucrose (Group S) (n = 4). Infants in Group L had greater intakes and growth rates during the initial 15 days of the study. No difference in weight for age z-scores was detected between groups at the end of the observation period. Infants in Group L had higher baseline and peak breath H2 levels indicating greater colonic carbohydrate fermentation than infants in Group S: however, breath H2 levels were not predictive of tolerance to lactose-containing meals. Carbohydrate absorption by infants in Group S appeared to exceed that of infants in Group L. Thus, colonic fermentation of malabsorbed carbohydrate may have prevented diarrhea and allowed acceptable rates of catch-up growth.

The effects of oral iodized oil on intelligence, thyroid status, and somatic growth in school-age children from an area of endemic goiter

One hundred goitrous school children received 475 mg iodized oil by mouth, while 100 controls received mineral oil, on a double-blind basis. On follow-up 22 months later the urinary iodine had increased and goiter size had decreased in both groups, more strikingly in the iodine-treated children. There were no consistent differences between the two treatment groups in rate of somatic growth or performance on the Stanford-Binet and Bender tests. Because of the complexities introduced by increases in urinary iodine in the controls, we compared goiter reduction with improvement in IQ score in all children, regardless of group, and found a significant relationship (p = 0.014), particularly in girls (p = 0.029). We conclude that oral iodized oil is an attractive alternative to its injection but we recommend an approximate doubling of the dose used here for more effective control. Also, while our data are not conclusive, they support the possibility that correction of iodine deficiency may improve mental performance in school age children, particularly girls.

Lack of correlation between thyroid size and body growth in an area of endemic goiter

There is conflicting information in the literature about the relationship between thyroid size and body growth in endemic goiter. This study reports data from highland Bolivia where 408 children were examined for thyroid size, height, weight, head circumference, and academic performance, the latter as measured by teacher evaluation. The presence or size of goiter showed no consistent correlation with height, weight, or head circumference. School performance was significantly correlated with all other variables in boys and not in girls, but there are severe limitations involved in the use of school grades alone for assessment of intelligence. Height and weight were less than for normals in the United States at each age level, but did not differ from those of other Quechuan children in neighboring Peru who were reportedly nongoitrous. Our data support the conclusion that there is no clear relationship between thyroid size and body growth in areas of endemic goiter.