Hiponatremia/Hyponatremia

Agosto 28, 2015. No. 2068

Diagnóstico y tratamiento de la hiponatremia: Guía AGREEing Diagnosis and management of hyponatraemia: AGREEing the guidelines. Maxwell AP. BMC Med. 2015 Feb 13;13:31. doi: 10.1186/s12916-015-0277-8. Abstract Hyponatraemia is a common electrolyte disorder associated with significant complications and controversies regarding its optimal management. Clinical practice guidelines and consensus statements have attempted to provide clinicians with evidence-based diagnostic and treatment strategies for hyponatraemia. Recently published guidance documents differ in their methods employed to review the quality of available evidence. Nagler et al. used the Appraisal of Guideline for Research and Evaluation (AGREE II) instrument in a systematic review of guidelines and consensus statements for the diagnosis and management of hyponatraemia. Nagler and colleagues highlighted the variability in methodological rigour applied to guideline development and inconsistencies between publications in relation to management of hyponatraemia (including the recommended rate of correction of a low serum sodium concentration). These differences could cause confusion for practising physicians managing patients with hyponatraemia. Please see related article: http://www.biomedcentral.com/1741-7015/12/231. PDF   Diagnóstico y manejo de la hiponatremia. Revisión sistemática de guías clínicas y consensos Diagnosis and treatment of hyponatremia: a systematic review of clinical practice guidelines and consensus statements. Nagler EV, Vanmassenhove J, van der Veer SN, Nistor I, Van Biesen W, Webster AC, Vanholder R. BMC Med. 2014 Dec 11;12:1. doi: 10.1186/s12916-014-0231-1. Abstract BACKGROUND: Hyponatremia is a common electrolyte disorder. Multiple organizations have published guidance documents to assist clinicians in managing hyponatremia. We aimed to explore the scope, content, and consistency of these documents. METHODS: We searched MEDLINE, EMBASE, and websites of guideline organizations and professional societies to September 2014 without language restriction for Clinical Practice Guidelines (defined as any document providing guidance informed by systematic literature review) and Consensus Statements (any other guidance document) developed specifically to guide differential diagnosis or treatment of hyponatremia. Four reviewers appraised guideline quality using the 23-item AGREE II instrument, which rates reporting of the guidance development process across six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Total scores were calculated as standardized averages by domain. RESULTS: We found ten guidance documents; five clinical practice guidelines and five consensus statements. Overall, quality was mixed: two clinical practice guidelines attained an average score of >50% for all of the domains, three rated the evidence in a systematic way and two graded strength of the recommendations. All five consensus statements received AGREE scores below 60% for each of the specific domains.The guidance documents varied widely in scope. All dealt with therapy and seven included recommendations on diagnosis, using serum osmolality to confirm hypotonic hyponatremia, and volume status, urinary sodium concentration, and urinary osmolality for further classification of the hyponatremia. They differed, however, in classification thresholds, what additional tests to consider, and when to initiate diagnostic work-up. Eight guidance documents advocated hypertonic NaCl in severely symptomatic, acute onset (<48 h) hyponatremia. In chronic (>48 h) or asymptomatic cases, recommended treatments were NaCl 0.9%, fluid restriction, and cause-specific therapy for hypovolemic, euvolemic, and hypervolemic hyponatremia, respectively. Eight guidance documents recommended limits for speed of increase of sodium concentration, but these varied between 8 and 12 mmol/L per 24 h. Inconsistencies also existed in the recommended dose of NaCl, its initial infusion speed, and which second line interventions to consider. CONCLUSIONS: Current guidance documents on the assessment and treatment of hyponatremia vary in methodological rigor and recommendations are not always consistent. PDF

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Ortopedia. Noticias

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Notificaciones diarias ⋅ 8 de septiembre de 2015
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Los últimos artículos publicados en Medwave son:

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• 23 de septiembre, inicio curso de “Calidad en los procesos asistenciales”. Detalles e inscripciones en http://ecampus.medwave.cl/?page_id=746
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Medwave 2015 Sep;15(8):e6258
http://dx.doi.org/10.5867/medwave.2015.08.6258


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Medwave 2015 ago;15(7):e6239
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Gabriel Rada (Chile)

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Embarazo patológico/Pathological pregnancy

Septiembre 12, 2015. No. 2083

Embarazo con co-morbilidades: Aspectos anestésicos durante cirugía Pregnancy with co-morbidities: Anesthetic aspects during operative intervention. Bajwa SJ1, Bajwa SK2, Ghuman GS1. Anesth Essays Res. 2013 Sep-Dec;7(3):294-301. doi: 10.4103/0259-1162.123207. Abstract The presence of co-morbidities during pregnancy can pose numerous challenges to the attending anesthesiologists during operative deliveries or during the provision of labor analgesia services. The presence of cardiac diseases, endocrinological disorders, respiratory diseases, renal pathologies, hepatic dysfunction, anemia, neurological and musculoskeletal disorders, connective tissue diseases and many others not only influence the obstetric outcome, but can significantly impact the anesthetic technique. The choice of anesthesia during the pregnancy depends upon the type of surgery, the period of gestation, the site of surgery, general condition of patient and so on. Whatever, the anesthetic technique is chosen the methodology should be based on evidentially supported literature and the clinical judgment of the attending anesthesiologist. The list of co-morbid diseases is unending. However, the present review describes the common co-morbidities encountered during pregnancy and their anesthetic management during operative deliveries. KEYWORDS: Anemia; anesthesia; asthma; cardiac diseases; critically ill; diabetes mellitus; pregnancy PDF Entendiendo y tratando pacientes embarazadas con lupus Understanding and Managing Pregnancy in Patients with Lupus. de Jesus GR, Mendoza-Pinto C, de Jesus NR, Dos Santos FC, Klumb EM, Carrasco MG, Levy RA. Autoimmune Dis. 2015;2015:943490. doi: 10.1155/2015/943490. Epub 2015 Jul 12. Abstract Systemic lupus erythematosus (SLE) is a chronic, multisystemic autoimmune disease that occurs predominantly in women of fertile age. The association of SLE and pregnancy, mainly with active disease and especially with nephritis, has poorer pregnancy outcomes, with increased frequency of preeclampsia, fetal loss, prematurity, growth restriction, and newborns small for gestational age. Therefore, SLE pregnancies are considered high risk condition, should be monitored frequently during pregnancy and delivery should occur in a controlled setting. Pregnancy induces dramatic immune and neuroendocrine changes in the maternal body in order to protect the fetus from immunologic attack and these modifications can be affected by SLE. The risk of flares depends on the level of maternal disease activity in the 6-12 months before conception and is higher in women with repeated flares before conception, in those who discontinue useful medications and in women with active glomerulonephritis at conception. It is a challenge to differentiate lupus nephritis from preeclampsia and, in this context, the angiogenic and antiangiogenic cytokines are promising. Prenatal care of pregnant patients with SLE requires close collaboration between rheumatologist and obstetrician. Planning pregnancy is essential to increase the probability of successful pregnancies. PDF   Encefalitis anti-NMDA receptor en una mujer embarazada Anti-NMDA Receptor Encephalitis in a Pregnant Woman. Kim J, Park SH, Jung YR, Park SW, Jung DS. J Epilepsy Res. 2015 Jun 30;5(1):29-32. doi: 10.14581/jer.15008. eCollection 2015. Abstract Anti N-methyl-D-aspartate (NMDA) receptor encephalitis is one of the most common types of autoimmune synaptic encephalitis. Anti-NMDA receptor encephalitis commonly occurs in young women with ovarian teratoma. It has variable clinical manifestations and treatment responses. Sometimes it is misdiagnosed as a psychiatric disorder or viral encephalitis. To the best of our knowledge, anti-NMDA receptor encephalitis is a rare condition in pregnant women. We report a case of anti-NMDA receptor encephalitis in a pregnant woman who presented with abnormal behavior, epileptic seizure, and hypoventilation. KEYWORDS: NMDA receptor antibodies; Outcome; Ovarian teratoma; Pregnancy PDF  Análisis retrospectivo de la evolución pacientes obstétricas en la UCI de un hospital de tercer nivel de atención A retrospective analysis of obstetric patient's outcome in intensive care unit of a tertiary care center. Gombar S, Ahuja V, Jafra A. J Anaesthesiol Clin Pharmacol. 2014 Oct;30(4):502-7. doi: 10.4103/0970-9185.142843. Abstract BACKGROUND AND AIMS: Admission to an intensive care unit (ICU) is considered as an objective marker of severe maternal morbidity. The aim was to assess the incidence and possible risk factors of obstetric patient admissions in the multidisciplinary ICU of a tertiary care center with emphasis on standardized mortality ratio (SMR).MATERIAL AND METHODS: A retrospective five year ICU record analysis was done for all pregnant women, who were admitted to multidisciplinary ICU of a tertiary care hospital during June 2007-12.RESULTS: During this 5-year period, 21,943 deliveries took place and 164 women required ICU admission. Out of these, the data of 151 patients were analyzed. Maternal mortality rate was 31.1% (47 deaths) for patients admitted to ICU. The simplified acute physiologic score (SAPS) II was 62 (55-68) in nonsurvivor versus 34.00 (28-46) in survivor group (P value < 0.001). The receiver operated characteristic curve was plotted using SAPS II scores and the area under the curve was 0.93 with 95% confidence interval (0.89-0.96). The calculated SMR was 0.97. CONCLUSIONS: Women admitted to ICU with diagnosis of puerperal sepsis and intrauterine death (IUD) with coexisting sepsis had higher mortality as compared to women with hypertensive disease of pregnancy and hemorrhage. The calculated SMR was less than one which is a predictor of good ICU care. KEYWORDS: Developing countries; ICU; IUD; SAPS II; obstetric; obstetric hemorrhage; preeclampsia; pregnancy; puerperal sepsis PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Lesión masiva de mango rotador y su reparación artroscopica

En este video mostramos una lesión masiva de mango rotador y su reparación artroscopica El manguito de los rotadores...
Posted by Dr. Francisco Cruz Ortopedia del Deporte de Alto Rendimiento México on Viernes, 11 de septiembre de 2015

Cirugía bariátrica y embarazo/Bariatric surgery and pregnancy

Septiembre 8, 2015. No. 2079

Nutrición y embarazo después de cirugía bariátrica Nutrition and pregnancy after bariatric surgery. Kaska L, Kobiela J, Abacjew-Chmylko A, Chmylko L, Wojanowska-Pindel M, Kobiela P, Walerzak A,Makarewicz W, Proczko-Markuszewska M, Stefaniak T. ISRN Obes. 2013 Jan 30;2013:492060. doi: 10.1155/2013/492060. eCollection 2013. Abstract Obesity is an escalating problem in all age groups and it is observed to be more common in females than males. About 25% of women meet the criteria of obesity and one-third of them are in the reproductive age. Because morbid obesity requiring surgical treatment is observed with increasing frequency, surgeons and gynecologists are undergoing new challenges. It is not only a matter of women's health and their quality of life but also proper development of the fetus, which should be a concern during bariatric treatment. Therefore complex perinatal care has to be provided for morbid obesity patients. The paper reviews pregnancy and fertility issues in bariatric surgery patients. PDF Efectos de la cirugía de bypass gástrico sobre la función reproductiva femenina Effects of gastric bypass surgery on female reproductive function. Legro RS, Dodson WC, Gnatuk CL, Estes SJ, Kunselman AR, Meadows JW, Kesner JS, Krieg EF Jr,Rogers AM, Haluck RS, Cooney RN. J Clin Endocrinol Metab. 2012 Dec;97(12):4540-8. doi: 10.1210/jc.2012-2205. Epub 2012 Oct 12. Abstract CONTEXT: Reproductive function may improve after bariatric surgery, although the mechanisms and time-related changes are unclear. OBJECTIVE: The objective of the study was to determine whether ovulation frequency/quality as well as associated reproductive parameters improve after Roux en Y gastric bypass surgery. DESIGN: This was a prospective cohort study that enrolled female subjects from 2005 to 2008 with study visits at baseline and then 1, 3, 6, 12, and up to 24 months after surgery. SETTING: The study was conducted at an academic health center. PATIENTS: Twenty-nine obese, reproductive-aged women not using confounding medications participated in the study. MAIN OUTCOME MEASURES: The primary outcome was integrated levels of urinary progestin (pregnanediol 3-glururonide) from daily urinary collections at 12 months postoperatively. Secondary outcomes were changes in vaginal bleeding, other biometric, hormonal, ultrasound, dual-energy x-ray absorptiometry measures, and Female Sexual Function Index. RESULTS: Ninety percent of patients with morbid obesity had ovulatory cycles at baseline, and the ovulatory frequency and luteal phase quality (based on integrated pregnanediol 3-glururonide levels) were not modified by bariatric surgery. The follicular phase was shorter postoperatively [6.5 d shorter at 3 months and 7.9-8.9 d shorter at 6-24 months (P < 0.01)]. Biochemical hyperandrogenism improved, largely due to an immediate postoperative increase in serum SHBG levels (P < 0.01), with no change in clinical hyperandrogenism (sebum production, acne, hirsutism). Bone density was preserved, contrasting with a significant loss of lean muscle mass and fat (P < 0.001), reflecting preferential abdominal fat loss (P < 0.001). Female sexual function improved 28% (P = 0.02) by 12 months. CONCLUSIONS: Ovulation persists despite morbid obesity and the changes from bypass surgery. Reproductive function after surgery is characterized by a shortened follicular phase and improved female sexual function. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015