Eduardo Tobar

Invasive infections by Candida strains are a relevant pathology in critically ill patients. Candida should be considered where a high risk of infection is present for a critical early diagnosis. Despite the incorporation of new drugs in the therapeutic armamentarium over the last decade, mortality remains high. The key in improving clinical outcomes of these patients are the use of early effective therapies that offer coverage against different strains of Candida: C. albicans and non-albicans. Recent international guidelines suggest empiric therapy with echinocandins in suspected invasive candidiasis in this patient population. This group of drugs adequately documented clinical efficacy and safe use in these patients. The emergence of new echinocandins could improve access to these drugs by reducing their cost.

BACKGROUND One of the complications of diabetes mellitus is the development of pancreatic exocrine insufficiency. AIM To study pancreatic exocrine function in diabetics patients. MATERIAL AND METHODS Seventy two diabetic patients were included in the protocol, but two were withdrawn because an abdominal CAT scan showed a chronic calcified pancreatitis, previously undiagnosed. Fecal elastase was measured by ELISA and the presence of fat in feces was assessed using the steatocrit. RESULTS Mean age was 60+/-12 years and 67 (96%) patients had a type 2 diabetes. Fecal elastase was normal (elastase >200 microg/g) in 47 (67%) patients, mildly decreased (100-200 microg/g) in 10 (14%) and severely decreased in 13 (19%). There was a significant association between elastase levels and time of evolution of diabetes (p=0.049) and between lower elastase levels and the presence of a positive steatocrit (p=0.042). No significant association was found between elastase levels and other chronic com...

BACKGROUND Sedatives and analgesic drugs give comfort and allow adequate respiratory support to critically ill patients in mechanical ventilation (MV). Its improper use may increase the duration of MV. Clinical guidelines suggest implementation of protocols, however this is seldom done in clinical practice. AIM To compare in MV patients, nurse-applied guided by protocol administration of sedatives and analgesic drugs (protocol: group P) with the habitual practice using physicians criteria (control: group C). MATERIAL AND METHODS Inclusion criteria was the need of MV more than 48 h. The exclusion criteria were acute neurological diseases, hepatic cirrhosis, chronic renal failure and limitation of therapeutic efforts. Midazolam and fentanyl were used in both groups. The level of sedation was monitored with the Sedation Agitation Scale (SAS). In the P group, trained nurses applied algorithms to adjust the sedative doses according to a predefined SAS goal. RESULTS Forty patients were in...

BACKGROUND Twenty percent of patients with chronic hepatitis C evolve to cirrhosis in 10 to 20 years. The degree of steatosis and hepatic iron stores in liver biopsy increase the risk. Age, high body mass index, diabetes mellitus and alcohol consumption are factors associated to the severity of liver damage. AIM To study the association of steatosis and increased iron stores in the liver biopsy and age, overweight, alcohol consumption and diabetes with the severity of liver damage in patients with hepatitis C virus infection. PATIENTS AND METHODS Retrospective study of 84 liver biopsies of patients with chronic infection with hepatitis C virus were studied. The pathological appearance was classified as stage I when chronic hepatitis with mild activity without fibrosis was observed; as stage II when moderate chronic hepatitis with mild fibrosis was observed and as stage III when there was a moderate chronic hepatitis with fibrosis or cirrhosis. The amount of steatosis and iron deposi...

Invasive infections by Candida strains are a relevant pathology in critically ill patients. Candida should be considered where a high risk of infection is present for a critical early diagnosis. Despite the incorporation of new drugs in the therapeutic armamentarium over the last decade, mortality remains high. The key in improving clinical outcomes of these patients are the use of early effective therapies that offer coverage against different strains of Candida: C. albicans and non-albicans. Recent international guidelines suggest empiric therapy with echinocandins in suspected invasive candidiasis in this patient population. This group of drugs adequately documented clinical efficacy and safe use in these patients. The emergence of new echinocandins could improve access to these drugs by reducing their cost.

Delirium has negative consequences such as increased mortality, hospital expenses and decreased cognitive and functional status. This research aims to determine the impact of occupational therapy intervention in duration, incidence and severity of delirium in elderly patients in the intensive care unit; secondary outcome was to assess functionality at hospital discharge. This is a pilot randomized clinical trial of patients without mechanical ventilation for 60 years. Patients were assigned to a control group that received standard strategies of prevention (n=70) or to an experimental group that received standard strategies plus occupational therapy twice a day for 5 days (n=70). Delirium was valued with Confusion Assessment Method and Delirium Rating Scale, and functional outcomes at discharge with Functional Independence Measure, Hand Dynamometer, and Mini-Mental State Examination. A total of 140 participants were recruited. The experimental group had lower duration (risk incidence ratios, 0.15 [P=.000; 95% confidence interval, 0.12-0.19] vs 6.6 [P=.000, 95% confidence interval, 5.23-8.3]) and incidence of delirium (3% vs 20%, P=.001), and had higher scores in Motor Functional Independence Measure (59 vs 40 points, P<.0001), cognitive state (MMSE: 28 vs 26 points, P<.05), and grip strength in the dominant hand (26 vs 18 kg, P<.05), compared with the control group. Occupational therapy is effective in decreasing duration and incidence of delirium in nonventilated elderly patients in the intensive care unit and improved functionality at discharge.

Resumen El desarrollo de las diversas técnicas de traquesotomía percutánea ha facilitado la ejecución de este procedimiento en pacientes críticos sometidos a ventilación mecánica, y ha demostrado ser tanto o más seguro que la traqueostomía abierta en este grupo de ...

Background: Sedatives and analgesic drugs give comfort and allow adequate respiratory support to critically ill patients in mechanical ventilation (MV). Its improper use may increase the duration of MV. Clinical guidelines suggest implementation of protocols, however this ...

Twenty percent of patients with chronic hepatitis C evolve to cirrhosis in 10 to 20 years. The degree of steatosis and hepatic iron stores in liver biopsy increase the risk. Age, high body mass index, diabetes mellitus and alcohol consumption are factors associated to the severity of liver damage. To study the association of steatosis and increased iron stores in the liver biopsy and age, overweight, alcohol consumption and diabetes with the severity of liver damage in patients with hepatitis C virus infection. Retrospective study of 84 liver biopsies of patients with chronic infection with hepatitis C virus were studied. The pathological appearance was classified as stage I when chronic hepatitis with mild activity without fibrosis was observed; as stage II when moderate chronic hepatitis with mild fibrosis was observed and as stage III when there was a moderate chronic hepatitis with fibrosis or cirrhosis. The amount of steatosis and iron deposition in the biopsy were also assesse...

Positive end-expiratory pressure (PEEP) and prone positioning may induce lung recruitment and affect alveolar dynamics in acute respiratory distress syndrome (ARDS). Whether there is interdependence between the effects of PEEP and prone positioning on these variables is unknown. To determine the effects of high PEEP and prone positioning on lung recruitment, cyclic recruitment/derecruitment, and tidal hyperinflation and how these effects are influenced by lung recruitability. Mechanically ventilated patients (Vt 6 ml/kg ideal body weight) underwent whole-lung computed tomography (CT) during breath-holding sessions at airway pressures of 5, 15, and 45 cm H2O and Cine-CTs on a fixed thoracic transverse slice at PEEP 5 and 15 cm H2O. CT images were repeated in supine and prone positioning. A recruitment maneuver at 45 cm H2O was performed before each PEEP change. Lung recruitability was defined as the difference in percentage of nonaerated tissue between 5 and 45 cm H2O. Cyclic recruitment/de-recruitment and tidal hyperinflation were determined as tidal changes in percentage of nonaerated and hyperinflated tissue, respectively. Twenty-four patients with ARDS were included. Increasing PEEP from 5 to 15 cm H2O decreased nonaerated tissue (501 ± 201 to 322 ± 132 grams; P…

Delirium has negative consequences such as increased mortality, hospital expenses and decreased cognitive and functional status. This research aims to determine the impact of occupational therapy intervention in duration, incidence and severity of delirium in elderly patients in the intensive care unit; secondary outcome was to assess functionality at hospital discharge. This is a pilot randomized clinical trial of patients without mechanical ventilation for 60 years. Patients were assigned to a control group that received standard strategies of prevention (n=70) or to an experimental group that received standard strategies plus occupational therapy twice a day for 5 days (n=70). Delirium was valued with Confusion Assessment Method and Delirium Rating Scale, and functional outcomes at discharge with Functional Independence Measure, Hand Dynamometer, and Mini-Mental State Examination. A total of 140 participants were recruited. The experimental group had lower duration (risk incidence ratios, 0.15 [P=.000; 95% confidence interval, 0.12-0.19] vs 6.6 [P=.000, 95% confidence interval, 5.23-8.3]) and incidence of delirium (3% vs 20%, P=.001), and had higher scores in Motor Functional Independence Measure (59 vs 40 points, P<.0001), cognitive state (MMSE: 28 vs 26 points, P<.05), and grip strength in the dominant hand (26 vs 18 kg, P<.05), compared with the control group. Occupational therapy is effective in decreasing duration and incidence of delirium in nonventilated elderly patients in the intensive care unit and improved functionality at discharge.

Delirium is a relevant condition in critically ill patients with long-term impacts on mortality, cognitive and functional status and quality of life. Despite the progress in its diagnosis, prevention and management during the last years, its impact persists being relevant, so new preventive and therapeutic strategies need to be explored. Among non-pharmacologic preventive strategies, recent reports suggest a role for occupational therapy through a series of interventions that may impact the development of delirium. The aim of this review is to evaluate the studies evaluating the role of occupational therapy in the prevention of delirium in critically ill patient populations, and suggests perspectives to future research in this area.

Invasive infections by Candida strains are a relevant pathology in critically ill patients. Candida should be considered where a high risk of infection is present for a critical early diagnosis. Despite the incorporation of new drugs in the therapeutic armamentarium over the last decade, mortality remains high. The key in improving clinical outcomes of these patients are the use of early effective therapies that offer coverage against different strains of Candida: C. albicans and non-albicans. Recent international guidelines suggest empiric therapy with echinocandins in suspected invasive candidiasis in this patient population. This group of drugs adequately documented clinical efficacy and safe use in these patients. The emergence of new echinocandins could improve access to these drugs by reducing their cost.

Central venous oxygen saturation calculated by gasometry (Gaso-Scvo2) is more available than central venous oxygen saturation measured by co-oximetry (Co-oxy-Scvo2) in environments with less resources and underdeveloped countries. Therefore, we aimed to determine the agreement between Co-oxy-Scvo2 and Gaso-Scvo2 and between central venous oxygen tension measured by gasometry (Gaso-Pcvo2) and Co-oxy-Scvo2, respectively. This is a prospective study in a university hospital's intensive care unit. Sixteen patients were studied during the first 48 hours after diagnosis of septic shock. All patients were intubated, connected to mechanical ventilation, and resuscitated according to the standards of care. One hundred eleven pairs of central venous blood measurements were analyzed both by conventional gasometry and co-oximetry. Bland and Altman analysis between Co-oxy-Scvo2 and Gaso-Scvo2 showed lack of agreement (1.7 [-10.7, +14.2]). A Gaso-Scvo2 less than 70% had a positive predictive value of 63% in relation to Co-oxy-Scvo2, and its negative predictive value was 90% with 20% false-positives and 5% false-negatives. The area under the receiver operator characteristic curve of Gaso-Pcvo2 to discriminate a Co-oxy-Scvo2 greater than or equal to 70% was 0.87 (confidence interval, 0.80-0.93), and the best cut-off point was a Gaso-Pcvo2 more than 40 mm Hg, (sensitivity, 75%; specificity, 93%). The reliability of Gaso-Scvo2 determination during the resuscitation phase of septic shock is not acceptable. There is a good agreement between a Gaso-Pcvo2 more than 40 mm Hg and a Co-oxy-Scvo2 greater than or equal to 70%. Our results suggest that given these limitations, Gaso-Scvo2 results should be interpreted with caution, helped by Gaso-Pcvo2 measurements and in context with other perfusion parameters.

ABSTRACT Previous reports describe 30-40% of small intestine bacterial overgrowth (SIBO) in patients with chronic pancreatitis (CP), SIBO is a cause of persistent symptoms in this group of patients even when they are treated with pancreatic enzymes. To asses the frequency of SIBO in patients with CP. We studied 14 patients with CP using an hydrogen breath test with lactulose to detect SIBO, a nonabsorbable carbohydrate, whose results are not influenced by the presence of exocrine insufficiency. Main symptoms and signs were bloating in 9 (64%), recurrent abdominal pain in 8 (57%), intermittent diarrhea in 5 (36%) and steatorrhea in 5 (36%). At the same time we studied a healthy control group paired by age and sex. SIBO was present in 13 of 14 patients with CP (92%) and in 1 of 14 controls (p<0.001). The only patient with CP and without SIBO was recently diagnosed and had minimal morphologic alterations in computed tomography and endoscopic pancreatography. SIBO is common in CP and may be responsible for persistent symptoms. Proper diagnosis and treatment could alleviate symptoms and improve quality of Ufe.

Antibiotic therapy improves the outcome of severe sepsis and septic shock, however pharmacokinetic properties are altered in this scenario. Amikacin (AMK) is an option to treat community or nosocomial infections, although standard doses might be insufficient in critically ill patients. The aim of this study was to evaluate two AMK dosage regimens in comparison with standard therapy with regard to efficacy in achieving adequate plasma levels as well as safety. In total, 99 patients with severe sepsis or septic shock were randomised to different AMK dose protocols: Group 1, 25 mg/kg/day; Group 2, 30 mg/kg/day; and Group 3, historical standard dose (15 mg/kg/day). Peak plasma concentrations at 1 h (C(max)) were determined. Pharmacokinetics was determined and renal function was monitored to evaluate toxicity. Groups were compared using bilateral T-test. Demographic characteristics of the three groups were comparable. AMK C(max) values were 57.4±9.8, 72.1±18.4 and 35.2±9.4 μg/mL, respectively (P<0.001 between Groups 1 and 2 versus Group 3, and…

Revista Chilena de Terapia Ocupacional, publicada anualmente, desde 2001 por la Escuela de Terapia Ocupacional de la Facultad de Medicina de la Universidad de Chile. La Revista Chilena de Terapia Ocupacional, publica trabajos originales sobre temas de interés vinculados a la Ciencia de la Ocupación ya la Terapia Ocupacional. ... Relación entre autoeficacia, autoestima, asertividad, y rendimiento académico, en estudiantes que ingresaron a Terapia Ocupacional, el año 2010. ... Relationship between self-efficacy, self-esteem, ...

Post-operative delirium is a serious complication in patients undergoing major abdominal surgery. It remains unclear whether peri-operative hemodynamic and perfusion variables affect the risk for postoperative delirium. The objective of this pilot study was to evaluate the association between perfusion and hemodynamics peri-operative with the appearance of post-operative delirium. Prospective cohort study of adults 60 years or older undergoing elective open colon surgery. Multimodal hemodynamic and perfusion variables were monitored, including central venous oxygenation (ScvO2), lactate levels, and non-invasive cerebral oxygenation (rSO2), according to a standard anesthesia protocol. Fisher's exact test or Student's t-test were used to compare patients who developed post-operative delirium with those who did not (p<0.05). We studied 28 patients, age 73±7 years, 60.7% female. Two patients developed post-operative delirium (7.1%). These two patients had fewer years of educa...

Delirium is a relevant condition in critically ill patients with long-term impacts on mortality, cognitive and functional status and quality of life. Despite the progress in its diagnosis, prevention and management during the last years, its impact persists being relevant, so new preventive and therapeutic strategies need to be explored. Among non-pharmacologic preventive strategies, recent reports suggest a role for occupational therapy through a series of interventions that may impact the development of delirium. The aim of this review is to evaluate the studies evaluating the role of occupational therapy in the prevention of delirium in critically ill patient populations, and suggests perspectives to future research in this area.

Delirium has negative consequences such as increased mortality, hospital expenses and decreased cognitive and functional status. This research aims to determine the impact of occupational therapy intervention in duration, incidence and severity of delirium in elderly patients in the intensive care unit; secondary outcome was to assess functionality at hospital discharge. This is a pilot randomized clinical trial of patients without mechanical ventilation for 60 years. Patients were assigned to a control group that received standard strategies of prevention (n=70) or to an experimental group that received standard strategies plus occupational therapy twice a day for 5 days (n=70). Delirium was valued with Confusion Assessment Method and Delirium Rating Scale, and functional outcomes at discharge with Functional Independence Measure, Hand Dynamometer, and Mini-Mental State Examination. A total of 140 participants were recruited. The experimental group had lower duration (risk incidence ratios, 0.15 [P=.000; 95% confidence interval, 0.12-0.19] vs 6.6 [P=.000, 95% confidence interval, 5.23-8.3]) and incidence of delirium (3% vs 20%, P=.001), and had higher scores in Motor Functional Independence Measure (59 vs 40 points, P<.0001), cognitive state (MMSE: 28 vs 26 points, P<.05), and grip strength in the dominant hand (26 vs 18 kg, P<.05), compared with the control group. Occupational therapy is effective in decreasing duration and incidence of delirium in nonventilated elderly patients in the intensive care unit and improved functionality at discharge.

One of the complications of diabetes mellitus is the development of pancreatic exocrine insufficiency. To study pancreatic exocrine function in diabetics patients. Seventy two diabetic patients were included in the protocol, but two were withdrawn because an abdominal CAT scan showed a chronic calcified pancreatitis, previously undiagnosed. Fecal elastase was measured by ELISA and the presence of fat in feces was assessed using the steatocrit. Mean age was 60+/-12 years and 67 (96%) patients had a type 2 diabetes. Fecal elastase was normal (elastase >200 microg/g) in 47 (67%) patients, mildly decreased (100-200 microg/g) in 10 (14%) and severely decreased in 13 (19%). There was a significant association between elastase levels and time of evolution of diabetes (p=0.049) and between lower elastase levels and the presence of a positive steatocrit (p=0.042). No significant association was found between elastase levels and other chronic complications of diabetes such as retinopathy, ...