miércoles, 12 de enero de 2011

Is Law School a Losing Game?

Is Law School a Losing Game?

IF there is ever a class in how to remain calm while trapped beneath $250,000 in loans, Michael Wallerstein ought to teach it.
Peter and Maria Hoey
Sally Ryan for The New York Times
Kimber A. Russell, who has a J.D., writes a blog about the high debts and grim job prospects facing law school graduates.
Here he is, sitting one afternoon at a restaurant on the Upper East Side of Manhattan, a tall, sandy-haired, 27-year-old radiating a kind of surfer-dude serenity. His secret, if that’s the right word, is to pretty much ignore all the calls and letters that he receives every day from the dozen or so creditors now hounding him for cash.
“And I don’t open the e-mail alerts with my credit score,” he adds. “I can’t look at my credit score any more.”
Mr. Wallerstein, who can’t afford to pay down interest and thus watches the outstanding loan balance grow, is in roughly the same financial hell as people who bought more home than they could afford during the real estate boom. But creditors can’t foreclose on him because he didn’t spend the money on a house.
He spent it on a law degree. And from every angle, this now looks like a catastrophic investment.
Well, every angle except one: the view from law schools. To judge from data that law schools collect, and which is published in the closely parsed U.S. News and World Report annual rankings, the prospects of young doctors of jurisprudence are downright rosy.
In reality, and based on every other source of information, Mr. Wallerstein and a generation of J.D.’s face the grimmest job market in decades. Since 2008, some 15,000 attorney and legal-staff jobs at large firms have vanished, according to a Northwestern Law study. Associates have been laid off, partners nudged out the door and recruitment programs have been scaled back or eliminated.
And with corporations scrutinizing their legal expenses as never before, more entry-level legal work is now outsourced to contract temporary employees, both in the United States and in countries like India. It’s common to hear lawyers fret about the sort of tectonic shift that crushed the domestic steel industry decades ago.
But improbably enough, law schools have concluded that life for newly minted grads is getting sweeter, at least by one crucial measure. In 1997, when U.S. News first published a statistic called “graduates known to be employed nine months after graduation,” law schools reported an average employment rate of 84 percent. In the most recent U.S. News rankings, 93 percent of grads were working — nearly a 10-point jump.
In the Wonderland of these statistics, a remarkable number of law school grads are not just busy — they are raking it in. Many schools, even those that have failed to break into the U.S. News top 40, state that the median starting salary of graduates in the private sector is $160,000. That seems highly unlikely, given that Harvard and Yale, at the top of the pile, list the exact same figure.
How do law schools depict a feast amid so much famine?
Enron-type accounting standards have become the norm,” says William Henderson ofIndiana University, one of many exasperated law professors who are asking the American Bar Association to overhaul the way law schools assess themselves. “Every time I look at this data, I feel dirty.”
IT is an open secret, Professor Henderson and others say, that schools finesse survey information in dozens of ways. And the survey’s guidelines, which are established not by U.S. News but by the American Bar Association, in conjunction with an organization called the National Association for Law Placement, all but invite trimming.
A law grad, for instance, counts as “employed after nine months” even if he or she has a job that doesn’t require a law degree. Waiting tables at Applebee’s? You’re employed. Stocking aisles at Home Depot? You’re working, too.
Number-fudging games are endemic, professors and deans say, because the fortunes of law schools rise and fall on rankings, with reputations and huge sums of money hanging in the balance. You may think of law schools as training grounds for new lawyers, but that is just part of it.
They are also cash cows.
Tuition at even mediocre law schools can cost up to $43,000 a year. Those huge lecture-hall classes — remember “The Paper Chase”? — keep teaching costs down. There are no labs or expensive equipment to maintain. So much money flows into law schools that law professors are among the highest paid in academia, and law schools that are part of universities often subsidize the money-losing fields of higher education.
“If you’re a law school and you add 25 kids to your class, that’s a million dollars, and you don’t even have to hire another teacher,” says Allen Tanenbaum, a lawyer in Atlanta who led the American Bar Association’s commission on the impact of the economic crisis on the profession and legal needs. “That additional income goes straight to the bottom line.”
There were fewer complaints about fudging and subsidizing when legal jobs were plentiful. But student loans have always been the financial equivalent of chronic illnesses because there is no legal way to shake them. So the glut of diplomas, the dearth of jobs and those candy-coated employment statistics have now yielded a crop of furious young lawyers who say they mortgaged their future under false pretenses. You can sample their rage, and their admonitions, on what are known as law school scam blogs, with names likeShilling Me SoftlySubprime JD and Rose Colored Glasses.
“Avoid this overpriced sewer pit as if your life depended on it,” writes the anonymous author of the blog Third Tier Reality — a reference to the second-to-bottom tier of the U.S. News rankings — in a typically scatological review. “Unless, of course, you think that you will be better off with $110k-$190k in NON-DISCHARGEABLE debt for a degree that qualifies you to wait tables at the Battery Park Bar and Lounge.”
Jim Wilson/The New York Times
William Henderson of Indiana University says law schools have a moral obligation to tell the truth about themselves.
Michael Falco for The New York Times
Michael Wallerstein, who has a law degree, has $250,000 in loans and only the occasional job as a legal temp.
But so far, the warnings have been unheeded. Job openings for lawyers have plunged, but law schools are not dialing back enrollment. About 43,000 J.D.’s were handed out in 2009, 11 percent more than a decade earlier, and the number of law schools keeps rising — nine new ones in the last 10 years, and five more seeking approval to open in the future.
Apparently, there is no shortage of 22-year-olds who think that law school is the perfect place to wait out a lousy economy and the gasoline that fuels this system — federally backed student loans — is still widely available. But the legal market has always been obsessed with academic credentials, and today, few students except those with strong grade-point averages at top national and regional schools can expect a come-hither from a deep-pocketed firm. Nearly everyone else is in for a struggle. Which is why many law school professors privately are appalled by what they describe as a huge and continuing transfer of wealth, from students short on cash to richly salaried academics. Or perhaps this is more like a game of three-card monte, with law schools flipping the aces and a long line of eager players, most wagering borrowed cash, in a contest that few of them can win.
And all those losers can remain cash-poor for a long time. “I think the student loans that kids leave law school with are more scandalous than payday loans,” says Andrew Morriss, a law professor at the University of Alabama. “And because it’s so easy to get a student loan, law school tuitionhas grossly outpaced the rate of inflation for the last 20 years. It’s now astonishingly high.”
Like everything else about the law, however, the full picture here is complicated. Independent surveys find that most law students would enroll even if they knew that only a tiny number of them would wind up with six-figure salaries. Nearly all of them, it seems, are convinced that they’re going to win the ring toss at this carnival and bring home the stuffed bear.
And many students enroll for reasons other than immediate financial returns. Mr. Wallerstein, for instance, was drawn by the prestige of the degree. He has no regrets, at least for now, even though he seems doomed to a type of indentured servitude at least through his 30s.
“Law school might not be worth it for another 10 or 15 years,” he says, “but the riskier approach always has the bigger payoff.”
True, say Professor Henderson and his allies. But he contends that law schools — which, let’s not forget, require students to take courses on disclosure and ethics — have a special moral obligation to tell the truth about themselves. It’s an obligation that persists, he says, even if students would sign on the dotted line no matter what.
“You’re beginning your legal education at an institution that is engaging in the kind of disreputable practices that we would be incredibly disappointed to discover our graduates engaging in,” he says. “What we have here is powder keg, and if law schools don’t solve this problem, there will be a day when the Federal Trade Commission, or some plaintiff’s lawyer, shows up and says ‘This looks like illegal deception.’”
WHEN he started in 2006, Michael Wallerstein knew little about the Thomas Jefferson School of Law, other than that it was in San Diego, which seemed like a fine place to spend three years.
“I looked at schools in Pennsylvania and Long Island,” he says, “but I thought, why not go somewhere I’ll enjoy?”
Mr. Wallerstein is chatting over lunch one recent afternoon with his fiancée, Karin Michonski. She, too, seems unperturbed by his dizzying collection of i.o.u.’s. Despite those debts, she hopes that he does not wind up in one of those time-gobbling corporate law jobs.
“We like hanging out together,” she says with a laugh.
If love paid the bills, these two would be debt-free tomorrow. But it doesn’t, and Mr. Wallerstein has no money in the bank, no assets and — aside from the occasional job as a legal temp — no wages to garnish. He and Ms. Michonski live rent-free in a nearby brownstone, in return for keeping an eye on the elderly man who owns the place.
This article has been revised to reflect the following correction:
Correction: January 11, 2011
An earlier version of this article  misstated the educational history of Jason Bohn, a recent law school graduate. While Mr. Bohn took classes at Columbia Law School, his law degree is from the University of Florida. And while nearly all of his student loan debt was accumulated at Columbia University, it was incurred while he was an undergraduate and while working on a master’s degree, and not at Columbia Law.
“Sometimes the banks will threaten to sue,” he says, “but one of the first things you learn in law school, in civil procedure class, is that it doesn’t make sense to sue someone who doesn’t have anything.”

He remembers little about the promotional materials the Thomas Jefferson school sent when he applied in 2006, other than a pamphlet with lots of promising numbers. That was before the economy crumbled, but the school’s postgraduate data still looks fabulous, particularly given its spot in the fourth and bottom tier of U.S. News’s rankings. The most recent survey says 92 percent of Thomas Jefferson grads were employed nine months after they earned their degrees.
Beth Kransberger, associate dean of student affairs at Thomas Jefferson, stands by that figure, noting that it includes 25 percent of those graduates who could not be located, as well as anyone who went on to other graduate studies — all perfectly kosher under the guidelines.
Like lots of administrators, she defends the figures she gathers and laments that so many other schools are manipulating results.
“You need to take the high road,” she said. “Schools that are behaving the most ethically want students who come to law school with their eyes open.”
Even students with open eyes, though, will have a hard time sleuthing through the U.S. News rankings. They are based entirely on unaudited surveys conducted by each law school, using questions devised by the American Bar Association and the National Association for Law Placement. Given the stakes and given that the figures are not double-checked by an impartial body, each school faces exactly the sort of potential conflict of interest lawyers are trained to howl about.
The surveys themselves have a built-in bias. As many deans acknowledge, the results are skewed because graduates with high-paying jobs are more likely to respond than people earning $9 an hour at Radio Shack. (Those who don’t respond are basically invisible, aside from reducing the overall response rate of the survey.)
Certain definitions in the surveys seem open to abuse. A person is employed after nine months, for instance, if he or she is working on Feb. 15. This is the most competitive category — it counts for about one-seventh of the U.S. News ranking — and in the upper echelons, it’s not unusual to see claims of 99 percent and, in a handful of cases, 100 percent employment rates at nine months.
A number of law schools hire their own graduates, some in hourly temp jobs that, as it turns out, coincide with the magical date. Last year, for instance, Georgetown Law sent an e-mail to alums who were “still seeking employment.” It announced three newly created jobs in admissions, paying $20 an hour. The jobs just happened to start on Feb. 1 and lasted six weeks.
A spokeswoman for the school said that none of these grads were counted as “employed” as a result of these hourly jobs. In a lengthy exchange of e-mails and calls, several different explanations were offered, the oddest of which came from Gihan Fernando, the assistant dean of career services. He said in an interview that Georgetown Law had “lost track” of two of the three alums, even though they were working at the very institution that was looking for them.
As absurd as the rankings might sound, deans ignore them at their peril, and those who guide their schools higher up the U.S. News chart are rewarded with greater alumni donations, better students and jobs at higher-profile schools.
“When I was a candidate for this job,” said Phillip J. Closius, the dean of the University of Baltimore School of Law, “I said ‘I can talk for 10 minutes about the fallacies of the U.S. News rankings,’ but nobody wants to hear about fallacies. There are millions of dollars riding on students’ decisions about where to go to law school, and that creates real institutional pressures.”
Mr. Closius came from the University of Toledo College of Law, where he lifted the school to No. 83 from No. 140, he said. Among his strategies: shifting about 40 students with lower LSAT scores into the part-time program. Because part-time students didn’t then count in the U.S. News survey — the rules have since been changed — Toledo’s bar passage rate rose, which helped its ranking.
“You can call it massaging the data if you want, but I never saw it that way,” he says. Weaker students wound up with lighter course loads, which meant that fewer of them flunked out. In his estimation, a dean who pays attention to the U.S. News rankings isn’t gaming the system; he’s making the school better.
Unfortunately, he says, not all schools play fair.
Of course, fair play is hardly encouraged. Any institution with the guts to report, say, a 4 percent drop in postgraduate employment would plunge in the rankings, leaving the dean to explain a lot of convoluted math, and the case for unvarnished truth, to a bunch of angry students and alums.
Critics of the rankings often cast the issue in moral terms, but the problem, as many professors have noted, is structural. A school that does not aggressively manage its ranking will founder, and because there are no cops on this beat, there is no downside to creative accounting. In such circumstances, the numbers are bound to look cheerier, even as the legal market flat-lines.
“We ought to be doing a better job for our students and spend less time worrying about whether another school is five spots ahead,” says David N. Yellen, dean of the Loyola University Chicago School of Law. “But in the real world you can’t escape from the pressures. We’re all sort of trapped. I don’t know if anyone is out-and-out lying, but I do know that a lot of schools are hyping a lot of misleading statistics.”
WHEN Mr. Wallerstein started at Thomas Jefferson, he was in no mood for austerity. He borrowed so much that before the start of his first semester he nearly put a down payment on a $350,000 two-bedroom, two-bath condo, figuring that the investment would earn a profit by the time he graduated. He was ready to ink the deal until a rep at the mortgage giant Countrywide asked if his employer at the time — a trade magazine publisher in New Jersey — would write a letter falsely stating that he was moving to San Diego for work.
“We were on a three-way call with my real estate agent and I said I didn’t feel comfortable with that,” he says. “The Countrywide guy chuckled and said, ‘Everyone lies on their mortgage application.’ ”
Instead, Mr. Wallerstein rented a spacious apartment. He also spent a month studying in the South of France and a month in Prague — all on borrowed money. There were cost-of-living loans, and tuition of about $33,000 a year. Later came a $15,000 loan to cover months of studying for the bar.
Today, his best guess is that he should be sending $2,000 to $3,000 a month in total, to lenders that include Wells Fargo, Citibank and Sallie Mae.
“There are a bunch of others,” he says. “I’m not really good at keeping records.”
Mr. Wallerstein didn’t know it at the time, but Thomas Jefferson leads the nation’s law schools in at least one category: 95 percent of students graduate with debt, the highest rate in the U.S. News rankings.
The reason, Ms. Kransberger says, is that many Thomas Jefferson students are either immigrants or, like Mr. Wallerstein, the first person in their family to get a law degree; statistically those are both groups with generally little or modest means. When Ms. Kransberger meets applicants engaged in what she calls “magical thinking” about their finances, she advises them to defer for a year or two until they are on stronger footing.
“But I don’t think you can act as a moral educator,” she says. “Should we really be saying to students who don’t have family help, ‘No, you shouldn’t have access to law school’? That’s a tough argument to make.”

It’s an argument complicated by the reality that a small fraction of graduates are still winning the Big Law sweepstakes. Yes, they tend to hail from the finest law schools, and have the highest G.P.A.’s. But still.
“Who’s to say to any particular student, ‘You won’t be the one to get the $160,000-a-year job,’ ” says Steven Greenberger, a dean at the DePaul College of Law. “I think they should have all the info, and the info should be accurate, but saying once they know that they shouldn’t be allowed to come, that’s predicated on the idea that students are really ignorant and don’t know what is best for them.”
Based on the seething and regret you hear from some law school grads, more than a few wish that someone had been patronizing enough to say, “Oh no you don’t.” But it’s often hard to convince students about the potential downside of law school, says Kimber A. Russell, a 37-year-old graduate of DePaul, who writes the Shilling Me Softly blog.
“This idea of exceptionalism — I don’t know if it’s a thing with millennials, or what,” she says, referring to the generation now in its 20s. “Even if you tell them the bottom has fallen out of the legal market, they’re all convinced that none of the bad stuff will happen to them. It’s a serious, life-altering decision, going to law school, and you’re dealing with a lot of naïve students who have never had jobs, never paid real bills.”
Graduates who have been far more vigilant about their finances than Mr. Wallerstein are in trouble. Today, countless J.D.’s are paying their bills with jobs that have nothing do with the law, and they are losing ground on their debt every day. Stories are legion of young lawyers enlisting in the Army or folding pants at Lululemon. Or baby-sitting, like Carly Rosenberg, of the Brooklyn Law School class of 2009.
“I guess I kind of assumed that someone would hook me up with something,” she says. She has sent out 15 to 20 résumés a week since March, when she passed the bar. So far, nothing.
Jason Bohn, who received his J.D. from the University of Florida, is earning $33 an hour as a legal temp while strapped to more than $200,000 in loans, nearly all of which he accumulated as an undergraduate and while working on a master's degree at Columbia University.
“I grew up a ward of the state of New York, so I don’t have any parents to call for help,” Mr. Bohn says. “For my sanity, I have to think there is an end in sight.”
AS a student, Mr. Wallerstein assumed that the very scale of law school — all the paperwork, all the professors, all the tests — implied that pots of gold awaited anyone with smarts, charm and a willingness to work hard. He began to doubt that assumption when the firm where he had interned told him that it hadn’t been profitable for two years and could not offer him a full-time job.
Mr. Wallerstein and his fiancée moved back East after graduation, and he landed a job at a small firm in Queens. He says he was paid $10 an hour and worked for a manager who seemed to have walked straight out of a Dickens novel. Over a firm-wide lunch, as Labor Day approached, she asked employees to thank her, one at a time, for giving them the holiday off.
“When it was my turn, I said, ‘Labor Day is about celebrating the 40-hour workweek, weekends, that sort of thing,’ ” Mr. Wallerstein recalls. “She said, ‘Well, workers have that now so you don’t need a day off to celebrate it.’ ”
He lasted less than a month.
Since then, he has found jobs at temporary projects reviewing documents. The latest of these gigs is in office space rented on the 11th floor of the Viacom building in Times Square. He sits in a small, windowless room with five other lawyers, all clicking through page after page of documents on computers under fluorescent lights. The walls are bare except for the name of each lawyer, tacked overhead.
“Welcome to the veal pen,” said one during a tour two weeks ago.
The job is set up through a company called Peak Discovery, which put an ad on Craigslist, seeking 100 lawyers. “We got about 300 responses overnight,” said John Thacher, who is managing the project.



    Mr. Thacher has managed about 2,500 people in his six years in the temporary legal business, and maybe five of them have gone on to associate jobs in law firms, the kind of work that nearly everyone aspires to when entering law school.
    “Most of us either went to the wrong law school, which is the bottom two-thirds, or we were too old when we graduated,” he said. “I was 32 when I graduated, and at 32 you’re washed up in this field, in terms of a shot at the real deal. They perceived me as somebody they can’t indoctrinate into slave labor and work to death for seven years and then release if they don’t like you.”
    This gets to what might be the ultimate ugly truth about law school: plenty of those who borrow, study and glad-hand their way into the gated community of Big Law are miserable soon after they move in. The billable-hour business model pins them to their desks and devours their free time.
    Hence the cliché: law school is a pie-eating contest where the first prize is more pie.
    Law school defenders note that huge swaths of the country lack adequate and affordable access to lawyers, which suggests that the issue here isn’t oversupply so much as maldistribution. But when the numbers are crunched, studies find that most law students need to earn around $65,000 a year to get the upper hand on their debt.
    That kind of money is hard to earn hanging a shingle in rural Ohio or in public defenders’ offices, the budgets of which are often being cut. As elusive, and inhospitable, as jobs in Big Law may be, they are one of the few ways for new grads to keep out of delinquency.
    The mismatch of student expectations and likely postgraduate outcomes is starting to yield some embarrassing headlines. In October, a student at Boston College Law School made news by posting online an open letter to the dean, offering to leave the school if he could get his tuition money back.
    “With fatherhood impending,” wrote the student, whose name was redacted, “I go to bed every night terrified of the thought of trying to provide for my child AND paying off my J.D., and resentful at the thought that I was convinced to go to law school by empty promises of a fulfilling and remunerative career.”
    After a few years of warnings by concerned professors, the American Bar Association is now studying whether it should refine the questions in its surveys in order to get more realistic and useful statistics for the U.S. News rankings. In mid-December, the organization held a two-day hearing in Fort Lauderdale, Fla., about the collection of job placement data.
    “There is a legitimate question about whether we’re asking for detailed-enough info and displaying that info for those who use it,” says Bucky Askew of the bar association. “I think it’s fair to say we’re aware of the criticism and have a committee working to getting to the bottom of this.”
    And what about U.S. News? The editors could, but won’t unilaterally demand better data from law schools. “Do we have the power to do that? Yes, I think we do,” said Robert Morse, who oversees the law school rankings. “But we’d have to create a whole new definition of ‘employed,’ and it would be awkward if U.S. News imposed that definition by itself. It would be preferable if the A.B.A. took a leadership role in this.”
    Instead of overhauling the rankings, some professors say, the solution may be to get law schools and the bar association out of the stat-collection business. Steven Greenberger of DePaul recommends a mandatory warning — a bit like the labels on cigarette packs — that every student taking the LSAT, the prelaw standardized test, must read.
    “Something like ‘Law school tuition is expensive and here is what the actual cost will be, the job market is uncertain and you should carefully consider whether you want to pursue this degree,’ ” he says. “And it should be made absolutely clear to students, that if they sign up for X amount of debt, their monthly nut will be X in three years.”
    Another approach would be to limit class sizes or the number of new law schools. But the bar association, which is granted accrediting authority by the Department of Education, says that it would run afoul of antitrust law if it imposed such limits.
    Today, American law schools are like factories that no force has the power to slow down — not even the timeless dictates of supply and demand.
    Solving the J.D. overabundance problem, according to Professor Henderson, will have to involve one very drastic measure: a bunch of lower-tier law schools will need to close. But nobody inside of the legal establishment, he predicts, has the stomach for that. “Ultimately,” he says, “some public authority will have to step in because law schools and lawyers are incapable of policing themselves.”

    MR. WALLERSTEIN, for his part, is not complaining. Once you throw in the intangibles of having a J.D., he says, he is one of law schools’ satisfied customers.
    “It’s a prestige thing,” he says. “I’m an attorney. All of my friends see me as a person they look up to. They understand I’m in a lot of debt, but I’ve done something they feel they could never do and the respect and admiration is important.”
    Compared with the life he left four years ago, he has lost ground. That research position in Newark, he figures, would pay him $60,000 a year now, with benefits. Instead, he’s vying with a crowd for jobs that pay at rates just a little higher, but that last only a few weeks at a time, with no benefits. And he’s a quarter-million dollars in the hole.
    Unless, somehow, the debt just goes away. Another of Mr. Wallerstein’s techniques for remaining cool in a serious financial pickle: believe that the pickle might somehow disappear.
    “Bank bailouts, company bailouts — I don’t know, we’re the generation of bailouts,” he says in a hallway during a break from his Peak Discovery job. “And like, this debt of mine is just sort of, it’s a little illusory. I feel like at some point, I’ll negotiate it away, or they won’t collect it.”
    He gives a slight shrug and a smile as he heads back to work. “It could be worse,” he says. “It’s not like they can put me jail.”
    This article has been revised to reflect the following correction:
    Correction: January 11, 2011
    An earlier version of this article  misstated the educational history of Jason Bohn, a recent law school graduate. While Mr. Bohn took classes at Columbia Law School, his law degree is from the University of Florida. And while nearly all of his student loan debt was accumulated at Columbia University, it was incurred while he was an undergraduate and while working on a master’s degree, and not at Columbia Law
    .

    The Real Problem With China

    ECONOMIC SCENE

    The Real Problem With China

    WASHINGTON
    Carlos Barria/Reuters
    Chinese-made products at a wholesale market in Yiwu in Zhejiang Province. China has major barriers to foreign goods.
    When China’s president, Hu Jintao, visits here next week, the exchange rate between Chinese and American currency will inevitably become a big topic of conversation.
    China has been holding down the value of its currency, the renminbi, for years, making Chinese exports to the United States cheaper and American exports to China more expensive. The renminbi’s recent rise has been too modest to change the situation, and Mr. Hu’s state visit is sure to highlight the real tensions between the countries.
    Yet the focus on the currency has nonetheless become excessive. The truth is that the exchange rate is not the main problem for American companies hoping to sell more products in China and, in the process, create more jobs in this country. The exchange rate does not need to be the focus of next week’s meetings.
    For the United States, the No. 1 problem with China’s economy is probably intellectual property theft. Technology companies, for example, continue to notice Chinesegovernment agencies downloading software updates for programs they have never bought, at least not legally.
    No wonder China has become the world’s second-largest market for computer hardware sales — but is only the eighth-largest for software sales.
    Next on the list, say people who work in China or do business there, is the myriadprotectionist barriers China has put up. These barriers make this country’s recent efforts at“buy American” protectionism look minor league. In some cases, Beijing has insisted that products sold in China must not only be made there but be conceived and designed there. The policy goes by the name “indigenous innovation.”
    The renminbi certainly matters, too. It affects the price of every American product sold there and every Chinese product sold here. But discussion of the renminbi typically ends up exaggerating the problem somewhat by relying on an imperfect measure.
    The most relevant comparison of two currencies is one that is adjusted for inflation in the two countries. When inflation is higher in one country, as in China today, it means that country’s products are becoming more expensive — and imports into the country become relatively cheaper. In effect, the real price of Chinese-made goods is rising faster than the exchange rate suggests.
    Without taking inflation into account, the renminbi has risen 3 percent against the dollarsince last summer, when China began letting it rise. Once inflation is accounted for, the real increase has been about 5 percent. At that pace, the renminbi could erase its artificial undervaluation — as some economists estimate it — in less than two years.
    Of course, one reason for the rise is the political pressure from the United States and other countries. As much as China’s Communist Party leaders may claim otherwise, they really do respond to international lobbying sometimes.
    The obvious question now is how the Obama administration can apply similar pressure on intellectual property theft and trade barriers. Arthur Kroeber, a Beijing-based consultant and editor of the China Economic Quarterly, goes so far as to call the currency discussion a distraction. “What exactly there is to be gained by quibbling over a point or two in the annual appreciation rate,” Mr. Kroeber says, “is beyond me.”
    The best hope for getting another country’s leaders to do anything is to persuade them that it’s in their interest. That task is not so easy with trade barriers, because every time an American company is kept from making a sale in China, a Chinese company presumably benefits. It makes the sale instead or, in the case of piracy, it saves money that it would have spent on the authentic product.
    Still, China’s leaders have reason to be nervous about all the barriers they have built. China’s elite, in government and business, are deeply concerned that their companies remain unable to create truly innovative products. The obsession with the fact that no Chinese citizen has won a scientific Nobel Prize stems partly from this worry.
    Opening up your economy to more competition may bring some short-term pain, but it also forces companies to become stronger and more creative — or to wither. Competition breeds innovation.
    This self-interest argument is the one that Mr. Obama and his advisers are most comfortable making. They worry that outright pressure on China will put it on the defensive and ultimately backfire. Sometimes, they may worry too much. Pressure clearly can work, as the last few months have demonstrated.
    The United States should be able to round up some allies on these issues, just as it has with recent military matters relating to China. BASF and Siemens, two big German companies, have already complained about Chinese protectionism, as have some European leaders. Other countries also have reason to be frustrated with the exchange rate: relative to many currencies other than the dollar, the renminbi has actually lost value in recent months.
    But even by itself, the United States is big enough — and important enough to Chinese companies — to exert some pressure. That is why the recent “buy American” provisions in a couple of bills, small as they may be, are useful. The same goes for continued discussion of Congressional bills that would penalize China.
    If anything, the Republican takeover of the House offers a new chance to hold hearings on those bills. Representative Dave Camp, the Michigan Republican who will become chairman of the Ways and Means Committee, has been a vocal critic of China’s protectionism.
    Finally, both Republicans and Democrats can use Mr. Hu’s coming visit to emphasize — to him and to the many Chinese citizens who will be following — just how frustrated many Americans are with the economy’s woes. As the scholar Zhang Guoqing wrote in a Chinese newspaper recently, “A high unemployment rate and the trouble in stimulating the economy” are helping to create “enormous hidden dangers” in the United States.
    One of those dangers is the possibility that American politicians will eventually decide that tough talk isn’t enough to satisfy voters’ anger. If that day comes, the United States and China could end up in a trade war that only worsens the situation for both countries.

    MOVEMENT DISORDERS

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    Welcome
     
    Dear colleagues and friends,

    It is our great pleasure to present you the advanced program of the Third International Symposium on Paediatric Movement Disorders which will take place in Barcelona 25-26 February 2011.

    Our aim to continue the collaborative activities between professionals interested in paediatric movement disorders, mainly neurologists and neuropaediatricians, successfully started in the Symposium 2004.

    As in the previous Symposiums we intend for the best qualified experts in the different aspects involved in paediatric movement disorders to take part in this Symposium. Their attendance will be a good opportunity to increase our knowledge, establish interesting contacts and develop creative ideas.

    We look forward to welcoming you in Barcelona, and hope that this meeting will be memorable experience for all of you, where you will be able to further friendship and strengthen scientific collaboration, in the enjoyable Mediterranean atmosphere for which Barcelona is well-known.

    Yours Sincerely,
    Belén
    Pérez
    Jaume
    Campistol
    Emilio
    Fernández-Alvarez

    International Working Group of Paediatric Movement Disorders © 2011

    Movement Disorder

    Movement Disorder

    Mortalidad, pérdida de peso y calidad de vida en pacientes con obesidad mórbida: evaluación del manejo médico y quirúrgicvo después de 2 años

    Mortalidad, pérdida de peso y calidad de vida en pacientes con obesidad mórbida: evaluación del manejo médico y quirúrgicvo después de 2 años 
    Mortality, weight loss and quality of life of patients with morbid obesity: evaluation of the surgical and medical treatment after 2 years.
    Pimenta GP, Saruwatari RT, Corrêa MR, Genaro PL, Aguilar-Nascimento JE.
    Federal University of Mato Grosso, Cuiabá, MT, Brazil.
    Arq Gastroenterol. 2010 Sep;47(3):263-9.
     
    Abstract
    CONTEXT: The surgical treatment for morbid obesity is becoming common in this country. Only a few papers reported the long-term results of the surgical approach for morbid obesity, mainly in terms of quality of life. OBJECTIVE: To compare mortality rate, weight loss, improvement of both diabetes and hypertension, and quality of life of patients from the public healthcare in Cuiabá, MT, Brazil, who underwent either medical or surgical interventions after a minimum of 2 years. METHODS: The population of this study was constituted by morbidly obese patients who initiated treatment between June 2002 and December 2006. The casuistic consisted of 89 patients submitted to medical therapy and 76 patients who underwent surgical procedures. The main variables were weight loss, improvement of hypertension and diabetes, quality of life, and mortality. RESULTS: The overall results showed that weight loss was significant in the two groups (P<0.001); however surgical patients showed a greater loss than the medical group (P = 0.05). The improvement of diabetes and hypertension was significantly greater in the surgical group (P<0.001), in which no cases of diabetes persisted. There was an increase in cases of hypertension among patients receiving medical attention. Mortality occurred in six cases (6.7%) of the medical group and in five cases (6.6%) of the surgical group (P = 0.97). The median grade of the quality of life score obtained by surgical patients (2.37 [range: -2.50 to 3.00]) was significantly greater (P<0.001) when compared to the medical group (1.25 [range: -1.50 to 3.00]). CONCLUSION: The surgical group presented better results regarding the weight loss, quality of life and improvement of hypertension and diabetes. There was no significant difference in mortality rate between the two groups after a minimum of 2 years.

     
    Tendencias en cirugía bariátrica para la obesidad mórbida en Wisconsin: seguimiento a 6 años.
    Trends in bariatric surgery for morbid obesity in Wisconsin: a 6-year follow-up.
    Henkel DS, Remington PL, Athens JK, Gould JC.
    University of Wisconsin School of Medicine and Public Health, Madison, Wis, USA.
    WMJ. 2010 Feb;109(1):21-7.
     

    Abstract
    BACKGROUND: The prevalence of morbid obesity is increasing throughout Wisconsin and the United States. In 2004, we published a study, "Trends in Bariatric Surgery for Morbid Obesity in Wisconsin." We determined that surgery rates were increasing but felt the demand exceeded the capacity of the surgeons. This is a 6-year follow-up. METHODS: Data was gathered from 3 sources: the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System, the Wisconsin Hospital Association, and a survey administered to Wisconsin bariatric surgeons. RESULTS: From 2003-2008, an average of 2.8% of Wisconsin adults were morbidly obese. Although the number of bariatric surgeries performed in Wisconsin remained steady (1311 surgeries in 2003 and 1343 in 2008), the types of procedures shifted from open gastric bypass (73% in 2003) to laparoscopic gastric bypass (80% in 2008). The rate of surgery was 1 for every 100 morbidly obese adults. The majority of surgeons surveyed (70%) report that a lack of insurance benefits is the biggest barrier to performing bariatric surgery. CONCLUSION: The prevalence of morbid obesity continues to increase in Wisconsin compared to our previously published data. Bariatric surgery volumes have remained stable but the type of procedure has changed. Approximately 1% of bariatric surgery candidates have surgery each year
    .
     
    Manejo quirúrgico de la obesidad
     Surgical treatment of obesity.
    Bult MJ, van Dalen T, Muller AF.
    Department of Internal Medicine, Diakonessenhuis Utrecht, Bosboomstraat 1, 3582 KE Utrecht, The Netherlands.
    Eur J Endocrinol. 2008 Feb;158(2):135-45.
     
    Abstract
    More than half of the European population are overweight (body mass index (BMI) > 25 and < 30 kg/m2) and up to 30% are obese (BMI > or = 30 kg/m2). Being overweight and obesity are becoming endemic, particularly because of increasing nourishment and a decrease in physical exercise. Insulin resistance, type 2 diabetes, dyslipidemia, hypertension, cholelithiasis, certain forms of cancer, steatosis hepatis, gastroesophageal reflux, obstructive sleep apnea, degenerative joint disease, gout, lower back pain, and polycystic ovary syndrome are all associated with overweight and obesity. The endemic extent of overweight and obesity with its associated comorbidities has led to the development of therapies aimed at weight loss. The long-term effects of diet, exercise, and medical therapy on weight are relatively poor. With respect to durable weight reduction, bariatric surgery is the most effective long-term treatment for obesity with the greatest chances for amelioration and even resolution of obesity-associated complications. Recent evidence shows that bariatric surgery for severe obesity is associated with decreased overall mortality. However, serious complications can occur and therefore a careful selection of patients is of utmost importance. Bariatric surgery should at least be considered for all patients with a BMI of more than 40 kg/m2 and for those with a BMI of more than 35 kg/m2 with concomitant obesity-related conditions after failure of conventional treatment. The importance of weight loss and results of conventional treatment will be discussed first. Currently used operative treatments for obesity and their effectiveness and complications are described. Proposed criteria for bariatric surgery are given. Also, some attention is devoted to more basic insights that bariatric surgery has provided. Finally we deal with unsolved questions and future directions for research.
     
    Enlace para leer el artículo completo:
    Cirugía bariátrica: riesgos y recompensas
    Bariatric Surgery: Risks and Rewards
    Walter J. Porie
    J Clin Endocrinol Metab. 2008 November; 93(11 Suppl 1): S89-S9

     Context: Over 23 million Americans are afflicted with severe obesity, i.e. their body mass index (in kilograms per square meter) values exceed 35. Of even greater concern is the association of the adiposity with comorbidities such as diabetes, hypertension, cardiopulmonary failure, asthma, pseudotumor cerebri, infertility, and crippling arthritis. Objective: Diets, exercise, behavioral modification, and drugs are not effective in these individuals. This article examines the effect of surgery on the control of the weight and the comorbidities, as well as the safety of these operations. Interventions: Although the article focuses on the outcomes of the three most commonly performed operations, i.e. adjustable gastric banding, the gastric bypass, and the biliopancreatic bypass with duodenal switch, it aims for perspective with the inclusion of abandoned and current investigational procedures, a review of the complications, and an emphasis on the appropriate selection of patients. Positions: Ample evidence, including controlled randomized studies, now document that bariatric surgery produces durable weight loss exceeding 100 lb (46 kg), full and long-term remission of type 2 diabetes in over 80% with salutary effects on the other comorbidities as well with significant reductions in all-cause mortality. Although the severely obese present with serious surgical risks, bariatric surgery is performed safely with a 0.35% 90-d mortality in Centers of Excellence throughout the United States-similar to the complication rates after cholecystectomy. Conclusions: Until better approaches become available, bariatric surgery is the therapy of choice for patients with severe obesity

    Enlace para leer el artículo completo 
    Atentamente
    Dr. Juan Carlos Flores-Carrillo
    Anestesiología y Medicina del Dolor

    ¿Qué puede hacer tu ordenador mientras duermes?


    ¿Qué puede hacer tu ordenador mientras duermes?
    Aunque el hecho de utilizar un ordenador implica en general estar sentado frente al mismo, no hay que olvidar el enorme potencial de automatización que guarda cada sistema. Tareas tediosas, repetitivas o intensivas en recursos y tiempo pueden llevarse a cabo mientras tienes tu impostergable cita biológica con la almohada, para amanecer con el ordenador más actualizado y más seguro, o manteniéndolo activo en algo productivo. Aquí van algunas recomendaciones.
    FUENTE | El Mundo Digital12/01/2011
    Por alguna razón, el Programador de Tareas de Windows es una utilidad casi ignorada por los usuarios. No es complejo programar una tarea: Lo realmente difícil es determinar cuándo se pueden ejecutar sin que afecten al usuario mientras está frente al ordenador. Las quejas sobre actualizaciones de Windows o escaneos completos del antivirus en momentos inadecuados han sido muchas, pero en vez de ajustar los parámetros de la tarea, terminan por borrarla completamente. Desde siempre insistimos en la necesidad de mantener desfragmentados nuestros discos duros y realizar respaldos, pero no podemos negar que ambos procesos son tediosos.

    La "primera" desfragmentación de un disco duro puede demandar varias horas y un alto nivel de prioridad cuando se trata del disco de sistema. Por otro lado, los respaldos también consumen su cuota de tiempo, especialmente si debemos subir la información a la Web para mantenerla guardada en la nube. Si pueden mirar más allá de la idea de dejar encendido el ordenador toda la noche (sólo la carcasa y el módem o router, el resto no es necesario), entonces la automatización de tareas puede ahorrar mucho tiempo y frustraciones. Salvo un corte de energía o una falla catastrófica de hardware (algo que puede pasar en cualquier momento), no debería haber inconvenientes con mantener encendido al sistema. Veamos qué se puede hacer.

    1) DESFRAGMENTAR

    Nuestra primera opción es la más obvia, y una de las que mayor impacto puede tener en el rendimiento de un ordenador. Siempre que hablemos de discos duros convencionales, la desfragmentación de archivos tiene más de obligación que de cualquier otra cosa, fundamentalmente bajo plataformas Windows. El desfragmentador integrado en Windows ofrece varias opciones para programar esta tarea a través de uno o más discos, pero también podrás encontrar funciones similares en desfragmentadores hechos por terceros. El gratuito Defraggler sigue siendo una excelente alternativa para estos casos.

    2) ANTIVIRUS

    En sesiones ordinarias, un antivirus debería ser capaz de atrapar al vuelo cualquier bicho que intente infectar al sistema, pero siempre existe la posibilidad de que algún remanente quede oculto entre las carpetas del disco duro. El proceso de revisión completa en un antivirus es una de las actividades más tediosas que un usuario puede encontrar, por lo tanto es inevitable recomendarla como candidata a programación automatizada. Su frecuencia tampoco necesita ser extrema: Una vez por semana debería ser suficiente.

    3) INTERCAMBIO DE ARCHIVOS

    De todo tipo, bajo cualquier red, sin importar el cliente o el sistema operativo. De hecho, ni siquiera es necesario programar la actividad. Basta con dejar abierto el cliente e irse a dormir. Las historias de ordenadores encendidos durante días intercambiado archivos no son ninguna fábula. Si un usuario logra coordinar con precisión estos momentos de "vacío" en sus sesiones diarias, esa terrible imagen ISO a descargar puede convertirse en un paseo por el parque. Y esto también incluye a la descarga directa.

    4) CONVERSIÓN DE VIDEO

    Es sencillo: Tienes la edición "ultra-mega-súper" extrema del "Director's Cut" revisado de "Avatar", y quieres verla en otro dispositivo que no sea el ordenador, el reproductor de DVD o el Blu-ray. A menos que prefieras copiar imágenes ISO enteras y sin procesar a estos dispositivos, la conversión y recompresión del vídeo es la única opción. Factores como duración del vídeo, resolución y filtros pueden incrementar o reducir de forma considerable la demora en la conversión, y aunque los ordenadores han avanzado mucho en este aspecto, configuraciones extremas de calidad tienden a demandar mucho tiempo de procesamiento.

    5) RESPALDOS DE INFORMACIÓN

    "Backup", una de las palabras más temidas entre los usuarios. Por un lado, están los que no saben hacerlo. Por el otro, están los que saben hacerlo pero se niegan sistemáticamente a llevarlo a cabo debido al tiempo que consume. En primer lugar, cuanto más organizado sea el usuario con sus datos, más sencillo será hacer el respaldo. Y en segundo lugar, servicios como Dropbox o Mozy ofrecen funciones de respaldo automatizadas. Los respaldos programados también sirven para aquellos que prefieren guardar sus datos en forma local, como por ejemplo un disco duro externo.

    6) ACTUALIZACIONES DE SISTEMA

    Si tienes desactivadas las actualizaciones de Windows, la gran pregunta sería "¿por qué?", pero tampoco queremos ser cerrados al respecto. No todas las condiciones son iguales para todos los usuarios, y también hay que reconocer que la política "haz-lo-que-te-digo-y-no-preguntes" por defecto del Windows Update puede dar problemas en ciertas ocasiones. Aún así, las actualizaciones de Windows, en la gran mayoría de los casos, requieren de un reinicio del sistema una vez que se han instalado. Si dejas el ordenador encendido, nada mejor que programarlo para que opere de madrugada, sin afectar tus sesiones diarias.

    7) FOLDING@HOME
    El ordenador puede ser productivo para ti, pero también puede serlo para los demás. Folding@homelleva más de diez años en operación, y se ha convertido en el nodo de procesamiento computacional más poderoso del planeta. No importa si posees un solo núcleo o varias tarjetas de vídeo en SLI, podrás aportar tu grano de arena en Folding@home, pero si tienes una PlayStation 3, también es posible hacerlo a través de dicho sistema. Con unas pocas horas diarias de F@H serás parte de un esfuerzo global para derrotar enfermedades y condiciones que afectan la calidad de vida de la raza humana.

    8) JUEGOS VÍA STEAM

    La amplia cantidad de títulos disponibles y las increíbles ofertas siguen haciendo de Steam el sistema de distribución de juegos más importante del momento. Pero aún con todas sus virtudes, la magia de Steam se ve limitada a qué tan rápido puedes descargar el juego e instalarlo en tu sistema. En muchas ocasiones, los tiempos de descarga por Steam son afectados sobrecargas en los servidores, y el promedio de 4.5 GB en juegos de alto calibre no ayuda en nada. Si utilizas Steam, nada mejor que dejar tu sistema encendido durante la noche para obtener esos títulos pesados.

    9) COMPILAR CÓDIGO Y/O RENDERIZAR

    Aquellos que prefieren hacer su propio software en vez de descargarlo saben muy bien que el tiempo de compilado para cierto código puede convertirse en toda una tortura. El mismo concepto se puede aplicar a quienes hacen serios procesos de renderizado. Hoy en día tenemos buen hardware, pero estas tareas están en la cima de la pirámide, y demandan respeto por esencia propia. Una vez hechos los cambios pertinentes, ejecuta la operación, deja que el ordenador trabaje, y descansa un poco. Tendrás tiempo de sobra.

    10) APAGADO POR COMPLETO

    El atajo fácil. La ley del menor esfuerzo. Apagar el ordenador no deja de ser algo razonable para quien no necesita usarlo más, pero hay que prestar especial atención sobre el término "por completo". Aún si en apariencia se ve apagado, lo cierto es que un sistema puede llevarse algún que otro vatio gracias al llamado "consumo vampírico". Este efecto puede encontrarse en una gran cantidad de dispositivos modernos, y es una de las causas más importantes del desperdicio de energía. Ya existe hardware capaz de entrar en un "estado cero" de consumo, pero el mejor remedio es y será un interruptor manual. Con eso, el "cero" lo pones tú.

    Si bien requieren de energía para funcionar, la ventaja de los ordenadores es que no necesitan dormir y puedes dejar que el ordenador continúe con todo lo que ha quedado pospuesto durante el día. El mantenimiento surge como la opción más lógica, debido a la demora en los procesos. Compartir archivos puede tener una utilidad personal muy profunda, mientras que el resto de las opciones tienen su atractivo propio. A quienes les preocupe el consumo, deben recordar que no es necesario dejar la pantalla encendida, y hay muchas aplicaciones capaces de apagar el sistema una vez que han finalizado. No dejes de explorar las opciones disponibles. 

    Un test de sangre, futuro sustituto de la amniocentesis


    Un test de sangre, futuro sustituto de la amniocentesis
    La amniocentesis podría tener los días contados. Un estudio publicado en 'British Medical of Journal' ha comprobado que una prueba tan sencilla como un análisis de sangre de la madre tiene una sensibilidad de más del 98% para detectar síndrome de Down en el futuro bebé. "Es una noticia esperanzadora porque su uso evitaría los riesgos de la técnica que se utiliza actualmente", afirman los autores de la investigación, de la Universidad de Hong Kong (China).
    FUENTE | El Mundo Digital12/01/2011
    Dicha técnica, la amniocentesis, es un procedimiento invasivo que requiere una punción para extraer el líquido amniótico del interior del saco que rodea al feto. "Puede provocar un aborto en una de cada 100 mujeres y, por lo tanto, se reserva sólo para los embarazos de riesgo", señalan los expertos en su artículo. Algo que corrobora Carmen Barbancho, ginecóloga del Hospital Infanta Sofía (Madrid). Por ese peligro de pérdida del feto, sólo se recomienda la amniocentesis a las mujeres con mayor riesgo. Para seleccionarlas "analizamos dos hormonas en la sangre de la madre (la gonadotropina y la proteína A plasmática), hacemos una ecografía para observar la morfología del feto, recogemos datos sobre el peso de la mujer, la raza, la edad, si es o no fumadora, etc.".

    Con la nueva y tan esperada prueba desaparecería el riesgo de aborto. El médico extraería una muestra de sangre de la madre para analizar el ADN del feto con técnicas de secuenciación masiva. Con este material genético, se comprueba si el cromosoma 21 presenta tres copias (trisomía) en lugar de dos. Así lo han hecho los investigadores en 753 mujeres embarazadas de Hong Kong, Reino Unido y Holanda con alta probabilidad de tener un hijo con síndrome de Down.

    Comparando los resultados de la amniocentesis y del análisis sanguíneo, los autores observaron que esta prueba no invasiva era altamente eficaz, en más del 98% de los casos. Hace tiempo que los investigadores buscan una alternativa fiable, pero este tipo de pruebas sigue sin generalizarse.

    "Se trata de una tecnología muy prometedora, pero tiene dos inconvenientes: es muy costosa y sólo detecta síndrome de Down", argumenta Pablo Lapunzina, coordinador del Instituto de Genética Médica y Molecular (INGEMM) del Hospital La Paz (Madrid). Teniendo en cuenta que "la mitad de las patologías prenatales que hoy se pueden identificar corresponden a síndrome de Down, aún queda un 50% de otras alteraciones genéticas que no podría descartar, al contrario que la amniocentesis, que sí puede".

    La doctora Barbancho coincide con este experto en que el análisis sanguíneo "no sustituye a la amniocentesis". En cualquier caso, añade Lapunzina, "lo más prometedor sería que esta técnica se pudiese extender al resto de enfermedades genéticas. Esto sería el futuro".

    Autor:   Laura Tardón

    Dosis de desfibrilación bifásica interna y externa para la fibrilación y la taquicardia ventricular sin pulso en niños


    REMI envía todos sus contenidos gratuitamente por correo electrónico a más de 8.700 suscriptores. [Suscripción]
    Artículo nº 1588. Vol 11 nº 1, enero 2011.
    Autor: Jesús López-Herce Cid

    Dosis de desfibrilación bifásica interna y externa para la fibrilación y la taquicardia ventricular sin pulso en niños

    Artículo original: External and internal biphasic direct current shock doses for pediatric ventricular fibrillation and pulseless ventricular tachycardia. Tibballs J, Carter B, Kiraly NJ, Ragg P, Clifford M. Pediatr Crit Care Med 2011; 12(1): 14-20. [Resumen] [Artículos relacionados]

    Introducción: La fibrilación ventricular (FV) y la taquicardia ventricular sin pulso (TVSP) son ritmos relativamente poco frecuentes durante la parada cardiaca (PC) en niños. Estos ritmos ocurren aproximadamente en el 10 % de los niños con PC, siendo más frecuentes en los pacientes con cardiopatías y en los adolescentes. Existen muy pocos estudios que hayan analizado la eficacia de la desfibrilación en niños y sobre todo que hayan evaluado la efectividad de diversas dosis. De hecho las dosis iniciales de desfibrilación para la FV y TVSP en niños recomendadas por el Consejo Europeo de Resucitación, la Asociación Americana del Corazón y el Consejo Australiano de Resucitación son diferentes, aunque están basadas en el mismo consenso de la ciencia.

    Resumen: Se realizó un registro prospectivo observacional unicéntrico en el que se incluyeron los niños menores de 20 años que sufrieron FV (75%) o TVSP (25%) y fueron tratados con desfibrilación bifásica interna o externa. Se estudiaron 48 pacientes con 117 choques. La supervivencia al año fue del 73%. La dosis inicial de desfibrilación fue de 1,7 (0,8) J/kg. Sólo un 48% de los pacientes tratados con una dosis de 2 J/Kg consiguió la reversión del ritmo. El número de dosis de desfibrilación por paciente fue de 2,4. La dosis de desfibrilación eficaz  estuvo en el rango de 3 a 5 J/kg. La impedancia fue menor con los parches colocados en posición anteroposterior que con las palas del desfibrilador. 8 pacientes recibieron desfibrilación interna con una dosis entre 0,6-0,7 J/kg. Todos los pacientes tratados con desfibrilación interna lograron la RCE con una supervivencia al alta del 90%.

    Comentario: Este estudio confirma lo encontrado en algunos estudios previos que mostraron que la dosis de desfibrilación de 2 J/kg es frecuentemente ineficaz en niños y que una dosis de 4 J/kg es más efectiva y sigue siendo igualmente segura. Estos hallazgos coinciden con las recomendaciones europeas, que por otra parte son más sencillas porque utilizan siempre la misma dosis de 4 J/kg en todos los casos. No se conoce si dosis más elevadas de 6 J/kg pueden ser eficaces en algunos pacientes con FV refractaria sin aumentar el riesgo de daño miocárdico. Por otra los parches parecen más recomendables que las palas ya que presentan menos impedancia y permiten reducir el tiempo de interrupción del masaje para realizar la desfibrilación.
    Jesús López-Herce Cid
    Hospital General Universitario Gregorio Marañón, Madrid.
    ©REMI, http://remi.uninet.edu. Enero 2011.

    Enlaces:
    1. Defibrillation in children. Haskell SE, Atkins DL. J Emerg Trauma Shock 2010; 3(3): 261-266. [PubMed]
    2. European Resuscitation Council Guidelines for Resuscitation 2010 Section 6. Paediatric life support. Biarent D, Bingham R, Eich C, López-Herce J, Maconochie I, Rodríguez-Núñez A, Rajka T, Zideman D.Resuscitation 2010; 81(10): 1364-1388. [ PubMed]
    Búsqueda en PubMed:
    • Enunciado: Desfibrilación en pediatría
    • Sintaxis: defibrillation AND pediatrics
    • [Resultados]
    Palabras clave: Paro cardiaco, Fibrilación ventricular, Taquicardia ventricular sin pulso, Resucitación cardiopulmonar, Desfibrilación, Pediatría.