Publications by authors named "Guillermo Moreno"

31 Publications

Intra-Day Solar Power Forecasting Strategy for Managing Virtual Power Plants.

Sensors (Basel) 2021 Aug 22;21(16). Epub 2021 Aug 22.

School of Engineering, University of Portsmouth, Winston Churchill Ave., Portsmouth PO1 3HJ, UK.

Solar energy penetration has been on the rise worldwide during the past decade, attracting a growing interest in solar power forecasting over short time horizons. The increasing integration of these resources without accurate power forecasts hinders the grid operation and discourages the use of this renewable resource. To overcome this problem, Virtual Power Plants (VPPs) provide a solution to centralize the management of several installations to minimize the forecasting error. This paper introduces a method to efficiently produce intra-day accurate Photovoltaic (PV) power forecasts at different locations, by using free and available information. Prediction intervals, which are based on the Mean Absolute Error (MAE), account for the forecast uncertainty which provides additional information about the VPP node power generation. The performance of the forecasting strategy has been verified against the power generated by a real PV installation, and a set of ground-based meteorological stations in geographical proximity have been used to emulate a VPP. The forecasting approach is based on a Long Short-Term Memory (LSTM) network and shows similar errors to those obtained with other deep learning methods published in the literature, offering a MAE performance of 44.19 W/m under different lead times and launch times. By applying this technique to 8 VPP nodes, the global error is reduced by 12.37% in terms of the MAE, showing huge potential in this environment.
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http://dx.doi.org/10.3390/s21165648DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8402480PMC
August 2021

Impact of the COVID-19 pandemic on a pediatric cardiovascular surgery program of a public hospital from Argentina.

Arch Argent Pediatr 2021 08;119(4):266-269

Servicio de Terapia Intensiva (UCI 35), Hospital de Pediatría Dr. Prof. Juan P. Garrahan, Ciudad Autónoma de Buenos Aires, Argentina.

Objective: To describe the impact of the COVID-19 pandemic on a pediatric cardiovascular surgery program and estimate the necessary time to reduce the surgery waiting list.

Methods: Retrospective, descriptive study. Surgical outcomes from the pre-COVID-19 period and COVID-19 period were compared. A mathematical model was used to estimate the time necessary to reduce the waiting list.

Results: Between March 23rd and August 31st, 2020, 83 patients underwent surgery, accounting for a 60 % reduction compared to the pre-COVID-19 period. Their median age was 6 months (interquartile range [IQR]: 25-75, 1.8 months to 2.9 years; p = 0.0023). The time necessary to eliminate the waiting list ranges from 10 to 19 months.

Conclusions: There was a 60 % reduction in the program. The time required to clear the backlog of cases may range from, at least, 10 to 19 months.
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http://dx.doi.org/10.5546/aap.2021.eng.266DOI Listing
August 2021

Improvement in communication during patient handoff between areas from a children's hospital.

Arch Argent Pediatr 2021 08;119(4):259-265

Hospital de Pediatría S.A.M.I.C. "Prof. Dr. Juan P. Garrahan", Ciudad Autónoma de Buenos Aires, Argentina.

Introduction: Patient handoff is an interactive process including data communication and responsible transfer in order to safely maintain the continuity of care. Failure in this process may result in inadequate care and favor the occurrence of errors.

Objective: To implement a standardized instrument for patient handoff from the intensive care unit (ICU) to the intermediate-medium care unit (IMCU), and compare communication between health care providers before and after the intervention.

Population And Methods: Before-and-after study conducted at Hospital de Pediatría "Prof. Dr. Juan P. Garrahan." The intervention consisted in a written handoff form. The pre-intervention sample included patients transferred from ICUs to IMCUs between October 1st and October 31st, 2015. The post-intervention sample included patients transferred between March 1st and March 31st, 2016. A total of 4 IMCUs and 3 ICUs participated in the study. The main study variable was the written part of the handoff; in particular, whether it was timely and complete.

Results: A total of 50 handoffs were analyzed for each stage. With the written handoff, there was an increase in the communication of clinical data in 88 % of variables (oral communication between physicians, treating physician, therapeutic adequacy, diagnosis, course, etc.); the difference was statistically significant.

Conclusion: After implementing the tool, there was an improvement in the transfer of patient clinical data relevant to the safe continuity of care.
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http://dx.doi.org/10.5546/aap.2021.eng.259DOI Listing
August 2021

A Novel Circulating MicroRNA for the Detection of Acute Myocarditis.

N Engl J Med 2021 05;384(21):2014-2027

From the Vascular Pathophysiology Area (R.B.-D., R.S.-D., A.M.-M., M. Relaño, R.J.-A., B.L.-P., K.T., D.A.P.-F., V.F., F.S.-M., P.M.) and the Myocardial Pathophysiology Area (L.A.-H., M. Ricote, H.B., L.F.-F., B.I.), Centro Nacional de Investigaciones Cardiovasculares (CNIC), the Department of Immunology (H.F., F.S.-M.), the Department of Cardiology (L.J.J.-B., M.M.G.-G., F.A.), the Department of Dermatology (E.D.), and the Department of Rheumatology (I.G.-A.), Instituto de Investigación Sanitaria, Hospital Universitario de la Princesa, Fundación Jiménez Díaz (M.L.M.-M., B.I.), the Cardiology Department, Hospital Universitario 12 de Octubre, and Instituto de Investigación Sanitaria Hospital 12 de Octubre (G.M., R.M.-A., H.B.), the Department of Immunology, Hospital Ramón y Cajal (L.M.V.-G.), HM Hospitales-Centro Integral de Enfermedades Cardiovasculares (L.F.-F.), and CIBER de Enfermedades Cardiovasculares (R.S.-D., H.F., L.J.J.-B., F.A., D.A.P.-F., B.I., F.S.-M., P.M.), Madrid, Hospital Universitario Central de Asturias, Oviedo (A.M.-L.), and the Cardiology Department, Hospital Universitario Virgen de la Arrixaca, Murcia (D.A.P.-F.) - all in Spain; the Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL (K.A.B., D.F.); the Cardiovascular Division and Corrigan Minehan Heart Center, Massachusetts General Hospital, and Harvard Medical School, Boston (A.M.S.-G., S.A.M., N.E.I., J.L.J., S.D.); Kanntonsspital St. Gallen Klinik für Anesthesiologie und Intensivmedizin, St. Gallen, Switzerland (J.K.); Cardiology (S.I., A.B., A.L.P.C.) and the Cardiovascular Pathology Unit (C.B.), the Department of Cardiac, Thoracic, Vascular Sciences and Public Health, the Department of Laboratory Medicine (M.P., M.S.), and the Department of Medicine, Hematology and Clinical Immunology (R.M.), University of Padua, Padua, Italy; Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin (B.H.); Imperial College and Royal Brompton and Harefield Hospital, London (T.F.L.); and the Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (V.F.).

Background: The diagnosis of acute myocarditis typically requires either endomyocardial biopsy (which is invasive) or cardiovascular magnetic resonance imaging (which is not universally available). Additional approaches to diagnosis are desirable. We sought to identify a novel microRNA for the diagnosis of acute myocarditis.

Methods: To identify a microRNA specific for myocarditis, we performed microRNA microarray analyses and quantitative polymerase-chain-reaction (qPCR) assays in sorted CD4+ T cells and type 17 helper T (Th17) cells after inducing experimental autoimmune myocarditis or myocardial infarction in mice. We also performed qPCR in samples from coxsackievirus-induced myocarditis in mice. We then identified the human homologue for this microRNA and compared its expression in plasma obtained from patients with acute myocarditis with the expression in various controls.

Results: We confirmed that Th17 cells, which are characterized by the production of interleukin-17, are a characteristic feature of myocardial injury in the acute phase of myocarditis. The microRNA mmu-miR-721 was synthesized by Th17 cells and was present in the plasma of mice with acute autoimmune or viral myocarditis but not in those with acute myocardial infarction. The human homologue, designated hsa-miR-Chr8:96, was identified in four independent cohorts of patients with myocarditis. The area under the receiver-operating-characteristic curve for this novel microRNA for distinguishing patients with acute myocarditis from those with myocardial infarction was 0.927 (95% confidence interval, 0.879 to 0.975). The microRNA retained its diagnostic value in models after adjustment for age, sex, ejection fraction, and serum troponin level.

Conclusions: After identifying a novel microRNA in mice and humans with myocarditis, we found that the human homologue (hsa-miR-Chr8:96) could be used to distinguish patients with myocarditis from those with myocardial infarction. (Funded by the Spanish Ministry of Science and Innovation and others.).
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http://dx.doi.org/10.1056/NEJMoa2003608DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8258773PMC
May 2021

Pulmonary Vein Stenosis: A Rare Disease with a Global Reach.

Children (Basel) 2021 Mar 6;8(3). Epub 2021 Mar 6.

Center for Applied Pediatric Quality Analytics, Department of Cardiology, Boston Children's Hospital, Boston, MA 02115, USA.

Pulmonary vein stenosis (PVS) is a rare, but high mortality and resource intensive disease caused by mechanical obstruction or intraluminal myofibroproliferation, which can be post-surgical or idiopathic. There are increasing options for management including medications, cardiac catheterization procedures, and surgery. We queried the International Quality Improvement Collaborative for Congenital Heart Disease (IQIC) database for cases of PVS and described the cohort including additional congenital lesions and surgeries as well as infectious and mortality outcomes. IQIC is a quality improvement project in low-middle-income countries with the goal of reducing mortality after congenital heart surgery. Three cases were described in detail with relevant images. We identified 57 cases of PVS surgery, with similar mortality to higher income countries. PVS should be recognized as a global disease. More research and collaboration are needed to understand the disease, treatments, and outcomes, and to devise treatment approaches for low resource environments.
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http://dx.doi.org/10.3390/children8030198DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8000109PMC
March 2021

Diagnosis, prevention, and management of delirium in the intensive cardiac care unit.

Am Heart J 2021 02 28;232:164-176. Epub 2020 Nov 28.

Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain. Electronic address:

Delirium is a frequent complication in patients admitted to intensive cardiac care units (ICCU) with potentially severe consequences including increased risks of mortality, cognitive impairment and dependence at discharge, and longer times on mechanical ventilation and hospital stay. Delirium has been widely documented and studied in general intensive care units and in patients after cardiac surgery, but it has barely been studied in acute nonsurgical cardiac patients. Moreover, delirium (especially in its hypoactive form) is commonly misdiagnosed. We propose a protocol for delirium prevention and management in ICCUs. A daily comprehensive assessment to improve detection should be done using validated scales (ie, confusion assessment method). Preventive measures are particularly relevance and constitute the basis of treatment as well, acting on reversible risk factors, including environmental interventions, such as quiet time, sleep promotion, family support, communication, and adequate treatment of pain and dyspnea. Pharmacological prophylaxis is not indicated with the exception of patients at risk of withdrawal syndrome but should only be used in patients with confirmed delirium. Dexmedetomidine is the drug of choice in patients with severe agitation, and those weaning from invasive mechanical ventilation. As the complexity of ICCUs increases, clinical scenarios posing challenges for the management of delirium become more frequent. Efforts should be done to improve the identification of patients at risk during admission in order to establish preventive interventions to avoid this complication. Patient-centered protocols will increase the awareness of the healthcare professionals for better prevention and earlier diagnosis and will positively impact on prognosis.
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http://dx.doi.org/10.1016/j.ahj.2020.11.011DOI Listing
February 2021

Admittances characteristics by sepsis in the Spanish internal medicine services between 2005 and 2015: mortality pattern.

Postgrad Med 2020 Apr 28;132(3):296-300. Epub 2020 Jan 28.

Facultad de Medicina, Universidad Rey Juan Carlos , Móstoles, Madrid, Spain.

Background: Studies in recent years suggest an increase in the incidence of sepsis but a decrease in mortality. The aim of this study is to describe the characteristics of patients discharged after a sepsis episode from Spanish internal medicine services between 2005 and 2015.

Results: Since 2005, in which there were a total of 4,319 cases, sepsis hospitalizations has been consistently increasing yearly reaching a total of 25,820 cases in 2015. We observed that septic patients are older and with higher comorbidity than the general population admitted in Internal Medicine. On the other hand, we found a decreasing trend in the mortality rates of patients with sepsis in our series going from 35.7% in 2005 to 30.1% in 2015 (p < 0.005).

Discussion: In our study, a higher comorbidity at admission and developing complications during admittance, conditioned a higher probability of death due to sepsis. The variables that were associated with increased mortality risk were age, acute renal failure, acute respiratory failure, lactic acidosis, septic shock and chronic heart failure.

Conclusion: As in other similar studies, we observed an increase in the hospitalizations by sepsis as a diagnosis at discharge during the study period in Internal Medicine services with a simultaneous decrease in mortality. Comorbidity at admission and complications during admittance condition mortality.
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http://dx.doi.org/10.1080/00325481.2020.1718388DOI Listing
April 2020

[National Nursing Consensus on management of severe traumatic brain injury in children].

Arch Argent Pediatr 2019 08;117(4):S157-S174

Subcomisión Nacional de Derechos del Niño de la Sociedad Argentina de Pediatría.

The nursing professional who treats critically ill children with cerebral injury is a key element within the pediatric intensive care team, since, through exhaustive assessment, plans nursing care in an integral manner aimed at the child and the family, and plays an essential role in the care of patients mainly at the hospital level (as well as at home). Therefore, the role played by nursing in the care of children with severe brain trauma is crucial. This guide offers nursing recommendations on neurocritical care, focusing on a systemic view based on nursing diagnoses according to the North American Nursing Diagnosis Association.
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http://dx.doi.org/10.5546/aap.2019.S157DOI Listing
August 2019

Extracorporeal membrane oxygenation in pediatric cardiovascular care: Experience of a center in Argentina.

Arch Argent Pediatr 2019 06;117(3):157-163

Servicio de Cirugía Cardiovascular. Hospital de Pediatría "Prof. Dr. J. P. Garrahan", Buenos Aires, Argentina.

Objective: To describe the results of extracorporeal membrane oxygenation in patients undergoing heart surgery and analyze the risk factors for morbidity and mortality.

Methods: Retrospective study conducted in cardiac patients under circulatory support. Outcome measures, diagnosis, surgery, Risk Adjustment for Congenital Heart Surgery (RACHS) score, implantation time, cannulation, length of support during stay, complications, survival, and follow-up were recorded. Risks were analyzed in relation to age, weight, RACHS score, single-ventricle or biventricular disease, implantation time, length of support and stay, and complications. Descriptive statistical and logistic regression analyses for risk factors were done.

Results: Among 5295hospitalizations, 72 patients required extracorporeal membrane oxygenation (1.37 %). Median age: 6.5 months (interquartile range [IQR]: 20 days-2 years); weight: 5.5 kg (IQR: 3.25-9.5); pump time: 188 min (IQR: 134246.5); clamp time: 92 min (65-117). Cannulation was done in the operating room in 34 cases (47 %). The median length of support was 3 days (IQR: 2-5), and of stay, 20 days (IQR: 1132). Survival at discharge was 49 %; 8 patients died during follow-up. The most common complication was bleeding (57 %). Weight < 5 kg (p = 0.01) and vasopressor use during support (p = 0.012) were associated with a risk for mortality. The survival rate at 10 years was 77 %; 84 % of patients corresponded to functional class 1-2, and 37 % had some degree of developmental delay.

Conclusions: The most common complication was bleeding; weight and vasopressor use were associated with mortality.
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http://dx.doi.org/10.5546/aap.2019.eng.157DOI Listing
June 2019

A Hybrid Approach to Short-Term Load Forecasting Aimed at Bad Data Detection in Secondary Substation Monitoring Equipment.

Sensors (Basel) 2018 Nov 14;18(11). Epub 2018 Nov 14.

Department of Electronics, University of Alcalá, Alcalá de Henares, 28805 Madrid, Spain.

Bad data as a result of measurement errors in secondary substation (SS) monitoring equipment is difficult to detect and negatively affects power system state estimation performance by both increasing the computational burden and jeopardizing the state estimation accuracy. In this paper a short-term load forecasting (STLF) hybrid strategy based on singular spectrum analysis (SSA) in combination with artificial neural networks (ANN), is presented. This STLF approach is aimed at detecting, identifying and eliminating and/or correcting such bad data before it is provided to the state estimator. This approach is developed to improve the accuracy of the load forecasts and it is tested against real power load data provided by electricity suppliers. Depending on the week considered, mean absolute percentage error (MAPE) values which range from 1.6% to 3.4% are achieved for STLF. Different systematic errors, such as gain and offset error levels and outliers, are successfully detected with a hit rate of 98%, and the corresponding measurements are corrected before they are sent to the control center for state estimation purposes.
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http://dx.doi.org/10.3390/s18113947DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6263994PMC
November 2018

Temporal Trends in Mechanical Complications of Acute Myocardial Infarction in the Elderly.

J Am Coll Cardiol 2018 08;72(9):959-966

Cardiology Department, Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Spain. Electronic address:

Background: Reperfusion therapy led to an important decline in mortality after ST-segment elevation myocardial infarction (STEMI). Because the rate of cardiogenic shock has not changed dramatically, the authors speculated that a reduction in the incidence or fatality rate of mechanical complications (MCs), the second cause of death in these patients, could explain this decrease.

Objectives: This study sought to assess time trends in the incidence, management, and fatality rates of MC, and its influence on short-term mortality in old patients with STEMI.

Methods: Trends in the incidence and outcomes of MC between 1988 and 2008 were analyzed by Mantel-Haenszel linear association test in 1,393 consecutive patients ≥75 years of age with first STEMI.

Results: Overall in-hospital mortality decreased from 34.3% to 13.4% (relative risk reduction, 61%; p < 0.001). Although the absolute mortality due to MC decreased from 9.6% to 3.3% (p < 0.001), the proportion of deaths due to MC among all deaths did not change (28.1% to 24.5%; p = 0.53). The incidence of MC decreased from 11.1% to 4.3% (relative risk reduction 61%) with no change in their hospital fatality rate over time (from 87.1% to 82.4%; p = 0.66). The proportion of patients undergoing surgical repair decreased from 45.2% to 17.6% (p = 0.04), with no differences in post-operative survival (from 28.6% to 33.3%; p = 0.74).

Conclusions: Although the incidence of MC has decreased substantially since the initiation of reperfusion therapy in elderly STEMI patients, this reduction was proportional to other causes of death and was not accompanied by an improvement in fatality rates, with or without surgery. MCs are less frequent but remain catastrophic complications of STEMI in these patients.
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http://dx.doi.org/10.1016/j.jacc.2018.06.031DOI Listing
August 2018

[Pediatric emergency medicine specialty: Welcome!]

Arch Argent Pediatr 2018 08;116(4):298-300

Comité de Emergencias y Cuidados Críticos, Sociedad Argentina de Pediatría.

Pediatric Emergency Medicine has developed around the world as a subspecialty of pediatrics. There is plenty of data reflecting a growing need for its services. The subspecialty was initiated in the United States and Argentina, together with other Latin American countries, followed the same path. Nevertheless, there is yet much to be done. It is necessary to strengthen its promotion and to stimulate research and teaching activities in order to continue improving the quality of care delivered to the pediatric population, their families and society as a whole.
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http://dx.doi.org/10.5546/aap.2018.298DOI Listing
August 2018

Impact of a program aimed at reducing catheter-related infections implemented in nine pediatric intensive care units in Argentina.

Arch Argent Pediatr 2018 Apr;116(2):93-97

Hospital de Pediatría "J. P. Garrahan", Ciudad Autónoma de Buenos Aires.

Introduction: Catheter-related infections (CRIs) cause a high level of morbidity and mortality with the increasing use of hospital resources.

Objective: To describe the outcomes of a program implemented to reduce the rate of CRIs in pediatric intensive care units in Argentina.

Population And Methods: Collaborative, multi center, clinical-epidemiological, quasiexperimental, before-and-after intervention study. Children who had a central venous catheter during hospitalization in 9 pediatric intensive care units in the Autonomous City of Buenos Aires, Greater Buenos Aires, and other provinces between June 2011 and April 2012 were included. A bundle of measures based on health care staff training on catheter insertion, hand hygiene, and checklists was put into practice and implemented measures were monitored. The number and annual rate of CRIs and the rate of central venous catheter use before and after the program implementation were compared (Stata 8.0).

Results: The total number of CRIs was 117 and 74 before and after the intervention, respectively. The rate of CRIs was 8.6/1000 days of central venous catheter use and 5.8/1000 days before and after the intervention, respectively; RR: 0.82 (95% confidence interval: 0.68-0.98), p= 0.015. The rate of central venous catheter use decreased from 54% to 49%, a non-significant difference.

Conclusions: The program achieved a significant reduction in CRI rates. Based on the program, CRI surveillance was implemented in all participating pediatric intensive care units. Training and continuous surveillance are necessary to maintain and improve the outcomes accomplished with the program.
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http://dx.doi.org/10.5546/aap.2018.eng.93DOI Listing
April 2018

Morbidity in congenital heart surgery in a public hospital in Argentina.

Arch Argent Pediatr 2018 Feb;116(1):e14-e18

Servicio de Cirugía Cardiovascular,Hospital de Pediatría "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina.

Objective: To describe the complications associated with heart surgery, compare them to a reference population, and identify mortality risk factors.

Patients And Methods: Retrospective and descriptive study. All patients who underwent surgery at Hospital Garrahan in the 2013-2015 period were included. Age, weight, procedure, mechanical ventilation, length of stay in days, morbidity, and course were recorded. Renal failure requiring dialysis, neurological deficit, permanent pacemaker, circulatory support, phrenic nerve or vocal cord palsy, reoperation, wound infection, chylothorax, and tracheotomy were considered morbidities. A descriptive, statistical analysis by risk category was done using the Society of Thoracic Surgeons (STS) morbidity score.

Results: 1536 patients, median age: 12 months (interquartile range [IQR] 25-75: 3-60), weight: 8 kg (IQR 25-75: 4.4 to 17.5), mortality: 5%. A total of 361 events were recorded in 183 patients. An unplanned reoperation was the most common event (7.2%); the rest occurred in < 3% of patients. Compared to patients without complications, patients who had events required more days on mechanical ventilation: 9.95 (IQR 25-75: 7.6512.24) versus 1.8 (IQR 2575: 1.46-2.14), p< 0.00001; a longer length of stay: 28.8 (IQR 25-75: 25.1-32.5) versus 8.5 (IQR 25-75: 7.9-9.2), p< 0.0001; and had a higher mortality: 19.6% versus 3.1% (RR: 4.58, 95% CI: 3.4 to 6.0), p< 0.0001. Circulatory support and renal failure were associated with a higher mortality.

Conclusions: An unplanned reoperation was the most common event. Patients with complications required more days on mechanical ventilation and a longer length of stay and had a higher mortality. Circulatory support and renal failure were associated with a higher mortality.
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http://dx.doi.org/10.5546/aap.2018.eng.e14DOI Listing
February 2018

Management of late presentation congenital heart disease.

Cardiol Young 2017 Dec;27(S6):S31-S39

6Department of Pediatric and Congenital Heart Surgery,Fortis Escorts Heart Institute,New Delhi,India.

In many parts of the world, mostly low- and middle-income countries, timely diagnosis and repair of congenital heart diseases (CHDs) is not feasible for a variety of reasons. In these regions, economic growth has enabled the development of cardiac units that manage patients with CHD presenting later than would be ideal, often after the window for early stabilisation - transposition of the great arteries, coarctation of the aorta - or for lower-risk surgery in infancy - left-to-right shunts or cyanotic conditions. As a result, patients may have suffered organ dysfunction, manifest signs of pulmonary vascular disease, or the sequelae of profound cyanosis and polycythaemia. Late presentation poses unique clinical and ethical challenges in decision making regarding operability or surgical candidacy, surgical strategy, and perioperative intensive care management.
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http://dx.doi.org/10.1017/S1047951117002591DOI Listing
December 2017

Planning secondary prevention: Room for improvement.

Eur J Prev Cardiol 2017 06;24(3_suppl):22-28

1 Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain.

The prognosis of patients after acute coronary syndromes is still suboptimal, mainly due to the risk of recurrent adverse coronary events, which is greatest during the first year, but persists over one's lifetime. Meaningful progress in preventing cardiovascular events has been achieved. However, there remains much room for improvement by embracing innovative therapies and investing in multidisciplinary approaches. Pharmacological interventions focused on optimising antithrombotic and lipid-lowering therapies are both pillars of secondary prevention that have seen recent ground-breaking advances. Moreover, new approaches in diabetic patients with cardiovascular disease and new targets for anti-inflammatory treatment may significantly improve prevention strategies in the future. However, pharmacological treatments are expensive and can have significant side effects. Developing better tools in order to identify high-risk patients and promote more personalised strategies for each patient should be an absolute priority. Furthermore, adherence to medication is still low and represents a real challenge; several strategies to improve low adherence to treatment are currently under discussion. Non-pharmacological interventions are also essential. Improving communication with patients and advanced surveillance for those secondary risk factors that may negatively impact prognosis are crucial. Encouraging multidisciplinary teams that work effectively to optimise all aspects of secondary prevention, including a cardiac rehabilitation programme, is the optimal approach. Current secondary prevention strategies and suggestions for areas of improvement are discussed in this manuscript. However, the question remains: will research in secondary prevention continue to focus on stronger and more expensive drugs, or is it time for us to embrace a more patient-centred clinical and research model?
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http://dx.doi.org/10.1177/2047487317704954DOI Listing
June 2017

Reconstruction with non-vascularized fibular autograft after resection of clavicular benign tumor.

J Orthop 2015 Dec 11;12(Suppl 2):S255-9. Epub 2015 Nov 11.

Oncology-Orthopedic Surgeon, Ortopedia y Traumatología, Hospital Centro Médico Nacional de Occidente, Guadalajara, Mexico.

Chondroblastoma is a rare, benign cartilaginous neoplasm that accounts for approximately 1% of all bone tumors, and approximately 4% of all chondroblastomas arise in the clavicle. Here, we report a case of chondroblastoma in the right clavicle. 27-year-old female patient presented with a 12-month history of shoulder pain. Based on radiological and pathological examination, the diagnosis was compatible with chondroblastoma. After resection of the tumor, 1 cm of the distal clavicle was preserved, 15 cm of the non-vascularized fibula was taken from the contralateral leg and placed on the site of the clavicle and fixed with hook plate at distal clavicle and reconstruction plate attached to the sternum. 13 months of follow-up is scheduled for removal of osteosynthesis material, finding full consolidation of sternoclavicular segment and the distal segment. A good functional outcome was apparent after a limited 14-month follow-up, and the patient was highly satisfied with the result. We found no recurrence or metastasis.
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http://dx.doi.org/10.1016/j.jor.2015.10.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4796578PMC
December 2015

Characteristics of pediatric intensive care residency programs in Argentina: A national survey.

Arch Argent Pediatr 2015 Oct;113(5):425-32

Consejo de Acreditación de Espacios de Formación, Sociedad Argentina de Pediatría.

Introduction: Pediatric intensive care residency programs have been in place in Argentina for just a few years. Knowing their status offers the possibility to establish strategies to help with professional development and training.

Objectives: 1) To describe the characteristics of pediatric intensive care residency programs across Argentina. 2) To assess whether certain characteristics are related to a higher vacancy filling rate. 3) To assess job placement in the hospital where residents are trained.

Design: Descriptive, observational study. National survey.

Inclusion Criteria: Pediatric intensive care residency programs in place between April 1st, 2014 and May 31st, 2014.

Results: Thirty-one residency programs were analyzed. Only 11/31 had an annual hospitalization volume >400 patients. There were no guidelines and/or criteria for care in 9/31. The program suited the national reference framework in 17/31. There was no head of residents or resident trainer in 13/31. Only 5/31 had been certified by the Ministry of Health. There were 65 vacancies; this number increased in the past four years; vacancy filling rate decreased from 59% in 2009 to 30% in 2013. Sixty percent of residents got a job in the pediatric intensive care unit where they were trained. A multivariate logistic regression analysis identified the outcome measure annual hospitalization volume >400 patients as an independent predictor of vacancy filling rate >60%.

Conclusions: 1) Vacancy filling is deficient. 2) The number of certified residency programs is scarce. 3) Pediatric intensive care units with a higher number of hospitalizations were associated with a higher vacancy filling rate. 4) More than half of residents got a job in the pediatric intensive care unit where they were trained.
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http://dx.doi.org/10.5546/aap.2015.425DOI Listing
October 2015

Tumor necrosis factor-α inhibition attenuates middle cerebral artery remodeling but increases cerebral ischemic damage in hypertensive rats.

Am J Physiol Heart Circ Physiol 2014 Sep 11;307(5):H658-69. Epub 2014 Jul 11.

Department of Pharmacology and Toxicology, Michigan State University, East Lansing, Michigan.

Hypertension causes vascular inflammation evidenced by an increase in perivascular macrophages and proinflammatory cytokines in the arterial wall. Perivascular macrophage depletion reduced tumor necrosis factor (TNF)-α expression in cerebral arteries of hypertensive rats and attenuated inward remodeling, suggesting that TNF-α might play a role in the remodeling process. We hypothesized that TNF-α inhibition would improve middle cerebral artery (MCA) structure and reduce damage after cerebral ischemia in hypertensive rats. Six-week-old male stroke-prone spontaneously hypertensive rats (SHRSP) were treated with the TNF-α inhibitor etanercept (ETN; 1.25 mg·kg(-1)·day(-1) ip daily) or PBS (equivolume) for 6 wk. The myogenic tone generation, postischemic dilation, and passive structure of MCAs were assessed by pressure myography. Cerebral ischemia was induced by MCA occlusion (MCAO). Myogenic tone was unchanged, but MCAs from SHRSP + ETN had larger passive lumen diameter and reduced wall thickness and wall-to-lumen ratio. Cerebral infarct size was increased in SHRSP + ETN after transient MCAO, despite an improvement in dilation of nonischemic MCA. The increase in infarct size was linked to a reduction in the number of microglia in the infarct core and upregulation of markers of classical macrophage/microglia polarization. There was no difference in infarct size after permanent MCAO or when untreated SHRSP subjected to transient MCAO were given ETN at reperfusion. Our data suggests that TNF-α inhibition attenuates hypertensive MCA remodeling but exacerbates cerebral damage following ischemia/reperfusion injury likely due to inhibition of the innate immune response of the brain.
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http://dx.doi.org/10.1152/ajpheart.00018.2014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4280151PMC
September 2014

[Mechanical circulatory support in pediatrics. Experience at the Dr. Juan P. Garrahan Pediatric Hospital. Argentina].

Arch Cardiol Mex 2014 Oct-Dec;84(4):256-61. Epub 2014 Jul 4.

Servicio de Cirugía Cardiovascular, Hospital de Pediatría Dr. Juan P. Garrahan, Ciudad Autónoma de Buenos Aires, Argentina.

Introduction: Mechanical circulatory support provides oxygen to the tissues in patients with cardiac and/or respiratory reversible disease refractory to conventional treatments.

Objective: The aim of this study is to show our initial results of mechanical circulatory support in children with heart disease.

Method: Retrospective cohort between March 2006 and March 2012. Demographic data (age, sex, weight, cardiac diagnosis), surgery (technique, pump, aortic cross clamping time) and mechanical circulatory support (type of assistance, indication, duration, complications and outcome) were collected.

Results: Thirty-three patients were supported (1.3% of all surgeries), extracorporeal membrane oxygenation 32 cases and one ventricular assist device. The median age 7.4 months (one day-18 years) and weight 6kg (2.3-75). The most frequent cardiac malformations supported were the transpositions of the great arteries associated with other anomalies and the corrected transpositions (ventricular inversion or double discordance). The most common reason for admission was post-cardiotomy biventricular dysfunction. Twenty-eight patients were supported in the postoperative period, 4 in the preoperative period and in one with myocarditis. Median days of support were 3 days (1-10). The most common complications were infection (21%), bleeding (21%). Elective decannulation was achieved in 94% of cases. Hospital discharge survival: 52%.

Conclusions: The mechanical circulatory support in our institution is a safe and standard procedure. We have been using it in a small number of cases with a similar survival to that reported internationally. This complex procedure is widely justified because it allows for the recovery of more than half of the patients who otherwise would have died.
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http://dx.doi.org/10.1016/j.acmx.2013.12.009DOI Listing
November 2015

[Bidirectional Glenn: outcomes and risk factor analysis in a 5 years' experience].

Arch Cardiol Mex 2013 Apr-Jun;83(2):88-92

Unidad de Cuidados Intensivos Cardiovasculares, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina. Electronic address:

Objective: Bidirectional Glenn shunt is a palliative surgical procedure in patients with single ventricle. Although morbimortality in this surgery is low, risk factors have been described. The purpose of this study is to report our outcomes in Glenn surgery, identifying mortality risk factors in our population.

Methods: Retrospective study between 2005 and 2009. Age, weight, previous surgery, surgical procedure, and postoperative condition were analyzed. Results are reported as median and rank, or absolute values and percentage. Uni and multivariate analysis was made to identify risk factors of mortality and/or prolonged hospitalization (Stata 9.0).

Results: One hundred and one patients were operated; 87 bidirectional Glenn and 14 bilateral Glenn. Median age 15 months (2.5-108), median weight 8.5 kg (4.2-27), and 74% of them with previous surgery. In 54 patients an associated procedure was performed simultaneously, only in 4 additional pulmonary blood flow was left. Median hospitalization was 8 days (2-97). Thirty-five percent of the patients presented complications. No association between age, weight, pulmonary hypertension, cardiopulmonary bypass, cross clamping, associated procedures or Glenn bilateral with mortality or morbidity was found. Overall mortality was 3.9%.

Conclusion: Mortality was similar to other centers, but morbidity in this group of patients is high. No independent risk factors associated with morbidity or mortality were identified.
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http://dx.doi.org/10.1016/j.acmx.2013.01.014DOI Listing
May 2015

[Congenital heart disease: surgical results in a public hospital in Argentina].

Arch Cardiol Mex 2011 Jul-Sep;81(3):178-82

Unidad de Recuperación Cardiovascular.

Objective: To describe the results of congenital heart surgery at the Hospital de Pediatría J. P.Garrahan.

Methods: Between 2004 and 2009, 2942 patients, median age 2.5 years (1 d to 22.5 y), median weight 11.5 kg (1.6 kg to 96 kg), and 84% with cardiopulmonary bypass, were analyzed. Adjusted mortality risk analysis using RACHS and Aristotle score was performed. Newborn surgery and one stage repair in Fallot and ventricular septal defect with coarctation were analyzed as subgroupes.

Results: Mortality was 5.5%. Required mechanical ventilation 45%, 5% peritoneal dialysis, 12% delayed sternal closure and 8.4% reoperation. Twenty five percent with previous surgery, and 10% in poor clinical conditions. RACHS-1 categories morality distribution were 0.4% in one, 2.4% in two, 7.1% in three, 14% in four y 34 % in 5 and 6. One stage repair was performed in 84% of Fallots and 90% of ventricular septal defects with coarctation, with 3.2% and 10% mortality rate respectively. Two hundred and five newborns were operated with cardiopulmonary bypass with a mortality rate of 15% in the last year.

Conclusions: Almost every congenital heart disease can be repaired without previous palliation, with satisfactory results in our institution. Poor clinical conditions significantly increased morbidity and mortality.
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January 2015

Clinical experience with Berlin Heart Excor in pediatric patients in Argentina: 1373 days of cardiac support.

Pediatr Cardiol 2011 Jun 20;32(5):652-8. Epub 2011 Mar 20.

Cardiac Intensive Care Unit, Hospital de Pediatría "Dr. Juan P. Garrahan", Buenos Aires, Argentina.

The objective of this study was to describe our experience (1373 days of support) with the Berlin Heart Excor (BH) ventricular-assist device (VAD) as bridging to cardiac transplantation in pediatric patients with end-stage cardiomyopathy. This study involved a retrospective observational cohort. Records of patients supported with the BH VAD were reviewed. Data regarding age, sex, weight, diagnosis, preoperative condition, single versus biventricular support, morbidity, and mortality were collected. Criteria for single versus biventricular support and intensive care unit management were registered. The procedure was approved by our Institutional Ethics Committee, and informed consent was obtained. Between March 2006 and March 2010, 12 patients with diagnosis of dilated (n = 10) and restrictive (n = 2) cardiomyopathy were supported. Median age was 56.6 months (range 20.1-165.9); mean weight was 18.3 kg (range 8.5-45); and nine patients were female. Every patient presented with severe heart failure refractory to pharmacological therapy. Biventricular support was necessary in four patients. Nine patients underwent heart transplantation. No child was weaned off the BH VAD because of myocardial recovery. Mean length of support was 73 days (range 3-331), and the total number of days of support was 1373. Three patients had fatal complications: 2 had thrombo-hemorrhagic stroke leading to brain death, and one had refractory vasoplegic shock. The BH VAD is a useful and reasonable safe device for cardiac transplantation bridging in children with end-stage heart failure. Team experience resulted in less morbidity and mortality, and time for implantation, surgical procedure, anticoagulation monitoring, and patient care improved.
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http://dx.doi.org/10.1007/s00246-011-9949-0DOI Listing
June 2011

Haemostatic safety of a unique recombinant plasmin molecule lacking kringles 2-5.

Thromb Haemost 2010 Oct 30;104(4):780-7. Epub 2010 Aug 30.

David Geffen School of Medicine at UCLA, Los Angeles, California 90095–1795, USA.

We previously demonstrated a significant margin of haemostatic safety for full-length plasmin in comparison with tissue plasminogen activator (t-PA). We now report studies that compare haemostatic safety of full-length plasmin with a novel recombinant plasmin derivative, (Δ K2-5) plasmin, consisting of kringle 1 linked to the serine protease domain of plasmin. Agent was administered intravenously in a randomised, blinded manner in a rabbit model of fibrinolytic haemorrhage. A dose-related decrease in α2-antiplasmin, factor VIII, and fibrinogen followed administration of 1.8, 2.7, 3.7 and 4.6 mg/kg of (Δ K2-5) plasmin, with nadir fibrinogen concentrations of 65%, 40%, 30%, and 0% of initial levels, respectively. Mean primary bleeding time was undisturbed at 1.8 mg/kg (2.2 ± 0.7 minutes), minimally prolonged at 2.7 or 3.7 mg/kg (5 ± 2.9 and 4.4 ± 2.2 minutes), and prolonged at the purposefully toxic 4.6 mg/kg dose (12.8 ± 18.8 minutes). Equimolar amounts of (Δ K2-5) plasmin and full-length plasmin had equal in vitro clot lysis efficacy, but in the bleeding model, (Δ K2-5) plasmin showed better haemostatic competency than full-length plasmin. This safety advantage may be explained by higher residual amounts of plasma fibrinogen in animals given (Δ K2-5) plasmin rather than full-length plasmin. We demonstrate that a unique recombinant plasmin mutant, (Δ K2-5) plasmin, possesses an advantage in hemostatic safety over an equimolar amount of full-length plasmin.
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http://dx.doi.org/10.1160/TH09-10-0742DOI Listing
October 2010

[Cardiopulmonary resuscitation in nine pediatric intensive care units of the Argentine Republic].

Arch Argent Pediatr 2010 Jun;108(3):216-25

Unidad de Cuidados Intensivos Pediátricos, Hospital Municipal Materno Infantil de San Isidro Dr. C. Gianantonio, San Isidro.

Introduction: The cardiopulmonary resuscitation (CPR) is a common setting in the pediatric intensive care unit (PICU). There are very few reports or publications that evaluate the form of CPR administered in children.

Objectives: 1) Identify the etiology and epidemiology of the CPR in the PICU. 2) Describe how to conduct CPR. 3) Describe the drugs used. 4) Knowing the patient outcomes. 5) Knowing CPR training of physicians in the PICU.

Patients And Methods: All children with cardiopulmonary arrest who were resuscitated in the PICU between 01/04/2004- 31/03/2005. A prospective cohort study.

Results: There were 2065 admissions in nine 9 PICU and CPR was conducted in 132 patients (6.39%). Most common etiologies of PCR were hypoxia and hypotension (65.9% of total). The initial rates of PCR were 43.94% bradycardia, asystolia 43.18%, 9.85% ventricular arrhythmias. The average beginning of time of CPR was 0.08 minutes (SD 0.25) and the average total duration was 25.91 minutes (SD 18.56). Patients who require drugs were 131. The number (mean) dose of adrenaline was 4.03 (SD 2.78). Increased number of doses of adrenaline was associated with less chance of recovery of spontaneous circulation (ROSC), OR 0.48 95% CI 0.37-0.63. (p= 0.000). The duration of CPR was inversely associated and significantly related to achieve ROSC, OR 0.93 95% CI 0.87-0.99. One hundred and four (78.79%) patients died and 28 survived. All survived were discharged from PICU, but 26 from hospital. In 22 patients there were not evidence of severe neurological damage when discharged home.

Conclusions: Most common etiologies of PCR were hypoxia and shock. Most children received drugs. The drugs most used were the association adrenaline-bicarbonate and adrenaline alone. The chances of recovery were not favorable when CPR was conducted for over sixty minutes or more than six doses of adrenaline were given, without response. CPR in PICU children has a high mortality. Most patients discharged from hospital, had neurological normal state or slight disability. PICU physicians were highly trained in CPR with resuscitation courses.
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http://dx.doi.org/10.1590/S0325-00752010000300007DOI Listing
June 2010

[Prevention of catheter-related infection: usefulness and cost-effectiveness of antiseptic catheters in children].

Arch Argent Pediatr 2010 Jun;108(3):209-15

Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina.

Objective: To evaluate the cost-effectiveness of the antiseptic-impregnated catheter compared with conventional catheters in preventing catheter- related blood stream infections (CR-BSI).

Design: Cost-effectiveness analysis; clinical trial, experimental, randomized, controlled, prospective, open label. Patients and methods. A 172 patient cohort, under 1-year-old or less than 10 kg, postoperative cardiovascular children with central venous catheters (CVC) admitted to Cardiac Intensive Care Unit (UCI 35) at Hospital Nacional de Pediatría "Prof. Dr. Juan P. Garrahan", since September 2005 to December 2007. Demographic and CVC data were retrieved to compare: age, gender, weight, diagnosis, surgery, CVC days, costs and complications. Intervention. CVC Arrow, double-lumen, > 48 h of duration; intervention group: antiseptic-impregnated CVC vs. control group: CVC without antiseptics (conventional).

Results: The incidence of CR-IE (CR-Infected Events: colonization, local infection and/or CRBSI; combined end point) was 27% for antiseptic- impregnated CVC vs. 31% for conventional catheters (p= 0.6) with similar accumulated incidence of CR- BSI: 2.8 vs. 3.3 per 1000 dayscatheter. We found no differences between groups, except in weight: median 4.0 kg (r 2-17) vs. 4.7 kg (r 2-9) p= 0.0002 and age, median 2 months (r 1- 48) vs. 5 months (r 1- 24) p= 0.0019 in antiseptic-impregnated CVC group. These differences, though statistically significant were clinically non relevant. Median cost per patient during intensive care stay in the conventional CVC group was $3.417 (359-9.453) and in the antiseptic-impregnated-CVC group was $4.962 (239-24.532), p= 0.10.

Conclusions: The use of antiseptic-impregnated CVC compared with conventional CVC did not decrease CR-BSI in this population. The cost per patients was higher in the antiseptic impregnated CVC group. These results do not support the routine use of this type of CVC in our population.
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http://dx.doi.org/10.1590/S0325-00752010000300006DOI Listing
June 2010

[Cardiac surgical repair in newborns: five years' experience in neonatal open surgery].

Arch Argent Pediatr 2009 Oct;107(5):417-22

UCI 35. Recuperación Cardiovascular, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan.

Introduction: Four hundred newborns die every year in our country suffering from congenital heart disease. Definitive surgical repair, whenever possible, is nowadays the optimal therapeutic strategy. Our goal is to describe mortality and morbidity in neonatal surgery with cardiopulmonary bypass in a tertiary public hospital in Argentina.

Patients And Methods: Descriptive, retrospective study. Every patient, younger than 45 days, with cardiac surgery requiring cardiopulmonary bypass, at the Garrahan Hospital between 2004 and 2008 was included. Demographic, surgical and postoperative data were collected. Adjusted mortality risk analysis, and descriptive statistics from the most frequent diagnosis were performed. Results are expressed as median and rank or percentage.

Results: 200 newborns were operated, 62% males. Median age was 21 days (r 1- 45) and median weight 3.1 kg (r 1.6-6.2). Total anomalous pulmonary venous return, transposition of great arteries an hypoplastic left heart syndrome diagnoses accounted for 75% of the procedures. Median length of stay was 12 days (r 0-191), and 6 days of mechanical ventilation (r 0-180). Eighteen percent of the patients required peritoneal dialysis. Whole series mortality was 19% and fell to 14% in 2008. Unstable preoperative condition and postoperative complications increased mortality, OR= 2.23 (1.02-4.89) and OR= 10 (3.6-33.4), respectively.

Conclusions: Our postoperative mortality is similar to those reported in foreign countries databases. Patients with unstable preoperative condition and post-operative complications had higher mortality.
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http://dx.doi.org/10.1590/S0325-00752009000500008DOI Listing
October 2009

[Levosimendan, a new inotropic drug: experience in children with acute heart failure].

Arch Argent Pediatr 2009 Apr;107(2):139-45

Unidad de Cuidados Intensivos UCI 35, Recuperación Cardiovascular, Hospital Nacional de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina.

Introduction: Low cardiac output syndrome occurs frequently in pediatric patients after cardiac surgery. Catecholamines are used as inotropic drugs to treat this threatening condition, but may cause undesirable and potentially harmful side effects. This study was performed to evaluate the efficacy and safety of levosimendan (LEVO) in pediatric patients with low cardiac output syndrome.

Patients And Methods: Open prospective, quasi-experimental cohort. LEVO was given as compassionate treatment in patients with refractory post-surgical low cardiac output syndrome. Every patient received an IV infusion of LEVO at 6 microg/kg during a fifteen minutes period, followed by a 24 h IV infusion at 0.1 microg/kg/min. Clinical improvement of cardiac output was the primary end point of the study. Two independent observers performed clinical evaluation, bidimensional echocardiogram, hemodynamic and laboratory tests were performed pre and after LEVO infusion.

Results: LEVO was infused in 18 opportunities (fourteen children). The response was considered successful in 9/18 interventions (50%; p= 0.004). Both inotropic score (12.1 vs. 6,1, p= 0.01) and A-VDO(2)2 (26.78 +/- 11.5% vs. 20.81 +/- 7.72%, p= 0.029) showed reduction, while SvO2 improved (69.5 +/- 11.4% vs. 76 +/- 9.29%, p= 0.03). No adverse effects were noticed. Four patients died, none of them related to LEVO administration.

Conclusions: LEVO improved cardiac output in 50% of the interventions with post-surgical LCOS and no adverse effect was observed.
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http://dx.doi.org/10.1590/S0325-00752009000200008DOI Listing
April 2009

[Opinion of parents and caregivers of interned children about their presence during the realization of invasive procedures].

Arch Argent Pediatr 2008 Apr;106(2):110-8

Unidad de Cuidados Intensivos Pediátricos, Hospital Municipal Materno Infantil de San Isidro Dr. Carlos A. Gianantonio, Ciudad de Buenos Aires.

Introduction: The presence of family members during procedures is a controversial topic. Despite the widespread perception of its benefits, procedures are often carried out in places with restricted access.

Objectives: 1. To know parent s and caregiver s opinion about their presence during the performance of invasive procedures. 2. To determine the reasons to justify or deny their presence. Materials and methods.

Inclusion Criteria: parents and caregivers of children admited to Hospital Municipal Materno Infantil de San Isidro "Dr. Carlos Gianantonio" and Sanatorio "Mater Dei".

Design: transversal study. Anonymous survey.

Results: One hundred and seventy eight surveys were delivered and 172 were recovered. The average age of respondents was 33.75 years, 80.81% were women, 98.84% had children. The relationship to the patient: mother 70.93%, father 18.02%, grandparents 6.4%, uncle 2.33% and sibling 2.33%. The desire to be present at the different procedures was always greater than 50%. There is an inverse relationship with the invasiveness of the procedure: endovenous access 88.95%, laceration repair (sutures) 78.49%, lumbar puncture 73.84%, endotracheal intubation 56.98% and cardiopul-monary resuscitation 58.72%. Similar results were obtained for unconscious child. The most frequently reasons to justify the presence are emotional containment of the child and procedure monitoring.

Conclusions: 1) The majority of respondents wanted to be present. 2) There is an inverse relationship between the desire of the family and level of invasiveness. 3) There are not significant differences comparing conscious or unconscious child.
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April 2008

The pharmacology of the endocannabinoid system: functional and structural interactions with other neurotransmitter systems and their repercussions in behavioral addiction.

Addict Biol 2008 Jun 16;13(2):160-87. Epub 2008 Apr 16.

Department of Psychobiology, Faculty of Psychology, Campus de Somosaguas, Complutense University of Madrid, Spain.

Addiction is a chronic, recurring and complex disorder. It is characterized by anomalous behaviors that are linked to permanent or long-lasting neurobiological alterations. Furthermore, the endocannabinoid system has a crucial role in mediating neurotransmitter release as one of the main neuromodulators of the mammalian central nervous system. The purpose of the present review is to instruct readers about the functional and structural interactions between the endocannabinoid system and the main neurotransmitter systems of the central nervous system in the context of drug addiction. With this aim, we have systematically reviewed the main findings of most of the existing literature that explores cross-talk in the five brain areas that are most traditionally implicated in addiction: amygdala, prefrontal cortex, nucleus accumbens, hippocampus and ventral tegmental area (VTA). The neurotransmission systems influenced by the pharmacology of the endocannabinoid system in these brain areas, which are reviewed here, are gamma-aminobutyric acid (GABA), glutamate, the main biogenic amines (dopamine, noradrenaline and serotonin), acetylcholine and opioids. We show that all of these neurotransmitter systems can be modulated differentially in each brain area by the activation or deactivation of cannabinoid CB1 brain receptors. Specifically, most of the studies relate to the hippocampus and nucleus accumbens. Moreover, the neurotransmitter with the fewest number of related studies is acetylcholine (excepting in the hippocampus), whereas there is a large number that evaluates GABA, glutamate and dopamine. Finally, we propose a possible interpretation of the role of the endocannabinoid system in the phenomenon of addiction.
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http://dx.doi.org/10.1111/j.1369-1600.2008.00105.xDOI Listing
June 2008
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