tag:blogger.com,1999:blog-23451135058360372982024-02-18T23:00:44.091-08:00Casimiro UlloaBLOG de los medicos residentes internos del hospital Jose Carimiro Ulloa. Hospital especializado en EMERGENCIAS. Ubicado en San Antonio Miraflorez, av Republica de Panama.Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.comBlogger404125tag:blogger.com,1999:blog-2345113505836037298.post-32245082623431427722012-05-28T21:29:00.001-07:002012-05-28T21:29:53.641-07:00CURSO CLINICA SAN MIGUEL [Archivo adjunto 1]<br><br> <div class="gmail_quote">---------- Mensaje reenviado ----------<br>De: <b class="gmail_sendername">LUIS LORO CHERO</b> <span dir="ltr"><<a href="mailto:lorochero@yahoo.es">lorochero@yahoo.es</a>></span><br>Fecha: 27 de mayo de 2012 23:42<br> Asunto: [jefaturandolaguardiamedica] CURSO CLINICA SAN MIGUEL [Archivo adjunto 1]<br>Para: "<a href="mailto:jefaturandolaguardiamedica@yahoogroups.com">jefaturandolaguardiamedica@yahoogroups.com</a>" <<a href="mailto:jefaturandolaguardiamedica@yahoogroups.com">jefaturandolaguardiamedica@yahoogroups.com</a>>, residente medico PERU interno <<a href="mailto:interno_residente_medico_PERU@yahoogroups.com">interno_residente_medico_PERU@yahoogroups.com</a>>, "<a href="mailto:sanfernandoperu@yahoogroups.com">sanfernandoperu@yahoogroups.com</a>" <<a href="mailto:sanfernandoperu@yahoogroups.com">sanfernandoperu@yahoogroups.com</a>>, EMERGENCIA GRUPO <<a href="mailto:emergencias_y_desastres@yahoogroups.com">emergencias_y_desastres@yahoogroups.com</a>>, EMERGENCIA DOCENCIA <<a href="mailto:docenciaemergencia@yahoogroups.com">docenciaemergencia@yahoogroups.com</a>>, DESASTRES EMERGENCIAS <<a href="mailto:medicinadeemergenciasydesastres@yahoogroups.com">medicinadeemergenciasydesastres@yahoogroups.com</a>><br> <br><br><u></u> <div><span> </span> <div> <div> <div><span style="DISPLAY:block;MARGIN-BOTTOM:20px;FONT-SIZE:12px;FONT-WEIGHT:700">[Más abajo se incluyen <a style="TEXT-DECORATION:none" href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#13791c04f7d79455_TopText">archivos adjuntos</a> de LUIS LORO CHERO]</span> <p> <div style="FONT-FAMILY:lucida console,sans-serif;FONT-SIZE:12pt"><br> <div style="FONT-FAMILY:lucida console,sans-serif;FONT-SIZE:12pt"> <div style="FONT-FAMILY:times new roman,new york,times,serif;FONT-SIZE:12pt"><span style="FONT-FAMILY:lucida console,sans-serif">Estimados colegas:</span> <div> <div> <div style="FONT-FAMILY:lucida console,sans-serif;FONT-SIZE:12pt"> <div><br><span></span></div> <div><span>Con las disculpas del caso, les reitero la invitación al Curso de Emergencias y Reanimación Cardiopulmonar que organiza la Clínica San Miguel de San Juan de Lurigancho.</span></div> <div><br><span></span></div> <div><span>Adjunto esta vez el programa final del curso para su conocimiento y difusión si así lo consideran.</span></div> <div><br><span></span></div> <div><span>Gracias de antemano.</span></div> <div> </div> <div> <div align="center"><font color="#0060bf"><i><b></b></i></font> </div> <div align="center"> <font style="FONT-FAMILY:bookman old style,new york,times,serif" size="4">"<i>La Humildad consiste en callar nuestras virtudes y permitirle a los demás descubrirlas; nadie está más vacío, que aquel que está lleno del Yo Mismo</i>"</font><span style="FONT-STYLE:italic;FONT-FAMILY:bookman old style,new york,times,serif;FONT-WEIGHT:bold"><br style="FONT-FAMILY:bookman old style,new york,times,serif"> <br></span><span style="FONT-STYLE:italic;FONT-FAMILY:bookman old style,new york,times,serif"></span></div> <div align="center"><font color="#0060bf"><b><i>Med. Emerg. LUIS M. LORO CHERO<br>Director Médico Clínica San Miguel - SJL<br>C.M.P. 23627 - R.N.E. 17261<br>Teléfonos: 3875457 - 994185938 - *753201<br></i></b></font></div> <span style="FONT-STYLE:italic"><span style="FONT-WEIGHT:bold"></span></span> <div style="FONT-FAMILY:times new roman,new york,times,serif;FONT-SIZE:12pt"> <br></div></div> <div style="FONT-FAMILY:lucida console,sans-serif;FONT-SIZE:12pt"></div></div></div></div><br><br></div></div></div> <p></p></p></div> <div style="MIN-HEIGHT:0px;COLOR:#fff">__._,_.___</div><a name="13791c04f7d79455_TopText"> <p style="PADDING-BOTTOM:3px;MARGIN:0px;PADDING-LEFT:0px;PADDING-RIGHT:0px;CLEAR:both;PADDING-TOP:0px"><span style="COLOR:#628c2a;FONT-SIZE:13px;FONT-WEIGHT:700">Archivos adjuntos de LUIS LORO CHERO</span></p></a> <p style="PADDING-BOTTOM:0px;MARGIN:0px 0px 2px;PADDING-LEFT:0px;PADDING-RIGHT:0px;PADDING-TOP:10px"><span style="COLOR:#628c2a;FONT-WEIGHT:700">Archivo 1 de 1 </span></p> <div> <div style="MARGIN:2px 0px;WHITE-SPACE:nowrap;FLOAT:left;CLEAR:both"> <div><img style="VERTICAL-ALIGN: middle; MARGIN-RIGHT: 5px"> <a style="TEXT-DECORATION:none" title="CURSO RCP Y EMERGENCIAS.doc" href="http://xa.yimg.com/kq/groups/82255301/480391450/name/CURSO%20RCP%20Y%20EMERGENCIAS.doc" target="_blank">CURSO RCP Y EMERGENCIAS.doc</a></div> </div></div> <div style="PADDING-BOTTOM:10px;BACKGROUND-COLOR:#e0ecee;PADDING-LEFT:10px;PADDING-RIGHT:10px;FONT-FAMILY:Verdana;MARGIN-BOTTOM:10px;FONT-SIZE:10px;PADDING-TOP:10px"><span style="TEXT-TRANSFORM:uppercase;COLOR:#333;FONT-WEIGHT:bold">Actividad reciente:</span> <ul style="PADDING-BOTTOM:0px;LIST-STYLE-TYPE:none;MARGIN:0px;PADDING-LEFT:0px;PADDING-RIGHT:0px;DISPLAY:inline;PADDING-TOP:0px"></ul> <div style="COLOR:#1e66ae;CLEAR:both;PADDING-TOP:2px"><a style="TEXT-DECORATION:none" href="http://es.groups.yahoo.com/group/jefaturandolaguardiamedica;_ylc=X3oDMTJmZTBzOXJzBF9TAzk3NDkwNDYzBGdycElkAzgyMjU1MzAxBGdycHNwSWQDMTY2MzE1MzMwMgRzZWMDdnRsBHNsawN2Z2hwBHN0aW1lAzEzMzgxODAxMjc-" target="_blank">Visita tu grupo</a> </div> </div> <div style="PADDING-BOTTOM:0px;MARGIN-TOP:5px;PADDING-LEFT:0px;PADDING-RIGHT:2px;FONT-FAMILY:Arial;CLEAR:both;FONT-SIZE:11px;PADDING-TOP:0px"><a style="FLOAT:left" href="http://es.groups.yahoo.com/;_ylc=X3oDMTJlcHBkZ2VrBF9TAzk3NDkwNDYxBGdycElkAzgyMjU1MzAxBGdycHNwSWQDMTY2MzE1MzMwMgRzZWMDZnRyBHNsawNnZnAEc3RpbWUDMTMzODE4MDEyNw--" target="_blank"><img style="BORDER-BOTTOM: 0px; BORDER-LEFT: 0px; BORDER-TOP: 0px; BORDER-RIGHT: 0px" alt="Yahoo! Grupos" width="141" height="19"></a> <div style="FLOAT:right;COLOR:#747575">Cambiar a: <a style="TEXT-DECORATION:none" href="mailto:jefaturandolaguardiamedica-traditional@yahoogroups.com?subject=Cambiar+Formato+de+EnvÃo:+Tradicional" target="_blank">Solo Texto</a>, <a style="TEXT-DECORATION:none" href="mailto:jefaturandolaguardiamedica-digest@yahoogroups.com?subject=EnvÃo+de+Correo:+Reseña" target="_blank">Rese\xc3\xb1a Diaria</a> • <a style="TEXT-DECORATION:none" href="mailto:jefaturandolaguardiamedica-unsubscribe@yahoogroups.com?subject=Cancelar+suscripción" target="_blank">Cancelar suscripción</a> • <a style="TEXT-DECORATION:none" href="http://es.docs.yahoo.com/info/utos.html" target="_blank">Condiciones de uso</a></div> </div></div> <div style="MARGIN:0px 0px 25px;WIDTH:160px;BACKGROUND:#fff;FLOAT:right;CLEAR:none"> <div></div></div> <div style="COLOR:#fff;CLEAR:both;FONT-SIZE:1px">.</div></div><img width="1" height="1"> <br> <div style="MIN-HEIGHT:0px;COLOR:#fff">__,_._,___</div></div></div><br> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com4tag:blogger.com,1999:blog-2345113505836037298.post-28406610599836970952012-05-27T08:33:00.001-07:002012-05-27T08:33:13.792-07:00como el sistema inmune reconoce a los virus<table border="0" cellspacing="0" cellpadding="2" width="98%"> <tbody> <tr> <td height="24" colspan="2"></td> <td height="24" valign="top" width="25"> <div align="right"><a class="no_line" href="http://www.nobelprize.org/nobel_prizes/medicine/laureates/1996/illpres/implications.html"><img id="next1" border="0" name="next1" alt=" " src="http://www.nobelprize.org/ssi/images/next.gif" width="23" height="21"></a> </div> </td></tr></tbody></table> <table border="0" cellspacing="0" cellpadding="5" width="560" align="center"> <tbody> <tr> <td colspan="3"><img alt=" " src="http://www.nobelprize.org/nobel_prizes/medicine/laureates/1996/illpres/exp-mouse.jpg" width="465" height="208"></td></tr> <tr> <td class="largetext" rowspan="4">Doherty and Zinkernagel inoculated mice with a virus causing meningitis. They isolated the immune T killer cells and found that these had to recognize two things on the surface of the infected cells in order to kill them: virus antigen, as expected, but also an MHC molecule of the infected mouse strain. MHC molecules are normal components of healthy cells. They were known to differ among individuals and to cause rejection of organ transplants and they are therefore sometimes called transplantation antigens. It came as a surprise that they were also involved in recognition of infected cells. <p class="largetext">Doherty and Zinkernagel presented two main theoretical models to explain their observations. These models have inspired immunologists and set the stage for research on cell-mediated immunity for at least two decades.</p> </td> <td colspan="2"><img alt=" " src="http://www.nobelprize.org/nobel_prizes/medicine/laureates/1996/illpres/exp-text.gif" width="240" height="23"></td></tr> <tr> <td class="caption">Wrong combination: the right virus antigen (x) but the wrong MHC molecule (b).</td> <td><img alt=" " src="http://www.nobelprize.org/nobel_prizes/medicine/laureates/1996/illpres/exp-comb1.gif" width="100" height="118"></td></tr> <tr> <td class="caption">Wrong combination again: the right MHC molecule (a) but the wrong virus antigen (y).</td> <td><img alt=" " src="http://www.nobelprize.org/nobel_prizes/medicine/laureates/1996/illpres/exp-comb2.gif" width="100" height="118"></td></tr> <tr> <td class="caption">The correct combination or virus antigen (x) and MHC molecule (a) leads to killer cell attack.</td> <td><img alt=" " src="http://www.nobelprize.org/nobel_prizes/medicine/laureates/1996/illpres/exp-comb3.gif" width="100" height="118"></td></tr> <tr> <td valign="top"><img alt=" " src="http://www.nobelprize.org/nobel_prizes/medicine/laureates/1996/illpres/exp-kiss.jpg" width="300" height="318"></td> <td class="caption">A T killer cell (upper right) attaching to and sensing the antigens on a target cell. If the target cell carries the correct antigens fitting the receptor of this particular T cell, the "kiss of death" will follow: the target cell will be destroyed.</td> <td> </td></tr> <tr> <td colspan="3"> <blockquote> <blockquote> <p> </p> <p><span class="largetext">The "dual recognition" model assumed that two receptors on the T cell recognized virus antigen and the MHC molecule separately (best illustrated by the previous figure of the "correct combination").</span></p> <p><span class="largetext">The "altered self" model was based on one T-cell receptor recognizing an MHC molecule modified by virus antigen - or "a little bit of transplantation antigen, a little bit of virus," as Doherty and Zinkernagel have phrased it. (This is illustrated in the "zoom" above, like the previous model based on figures in the original reports.) Through important discoveries made later by other scientists, we are now getting a clearer picture of the scenario. The T-cell receptor, not yet identified at the time of the discovery, recognizes a small part of a virus protein, attached in a cleft formed by the transplantation antigen.</span></p> </blockquote></blockquote></td></tr></tbody></table><br><br> <div style="CLEAR:both"></div><br><br>Copyright © Nobel Media AB 2012 Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-39881311356167759152012-05-24T14:37:00.001-07:002012-05-24T14:37:19.257-07:00oe cunao lee un poquito pes<div style="MIN-HEIGHT:294px" class="drugdbsectioncontent"> <div id="content_a1"> <h2>Overview</h2> <div class="refsection_content"> <p>The dermatologic manifestations of either toxic epidermal necrolysis or <a href="http://emedicine.medscape.com/article/1197450-overview" target="_self">Stevens-Johnson syndrome</a> may constitute a true emergency. <a href="http://emedicine.medscape.com/article/229698-overview" target="_self">Toxic epidermal necrolysis</a>, an acute disorder, is characterized by widespread erythematous macules and targetoid lesions; full-thickness epidermal necrosis, at least focally; and involvement of more than 30% of the cutaneous surface. Commonly, the mucous membranes are also involved. Nearly all cases of toxic epidermal necrolysis are induced by medications, and the mortality rate can approach 40%.<sup><a href="javascript:showrefcontent('refrenceslayer');">[1] </a></sup></p> <p>Manifestations of Stevens-Johnson syndrome include purpuric macules and targetoid lesions; full-thickness epidermal necrosis, although with lesser detachment of the cutaneous surface; and mucous membrane involvement. As with toxic epidermal necrolysis, medications are important inciting agents, although <em>Mycoplasma</em> infections may induce some cases. The mortality rate is much lower than in toxic epidermal necrolysis, approaching 5% of cases. </p> <p>The prognosis in these diseases is largely a function of the degree of skin sloughing. As the percentage of skin sloughing increases, the mortality rate dramatically worsens. For unknown reasons, however, the disease process in some patients simply stops progressing, and rapid epithelialization ensues. For patients experiencing sloughing over a large area of their skin surface, the mortality rate is much higher. (See the images below.)</p> <a href="javascript:refimgshow(1)"><img class="pborder" alt="Note early cutaneous slough with areas of violaceo" src="http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1122151-1124127-1610118tn.jpg"></a><span class="capt">Note early cutaneous slough with areas of violaceous erythema. </span><a href="javascript:refimgshow(2)"><img class="pborder" alt="Extensive sloughing on the face. " src="http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1122151-1124127-1610122tn.jpg"></a><span class="capt">Extensive sloughing on the face. </span><a href="javascript:refimgshow(5)"><img class="pborder" alt="Extensive sloughing on the back. " src="http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1122151-1124127-1610121tn.jpg"></a><span class="capt">Extensive sloughing on the back. </span> <p>Together, Stevens-Johnson syndrome and toxic epidermal necrolysis may represent a spectrum of a single disease process. Stevens-Johnson syndrome may also have features of the dermatologic condition <a href="http://emedicine.medscape.com/article/1122915-overview" target="_self">erythema multiforme</a> (which has led to confusion in nosology). </p> <h3>Treatment</h3> <p>Only early transfer to and care in a burn unit has been demonstrated to decrease mortality. Coupled with early withdrawal of offending agents, this intervention is the best treatment that can be offered at this time.<sup><a href="javascript:showrefcontent('refrenceslayer');">[2, 3] </a></sup></p> </div> <div style="DISPLAY:block" class="back_next_btn"> <div class="next_btn"><a onclick="wmdTrack('cr-sn_next'); wmdPageview('http://emedicine.medscape.com/article/1124127-overview#aw2aab6b3', '1');" href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#aw2aab6b3">Next Section: Patient History and Physical Examination </a></div> <div class="spacer"></div></div></div> <div id="content_aw2aab6b3" class="inactive"> <h2>Patient History and Physical Examination</h2> <div class="refsection_content"> <p>Constitutional symptoms, such as fever, cough, or sore throat, may appear 1-3 days prior to any cutaneous lesions. Patients may complain of a burning sensation in their eyes, photophobia, and a burning rash that begins symmetrically on the face and the upper part of the torso. Delineation of a drug exposure timeline is essential, especially in the 1-3 weeks preceding the cutaneous eruption. </p> <h3>Primary lesions</h3> <p>The initial skin lesions of Stevens-Johnson syndrome/toxic epidermal necrolysis are poorly defined, erythematous macules with darker, purpuric centers. The lesions differ from classic target lesions of erythema multiforme by having only 2 zones of color: a central, dusky purpura or a central bulla, with a surrounding macular erythema. A classic target lesion has 3 zones of color: a central, dusky purpura or a central bulla; a surrounding pale, edematous zone; and a surrounding macular erythema. (See the image below.)</p> <a href="javascript:refimgshow(3)"><img class="pborder" alt="Note the presence of both 2-zoned atypical targeto" src="http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1122151-1124127-1610119tn.jpg"></a><span class="capt">Note the presence of both 2-zoned atypical targetoid lesions and bullae. </span> <p>Lesions, with the exception of central bullae, are typically flat. (Lesions of erythema multiforme are more likely to be palpable.) Less frequently, the initial eruption may be scarlatiniform. Flaccid blisters are typically present with full-thickness epidermal necrosis. (See the images below.)</p> <a href="javascript:refimgshow(4)"><img class="pborder" alt="Extensive blistering and sloughing on the back. " src="http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1122151-1124127-1610120tn.jpg"></a><span class="capt">Extensive blistering and sloughing on the back. </span><a href="javascript:refimgshow(8)"><img class="pborder" alt="Low-power view showing full-thickness epidermal ne" src="http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1122151-1124127-1610124tn.jpg"></a><span class="capt">Low-power view showing full-thickness epidermal necrosis. </span> <p>Nondenuded areas have a wrinkled paper appearance. A Nikolsky sign is easily demonstrated by applying lateral pressure to a bulla. With regard to the arrangement of lesions, individual macules are found surrounding large areas of confluence. (See the image below.)</p> <a href="javascript:refimgshow(7)"><img class="pborder" alt="Note extensive sloughing. " src="http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1122151-1124127-1610129tn.jpg"></a><span class="capt">Note extensive sloughing. </span> <h3>Distribution</h3> <p>Lesions begin symmetrically on the face and the upper part of the torso and extend rapidly, with maximal extension in 2-3 days. In some cases, maximal extension can occur rapidly over hours. Lesions may predominate in sun-exposed areas. </p> <p>Full detachment is more likely to occur in areas subjected to pressure, such as the shoulders, the sacrum, or the buttocks. Painful, edematous erythema may appear on the palms and the soles. The hairy scalp typically remains intact, but the entire epidermis, including the nail beds, may be affected. (See the image below.)</p> <a href="javascript:refimgshow(6)"><img class="pborder" alt="Sheetlike desquamation on the foot in a patient wi" src="http://img.medscape.com/pi/emed/ckb/dermatology/1048885-1124127-2927tn.jpg"></a><span class="capt">Sheetlike desquamation on the foot in a patient with toxic epidermal necrolysis. Courtesy of Robert Schwartz, MD. </span> <p>A classification proposes that epidermal detachment in Stevens-Johnson syndrome is limited to less than 10% of the body surface area (BSA). Overlapping Stevens-Johnson syndrome/toxic epidermal necrolysis has more extensive confluence of erythematous and purpuric macules, leading to epidermal detachment of 10-30% of the BSA. Classic toxic epidermal necrolysis has epidermal detachment of more than 30%. </p> <p>An uncommon form of toxic epidermal necrolysis (toxic epidermal necrolysis without spots) lacks targetoid lesions, and blisters form on confluent erythema. Greater than 10% epidermal detachment is required for diagnosis of these cases. </p> <p>In contrast, bullous erythema multiforme, which was previously grouped with Stevens-Johnson syndrome, may have epidermal detachment of less than 10% of the BSA, but typical target lesions or raised atypical targets are localized primarily in an acral distribution. </p> <p>Areas of denuded epidermis in Stevens-Johnson syndrome/toxic epidermal necrolysis are dark red with an oozing surface. Mucous membrane involvement is present in nearly all patients and may precede skin lesions, appearing during the prodrome. </p> <h3>Additional findings</h3> <p>Other findings in Stevens-Johnson syndrome/toxic epidermal necrolysis include the following:</p> <ul> <li> <div class="topbullet">Painful oral erosions cause severe crusting of the lips, increased salivation, and impaired alimentation</div></li> <li> <div class="topbullet">Lesions have been reported in the oropharynx, tracheobronchial tree, esophagus, gastrointestinal tract, genitalia, and anus</div></li> <li> <div class="topbullet">Involvement of the genitalia may lead to painful micturition</div></li> <li> <div class="topbullet">Intact expectorated cylindrical casts of bronchial epithelium have been reported</div></li> <li> <div class="topbullet">Patients may develop a profuse, protein-rich diarrhea</div></li> <li> <div class="topbullet">Internal involvement is not necessarily limited to patients with extensive cutaneous involvement</div></li></ul> <p>Ocular lesions are especially problematic because they have a high risk of sequelae. Initially, the conjunctivae are erythematous and painful. The lids are often stuck together, with efforts to loosen them resulting in tearing of the epidermis. Pseudomembranous conjunctival erosions may form synechiae between the eyelids and the conjunctivae. Keratitis, corneal erosions, and a siccalike syndrome may develop. </p> </div> <div style="DISPLAY:block" class="back_next_btn"> <div class="back_btn">Previous</div> <div class="next_btn"><a onclick="wmdTrack('cr-sn_next'); wmdPageview('http://emedicine.medscape.com/article/1124127-overview#aw2aab6b3', '1');" href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#aw2aab6b3">Next Section: Patient History and Physical Examination </a></div> <div class="spacer"></div></div></div> <div id="content_a30" class="inactive"> <h2>Pharmacologic Therapy</h2> <div class="refsection_content"> <h3>Corticosteroid therapy</h3> <p>The use of corticosteroids in the management of the Stevens-Johnson syndrome/toxic epidermal necrolysis spectrum is one of the most controversial areas in Dermatology. Administration early in the course of disease has been advocated, but multiple retrospective studies demonstrate no benefit or higher rates of morbidity and mortality related to sepsis. This risk is probably proportional to the area of sloughed skin. </p> <p>Halebian et al advised against the use of steroids based on 2 open, nonrandomized prospective studies of corticosteroids in 30 patients admitted to a burn unit with Stevens-Johnson syndrome or toxic epidermal necrolysis.<sup><a href="javascript:showrefcontent('refrenceslayer');">[4] </a></sup>Fifteen patients received corticosteroids and 15 did not. The groups were statistically similar in terms of age, morbid days before burn center admission, and the amount of skin sloughed. Thirty-three percent of the steroid group survived, versus 66% of the nonsteroid group. Sepsis occurred with similar frequency in both groups, but 91% of patients with sepsis in the steroid group died, versus 56% of the infected patients in the nonsteroid group.</p> <p>Steroids are suggested to predispose patients to gram-negative sepsis by impairing host resistance and by ultimately leading to late clinical recognition of sepsis through suppression of symptoms. Because multiple studies, albeit uncontrolled, have demonstrated a higher morbidity and mortality in patients receiving corticosteroids, most authorities do not recommend their use. </p> <h3>Intravenous immunoglobulin</h3> <p>A number of studies support the use of intravenous immunoglobulin (IVIG) in the treatment of toxic epidermal necrolysis. Viard et al suggested that apoptotic cell death occurs via activation of a cell-surface death receptor.<sup><a href="javascript:showrefcontent('refrenceslayer');">[5] </a></sup>In vitro, target cell death was blocked by a receptor-ligand blocking antibody and by antibodies present in pooled human IVIG. An open trial of IVIG in 10 patients with toxic epidermal necrolysis resulted in a halt of progression within 24-48 hours, with no mortality. </p> <p>Since 2000, a number of case reports and 8 noncontrolled, clinical studies containing 9 or more patients have analyzed the efficacy of IVIG in toxic epidermal necrolysis. Some studies did not demonstrate a therapeutic benefit, while others showed decreased mortality.<sup><a href="javascript:showrefcontent('refrenceslayer');">[6, 7, 8] </a></sup>Six of the 8 studies suggested a benefit from IVIG administered at doses above 2g/kg. </p> <p>Schneck et al published a retrospective study of patients from France and Germany enrolled in EuroSCAR, a case-control study of risk factors, and found that neither IVIG nor corticosteroids decreased mortality in comparison with supportive care alone.<sup><a href="javascript:showrefcontent('refrenceslayer');">[9] </a></sup></p> <p>Given the potentially fatal nature of toxic epidermal necrolysis and the ethical issues involved, a randomized, controlled trial will likely never be performed. Given the suggestion of a therapeutic benefit, many centers are incorporating IVIG into their treatment protocols. At University Hospital at Stony Brook, New York, Stevens-Johnson syndrome/toxic epidermal necrolysis patients are treated with a dosage of 1g/kg/day for 4 consecutive days. </p> <h3>Cyclosporine</h3> <p>An open study from the trauma literature demonstrated the efficacy of cyclosporine in the treatment of toxic epidermal necrolysis. Arevalo et al presented 11 patients admitted consecutively to a burn unit, with toxic epidermal necrolysis involving a large BSA (83% ± 17%).<sup><a href="javascript:showrefcontent('refrenceslayer');">[10] </a></sup>Each patient received 3mg/kg of cyclosporine daily, with the drug administered enterally every 12 hours. This group was compared to a series of 6 historical control subjects treated with cyclophosphamide and corticosteroids. </p> <p>In the study, the time from the onset of skin signs to arrest of disease progression and to complete reepithelialization was significantly shorter in the cyclosporine group. All patients in the cyclosporine group survived versus 50% surviving in the cyclophosphamide group. Given a mortality rate of approximately 30% in patients not infected with human immunodeficiency virus (HIV) with toxic epidermal necrolysis, cyclosporine may prove to be a life-saving therapy, but randomized, controlled trials are needed to make definitive recommendations. </p> <h3>Other medications</h3> <p>Cyclophosphamide, <em>N-</em> acetylcysteine, and monoclonal antibodies directed against cytokines have been used in isolated case reports and in small, uncontrolled studies. Thalidomide has been shown to have a deleterious effect on patients' outcomes.<sup><a href="javascript:showrefcontent('refrenceslayer');">[11] </a></sup></p> </div> <div style="DISPLAY:block" class="back_next_btn"> <div class="back_btn">Previous</div> <div class="spacer"></div></div></div></div> <div class="spacer"> </div> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-62924324884291093482012-05-22T21:24:00.001-07:002012-05-22T21:24:19.740-07:00sangre sin alcohol para armando<div>el jueves los de su grupo el A vamos donar sangre para Armando en el Rebagliati. Gil Malca esta coordinando con Manuel para contar con una ambulancia que nos lleve durante la guardia. Tarda un ratito.</div> <div>Como sabran armando tiene una endocarditis subaguda y va a ser intervenido actualmente esta en la unidad coronaria del Rebagliati</div> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-36059680481505550902012-05-22T21:05:00.001-07:002012-05-22T21:05:19.833-07:00Dia de la Medicina de Emergencias y Desastres<br><br> <div class="gmail_quote">---------- Mensaje reenviado ----------<br>De: <b class="gmail_sendername">Javier Vasquez Salas</b> <span dir="ltr"><<a href="mailto:javasa@speedy.com.pe">javasa@speedy.com.pe</a>></span><br> Fecha: 22 de mayo de 2012 22:58<br>Asunto: {emergencias_y_desastres} Dia de la Medicina de Emergencias y Desastres<br>Para: <a href="mailto:emergencias_y_desastres@yahoogroups.com">emergencias_y_desastres@yahoogroups.com</a>, <a href="mailto:medicinadeemergenciasydesastres@yahoogroups.com">medicinadeemergenciasydesastres@yahoogroups.com</a><br> <br><br><u></u> <div><span> </span> <div> <div> <div> <p><u></u> <div><font face="Arial">Estimados amigos de la SPMED</font></div> <div><font face="Arial"></font> </div> <div><font face="Arial"><u><strong>Invitación</strong></u></font></div> <div><font face="Arial"></font> </div> <div><font face="Arial">Nos complace invitar a todos nuestros asociados a la reunion académico y de confraternidad el dia 29 de Mayo en el Auditorio del HCFAP a las 16 horas para conmemorar el aniversario de nuestra especialidad.</font></div> <div><font face="Arial">Esperamos contar con la presencia de cada uno de Uds.</font></div> <div><font face="Arial">Ingreso Libre</font></div> <div><font face="Arial"></font> </div> <div><font face="Arial">Dr. Javier Vásquez Salas<br>Medicina de Emergencias y Desastres<br>Hospital Central de Aeronautica Perú - Clínica San Gabriel (CHSP)<br>Secretaria General SPMED<br>Representante IFEM - Perú<br>webmaster SPMED<br> <a href="http://www.spmed.org.pe/" target="_blank">www.spmed.org.pe</a></font></div> <p></p></p></div> <div style="MIN-HEIGHT:0px;COLOR:#fff">__._,_.___</div> <div style="WHITE-SPACE:nowrap;MARGIN-BOTTOM:10px;COLOR:#666;CLEAR:both;PADDING-TOP:15px"> <div><a style="PADDING-RIGHT:0px;MARGIN-RIGHT:0px" href="mailto:javasa@speedy.com.pe?subject=RE%3A%20Dia%20de%20la%20Medicina%20de%20Emergencias%20y%20Desastres" target="_blank">Responder a <span style="FONT-WEIGHT:700">remitente</span></a> | <a href="mailto:emergencias_y_desastres@yahoogroups.com?subject=RE%3A%20Dia%20de%20la%20Medicina%20de%20Emergencias%20y%20Desastres" target="_blank">Responder a <span style="FONT-WEIGHT:700">grupo</span></a> | <a href="http://es.groups.yahoo.com/group/emergencias_y_desastres/post;_ylc=X3oDMTJxYmxtb2M1BF9TAzk3NDkwNDYzBGdycElkAzIwODU4MTkwBGdycHNwSWQDMTY2MzE1MzMwMgRtc2dJZAM1ODc3BHNlYwNmdHIEc2xrA3JwbHkEc3RpbWUDMTMzNzc0NTUxNA--?act=reply&messageNum=5877" target="_blank">Responder <span style="FONT-WEIGHT:700">mediante la Web</span></a> | <a style="FONT-WEIGHT:700" href="http://es.groups.yahoo.com/group/emergencias_y_desastres/post;_ylc=X3oDMTJmZW0wZDdlBF9TAzk3NDkwNDYzBGdycElkAzIwODU4MTkwBGdycHNwSWQDMTY2MzE1MzMwMgRzZWMDZnRyBHNsawNudHBjBHN0aW1lAzEzMzc3NDU1MTQ-" target="_blank">Crear un tema nuevo</a> </div> <a href="http://es.groups.yahoo.com/group/emergencias_y_desastres/message/5877;_ylc=X3oDMTM1Nms1dDZvBF9TAzk3NDkwNDYzBGdycElkAzIwODU4MTkwBGdycHNwSWQDMTY2MzE1MzMwMgRtc2dJZAM1ODc3BHNlYwNmdHIEc2xrA3Z0cGMEc3RpbWUDMTMzNzc0NTUxNAR0cGNJZAM1ODc3" target="_blank">Mensajes con este tema</a> (<span style="FONT-WEIGHT:700">1</span>) </div> <div style="PADDING-BOTTOM:10px;BACKGROUND-COLOR:#e0ecee;PADDING-LEFT:10px;PADDING-RIGHT:10px;FONT-FAMILY:Verdana;MARGIN-BOTTOM:10px;FONT-SIZE:10px;PADDING-TOP:10px"><span style="TEXT-TRANSFORM:uppercase;COLOR:#333;FONT-WEIGHT:bold">Actividad reciente:</span> <ul style="PADDING-BOTTOM:0px;LIST-STYLE-TYPE:none;MARGIN:0px;PADDING-LEFT:0px;PADDING-RIGHT:0px;DISPLAY:inline;PADDING-TOP:0px"></ul> <div style="COLOR:#1e66ae;CLEAR:both;PADDING-TOP:2px"><a style="TEXT-DECORATION:none" href="http://es.groups.yahoo.com/group/emergencias_y_desastres;_ylc=X3oDMTJmbTJwZjc2BF9TAzk3NDkwNDYzBGdycElkAzIwODU4MTkwBGdycHNwSWQDMTY2MzE1MzMwMgRzZWMDdnRsBHNsawN2Z2hwBHN0aW1lAzEzMzc3NDU1MTQ-" target="_blank">Visita tu grupo</a> </div> </div> <div style="PADDING-BOTTOM:0px;MARGIN-TOP:5px;PADDING-LEFT:0px;PADDING-RIGHT:2px;FONT-FAMILY:Arial;CLEAR:both;FONT-SIZE:11px;PADDING-TOP:0px"><a style="FLOAT:left" href="http://es.groups.yahoo.com/;_ylc=X3oDMTJldDIxNW8yBF9TAzk3NDkwNDYxBGdycElkAzIwODU4MTkwBGdycHNwSWQDMTY2MzE1MzMwMgRzZWMDZnRyBHNsawNnZnAEc3RpbWUDMTMzNzc0NTUxNA--" target="_blank"><img style="BORDER-BOTTOM: 0px; BORDER-LEFT: 0px; BORDER-TOP: 0px; BORDER-RIGHT: 0px" alt="Yahoo! Grupos" width="141" height="19"></a> <div style="FLOAT:right;COLOR:#747575">Cambiar a: <a style="TEXT-DECORATION:none" href="mailto:emergencias_y_desastres-traditional@yahoogroups.com?subject=Cambiar+Formato+de+EnvÃo:+Tradicional" target="_blank">Solo Texto</a>, <a style="TEXT-DECORATION:none" href="mailto:emergencias_y_desastres-digest@yahoogroups.com?subject=EnvÃo+de+Correo:+Reseña" target="_blank">Rese\xc3\xb1a Diaria</a> • <a style="TEXT-DECORATION:none" href="mailto:emergencias_y_desastres-unsubscribe@yahoogroups.com?subject=Cancelar+suscripción" target="_blank">Cancelar suscripción</a> • <a style="TEXT-DECORATION:none" href="http://es.docs.yahoo.com/info/utos.html" target="_blank">Condiciones de uso</a></div> </div></div> <div style="MARGIN:0px 0px 25px;WIDTH:160px;BACKGROUND:#fff;FLOAT:right;CLEAR:none"> <div></div></div> <div style="COLOR:#fff;CLEAR:both;FONT-SIZE:1px">.</div></div><img width="1" height="1"> <br> <div style="MIN-HEIGHT:0px;COLOR:#fff">__,_._,___</div></div></div><br> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-18583100705024613612012-05-20T18:09:00.001-07:002012-05-20T18:09:05.101-07:00a proposito de un caso<div class="refsection_content"> <p>Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect. Its intracardiac effects include severe valvular insufficiency, which may lead to intractable congestive heart failure and <a href="http://emedicine.medscape.com/article/223700-overview" target="_self">myocardial abscesses</a>. IE also produces a wide variety of systemic signs and symptoms through several mechanisms, including both sterile and infected emboli and various immunological phenomena.<sup><a href="javascript:showrefcontent('refrenceslayer');">[1, 2, 3] </a></sup></p> <p>The history of IE can be divided into several eras. Lazaire Riviere first described gross autopsy findings of the disease in 1723. In 1885, William Osler presented the first comprehensive description of endocarditis in English. Lerner and Weinstein presented a thorough discussion of this disease in modern times in their landmark series of articles, "Infective Endocarditis in the Antibiotic Era," published in 1966 in the <em>New England Journal of Medicine</em>.<sup><a href="javascript:showrefcontent('refrenceslayer');">[4, 5, 6] </a></sup></p> <p>IE currently can be described as infective endocarditis in the era of intravascular devices, as infection of intravascular lines has been determined to be the primary risk factor for <em>Staphylococcus aureus</em> bloodstream infections (BSIs). <a href="http://emedicine.medscape.com/article/228816-overview" target="_self"><em>S aureus</em></a> has become the primary pathogen of endocarditis.<sup><a href="javascript:showrefcontent('refrenceslayer');">[7] </a></sup></p> <p>IE generally occurs as a consequence of nonbacterial thrombotic endocarditis, which results from turbulence or trauma to the endothelial surface of the heart. A transient bacteremia then seeds the sterile platelet/fibrin thrombus, with IE as the end result. Pathologic effects due to infection can include local tissue destruction and embolic phenomena. In addition, secondary autoimmune effects, such as immune complex glomerulonephritis and vasculitis, can occur. (See Pathophysiology.) </p> <p>IE remains a diagnostic and therapeutic challenge. Its manifestations may be muted by the indiscriminate use of antimicrobial agents or by underlying conditions in frail and elderly individuals or immunosuppressed persons. (See Diagnosis.) </p> <p>Effective therapy has become progressively more difficult to achieve because of the proliferation of implanted biomechanical devices and the rise in the number of resistant organisms. Antibiotic prophylaxis has probably had little effect in decreasing the incidence of IE. (See Treatment and Management.) </p> <p>For other discussions on IE, see Pediatric <a href="http://emedicine.medscape.com/article/896540-overview" target="_self">Bacterial Endocarditis</a>, Infectious Endocarditis, <a href="http://emedicine.medscape.com/article/1165712-overview" target="_self">Neurological Sequelae of Infective Endocarditis</a>, and <a href="http://emedicine.medscape.com/article/1672902-overview" target="_self">Antibiotic Prophylactic Regimens for Endocarditis</a>.</p> <h3>Types of infective endocarditis</h3> <p>Endocarditis has evolved into several variations, keeping it near the top of the list of diseases that must not be misdiagnosed or overlooked. Endocarditis can be broken down into the following categories: </p> <ul> <li> <div class="topbullet">Native valve endocarditis (NVE), acute and subacute</div></li> <li> <div class="topbullet">Prosthetic valve endocarditis (PVE),<sup><a href="javascript:showrefcontent('refrenceslayer');">[8] </a></sup>early and late </div></li> <li> <div class="topbullet">Intravenous drug abuse (IVDA) endocarditis</div></li></ul> <p>Other terms commonly used to classify types of IE include pacemaker IE and nosocomial IE (NIE).</p> <p>The classic clinical presentation and clinical course of IE has been characterized as either acute or subacute. Indiscriminate antibiotic usage and an increase in immunosuppressed patients have blurred the distinction between these 2 major types; however, the classification still has clinical merit.<sup><a href="javascript:showrefcontent('refrenceslayer');">[9] </a></sup></p> <p>Acute NVE frequently involves normal valves and usually has an aggressive course. It is a rapidly progressive illness in persons who are healthy or debilitated. Virulent organisms, such as <em>S aureus</em> and group B streptococci, are typically the causative agents of this type of endocarditis. Underlying structural valve disease may not be present. </p> <p>Subacute NVE typically affects only abnormal valves. Its course, even in untreated patients, is usually more indolent than that of the acute form and may extend over many months. Alpha-hemolytic streptococci or enterococci, usually in the setting of underlying structural valve disease, typically are the causative agents of this type of endocarditis. </p> <p>PVE accounts for 10-20% of cases of IE. Eventually, 5% of mechanical and bioprosthetic valves become infected. Mechanical valves are more likely to be infected within the first 3 months of implantation, and, after 1 year, bioprosthetic valves are more likely to be infected. The valves in the mitral valve position are more susceptible than those in the aortic areas.<sup><a href="javascript:showrefcontent('refrenceslayer');">[8] </a></sup></p> <p>Early PVE occurs within 60 days of valve implantation. Traditionally, coagulase-negative staphylococci, gram-negative bacilli, and <em>Candida</em> species have been the common infecting organisms. Late PVE occurs 60 days or more after valve implantation. Staphylococci, alpha-hemolytic streptococci, and enterococci are the common causative organisms. Recent data suggest that <em>S aureus</em> may now be the most common infecting organism in both early and late PVE.<sup><a href="javascript:showrefcontent('refrenceslayer');">[10] </a></sup></p> <p>In 75% of cases of IVDA IE, no underlying valvular abnormalities are noted, and 50% of these infections involve the tricuspid valve.<sup><a href="javascript:showrefcontent('refrenceslayer');">[11] </a></sup><em>S aureus</em> is the most common causative organism. </p> <p>Analogous to PVE are infections of implantable <a href="http://emedicine.medscape.com/article/1971142-overview" target="_self">pacemakers</a> and cardioverter-defibrillators. Usually, these devices are infected within a few months of implantation. Infection of pacemakers includes that of the generator pocket (the most common), infection of the proximal leads, and infection of the portions of the leads in direct contact with the endocardium. </p> <p>This last category represents true pacemaker IE, is the least common infectious complication of pacemakers (0.5% of implanted pacemakers), and is the most challenging to treat. Of pacemaker infections, 75% are produced by staphylococci, both coagulase-negative and coagulase-positive. </p> <p>NIE is defined as an infection that manifests 48 hours after the patient is hospitalized or that is associated with a hospital, based on a procedure performed within 4 weeks of clinical disease onset. The term healthcare-associated infective endocarditis (HCIE) is preferable to NIE, since it is inclusive of all sites that deliver patient care, such as hemodialysis centers. The term NIE should be applied to cases of IE acquired in the hospital. An appropriate alternative term would be iatrogenic IE. </p> <p>Two types of NIE have been described. The right-sided variety affects a valve that has been injured by placement of an intravascular line (eg, Swan-Ganz catheter). Subsequently, the valve is infected by a nosocomial bacteremia. The second type develops in a previously damaged valve and is more likely to occur on the left side. <em>S aureus</em> has been the predominant pathogen of NIE/HCIE since the recent prevalence of intravascular devices. Enterococci are second most commonly isolated pathogens. These usually arise from a genitourinary source. </p> <h3>Evolution of clinical characteristics of infective endocarditis</h3> <p>Since the 1960s, the clinical characteristics of IE have changed significantly. The dramatic "graying" of the disease and the increase in recreational drug use and proliferation of invasive vascular procedures underlie this phenomenon. Varieties of IE that were uncommon in the early antibiotic era have become prominent. Cases of NIE, IVDA IE, and PVE have markedly increased. Valvular infections have entered the era of IE caused by intravascular devices and procedures. </p> <p>The underlying valvular pathology has also changed. Rheumatic heart disease currently accounts for less than 20% of cases, and 6% of patients with rheumatic heart disease eventually develop IE. Approximately 50% of elderly patients have calcific <a href="http://emedicine.medscape.com/article/150638-overview" target="_self">aortic stenosis</a> as the underlying pathology. Congenital heart disease accounts for 15% of cases, with the bicuspid aortic valve being the most common example. </p> <p>Other contributing congenital abnormalities include <a href="http://emedicine.medscape.com/article/162692-overview" target="_self">ventricular septal defects</a>, <a href="http://emedicine.medscape.com/article/891096-overview" target="_self">patent ductus arteriosus</a>, and <a href="http://emedicine.medscape.com/article/163628-overview" target="_self">tetralogy of Fallot</a>. <a href="http://emedicine.medscape.com/article/162914-overview" target="_self">Atrial septal defect</a> (secundum variety) is rarely associated with IE. <a href="http://emedicine.medscape.com/article/155494-overview" target="_self">Mitral valve prolapse</a> is the most common predisposing condition found in young adults and is the predisposing condition in 30% of cases of NVE in this age group. IE complicates 5% of cases of asymmetrical septal hypertrophy, usually involving the mitral valve. </p> </div> <div style="DISPLAY:block" class="back_next_btn"> <div class="next_btn"><a onclick="wmdTrack('cr-sn_next'); wmdPageview('http://emedicine.medscape.com/article/216650-overview#a0104', '1');" href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#a0104">Next Section: Pathophysiology </a></div> <div class="spacer"></div></div> <div class="spacer"></div> <div id="content_a0104" class="inactive"> <h2>Pathophysiology</h2> <div class="refsection_content"> <p>IE develops most commonly on the mitral valve, closely followed in descending order of frequency by the aortic valve, the combined mitral and aortic valve, the tricuspid valve, and, rarely, the pulmonic valve. Mechanical prosthetic and bioprosthetic valves exhibit equal rates of infection. </p> <p>All cases of IE develop from a commonly shared process, as follows:</p> <ol class="bodylist"> <li class="topitem">Bacteremia (nosocomial or spontaneous) that delivers the organisms to the surface of the valve</li> <li class="topitem">Adherence of the organisms</li> <li class="topitem">Eventual invasion of the valvular leaflets</li></ol> <p>The common denominator for adherence and invasion is nonbacterial thrombotic endocarditis, a sterile fibrin-platelet vegetation. The development of subacute IE depends on a bacterial inoculum sufficient to allow invasion of the preexistent thrombus. This critical mass is the result of bacterial clumping produced by agglutinating antibodies. </p> <p>In acute IE, the thrombus may be produced by the invading organism (ie, <em>S aureus</em>) or by valvular trauma from intravenous catheters or pacing wires (ie, NIE/HCIE). <em>S aureus</em> can invade the endothelial cells (endotheliosis) and increase the expression of adhesion molecules and of procoagulant activity on the cellular surface. Nonbacterial thrombotic endocarditis may result from stress, renal failure, malnutrition, <a href="http://emedicine.medscape.com/article/332244-overview" target="_self">systemic lupus erythematosus</a>, or neoplasia. </p> <p>The Venturi effect also contributes to the development and location of nonbacterial thrombotic endocarditis. This principle explains why bacteria and the fibrin-platelet thrombus are deposited on the sides of the low-pressure sink that lies just beyond a narrowing or stenosis. </p> <p>In patients with mitral insufficiency, bacteria and the fibrin-platelet thrombus are located on the atrial surface of the valve. In patients with aortic insufficiency, they are located on the ventricular side. In these examples, the atria and ventricles are the low-pressure sinks. In the case of a ventricular septal defect, the low-pressure sink is the right ventricle and the thrombus is found on the right side of the defect. </p> <p>Nonbacterial thrombotic endocarditis may also form on the endocardium of the right ventricle, opposite the orifice that has been damaged by the jet of blood flowing through the defect (ie, the MacCallum patch). </p> <p>The microorganisms that most commonly produce endocarditis (ie, <em>S aureus; Streptococcus viridans;</em> group A, C, and G streptococci; enterococci) resist the bactericidal action of complement and possess fibronectin receptors for the surface of the fibrin-platelet thrombus. Among the many other characteristics of IE-producing bacteria demonstrated in vitro and in vivo, some features include the following: </p> <ul> <li> <div class="topbullet">Increased adherence to aortic valve leaflet disks by enterococci, <em>S viridans,</em> and <em>S aureus</em></div></li> <li> <div class="topbullet">Mucoid-producing strains of <em>S aureus</em></div></li> <li> <div class="topbullet">Dextran-producing strains of <em>S viridans</em></div></li> <li> <div class="topbullet"><em>S viridans</em> and enterococci that possess FimA surface adhesin</div></li> <li> <div class="topbullet">Platelet aggregation by <em>S aureus</em> and <em>S viridans</em> and resistance of <em>S aureus</em> to platelet microbicidal proteins</div></li></ul> <p>The pathogenesis of pacemaker IE is similar. Shortly after implantation, the development of a fibrin-platelet thrombus (similar to the nonbacterial thrombotic endocarditis described above) involves the generator box and conducting leads. After 1 week, the connective tissue proliferates, partially embedding the leads in the wall of the vein and endocardium. This layer may offer partial protection against infection during a bacteremia. </p> <p>Bacteremia (either spontaneous or due to an invasive procedure) infects the sterile fibrin-platelet vegetation described above. BSIs develop from various extracardiac types of infection, such as pneumonias or pyelonephritis, but most commonly from gingival disease. Of those with high-grade gingivitis, 10% have recurrent transient bacteremias (usually streptococcal species). Most cases of subacute disease are secondary to the bacteremias that develop from the activities of daily living (eg, brushing teeth, bowel movements). </p> <p>Bacteremia can result from various invasive procedures, ranging from oral surgery to sclerotherapy of esophageal varices to genitourinary surgeries to various abdominal operations. The potential for invasive procedures to produce a bacteremia varies greatly. Procedures, rates, and organisms are as follows: </p> <ul> <li> <div class="topbullet">Endoscopy - Rate of 0-20%; coagulase-negative staphylococci (CoNS), streptococci, diphtheroids</div></li> <li> <div class="topbullet"><a href="http://emedicine.medscape.com/article/1819350-overview" target="_self">Colonoscopy</a> - Rate of 0-20%; <em>Escherichia coli, Bacteroides</em> species</div></li> <li> <div class="topbullet">Barium enema - Rate of 0-20%; enterococci, aerobic and anaerobic gram-negative rods</div></li> <li> <div class="topbullet">Dental extractions - Rate of 40-100%; <em>S viridans</em></div></li> <li> <div class="topbullet">Transurethral resection of the prostate - Rate of 20-40%; coliforms, enterococci, <em>S aureus</em></div></li> <li> <div class="topbullet">Transesophageal echocardiography - Rate of 0-20%; <em>S viridans,</em> anaerobic organisms, streptococci</div></li></ul> <p>The incidence of nosocomial bacteremias, mostly associated with intravascular lines, has more than doubled in the last few years. Up to 90% of BSIs caused by these devices are secondary to the placement of various types of central venous catheters. Hickman and Broviac catheters are associated with the lowest rates, presumably because of their Dacron cuffs. Peripherally placed central venous catheters are associated with similar rates. </p> <p>Intravascular catheters are infected from 1 of the following 4 sources:</p> <ul> <li> <div class="topbullet">Infection of the insertion site</div></li> <li> <div class="topbullet">Infection of the catheter</div></li> <li> <div class="topbullet">Bacteremia arising from another site</div></li> <li> <div class="topbullet">Contamination of the infused solution</div></li></ul> <p>Bacterial adherence to intravascular catheters depends on the response of the host to the presence of this foreign body, the properties of the organism itself, and the position of the catheter. Within a few days of insertion, a sleeve of fibrin and fibronectin is deposited on the catheter. <em>S aureus</em> adheres to the fibrin component. </p> <p><em>S aureus</em> also produces an infection of the endothelial cells (endotheliosis), which is important in producing the continuous bacteremia of <em>S aureus</em> BSIs. Endotheliosis may explain many cases of persistent methicillin-susceptible <em>S aureus</em> (MSSA) and methicillin-resistant S aureus (MRSA) catheter-related BSIs without an identifiable cause. </p> <p><em>S aureus</em> catheter-related BSIs occur even after an infected catheter is removed, apparently attributable to specific virulence factors of certain strains of <em>S aureus</em> that invade the adjacent endothelial cells. At some point, the staphylococci re-enter the bloodstream, resulting in bacteremia.<sup><a href="javascript:showrefcontent('refrenceslayer');">[12] </a></sup></p> <p>Four days after placement, the risk of infection markedly increases. Lines positioned in the internal jugular are more prone to infection than those placed in the subclavian vein. Colonization of the intracutaneous tract is the most likely source of short-term catheter-related BSIs. Among lines in place for more than 2 weeks, infection of the hub is the major source of bacteremia. In some cases, the infusion itself may be a reservoir of infection. </p> <p>Colonization of heart valves by microorganisms is a complex process. Most transient bacteremias are short-lived, are without consequence, and are often not preventable. Bacteria rarely adhere to an endocardial nidus before the microorganisms are removed from the circulation by various host defenses. </p> <p>Once microorganisms do establish themselves on the surface of the vegetation, the process of platelet aggregation and fibrin deposition accelerate at the site. As the bacteria multiply, they are covered by ever-thickening layers of platelets and thrombin, which protect them from neutrophils and other host defenses. Organisms deep in the vegetation hibernate because of the paucity of available nutrients and are therefore less susceptible to bactericidal antimicrobials that interfere with bacterial cell wall synthesis. </p> <p>Complications of subacute endocarditis result from embolization, slowly progressive valvular destruction, and various immunological mechanisms. The pathological picture of subacute IE is marked by valvular vegetations in which bacteria colonies are present both on and below the surface. </p> <p>The cellular reaction in SBE is primarily that of mononuclear cells and lymphocytes, with few polymorphonuclear cells. The surface of the valve beneath the vegetation shows few organisms. Proliferation of capillaries and fibroblasts is marked. Areas of healing are scattered among areas of destruction. Over time, the healing process falls behind, and valvular insufficiency develops secondary to perforation of the cusps and damage to the chordae tendineae. Compared with acute disease, little extension of the infectious process occurs beyond the valvular leaflets.</p> <p>Levels of agglutinating and complement-fixing bactericidal antibodies and cryoglobulins are markedly increased in patients with subacute endocarditis. Many of the extracardiac manifestations of this form of the disease are due to circulating immune complexes. Among these include glomerulonephritis, peripheral manifestations (eg, Osler nodes, Roth spots, subungual hemorrhages), and, possibly, various musculoskeletal abnormalities. Janeway lesions usually arise from infected microemboli. </p> <p>The microscopic appearance of acute bacterial endocarditis differs markedly from that of subacute disease. Vegetations that contain no fibroblasts develop rapidly, with no evidence of repair. Large amounts of both polymorphonuclear leukocytes and organisms are present in an ever-expanding area of necrosis. This process rapidly produces spontaneous rupture of the leaflets, of the papillary muscles, and of the chordae tendineae. </p> <p>The complications of acute bacterial endocarditis result from intracardiac disease and metastatic infection produced by suppurative emboli. Because of their shortened course, immunological phenomena are not a part of acute IE. </p> </div> <div style="DISPLAY:block" class="back_next_btn"> <div class="back_btn">Previous</div> <div class="next_btn"><a onclick="wmdTrack('cr-sn_next'); wmdPageview('http://emedicine.medscape.com/article/216650-overview#a0104', '1');" href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#a0104">Next Section: Pathophysiology </a></div> <div class="spacer"></div></div> <div class="spacer"></div></div> <div id="content_aw2aab6b2b3aa" class="inactive"> <h2>Etiology </h2> <div class="refsection_content"> <p>The different types of IE have varying causes and involve different pathogens.</p> <h3>Native valve endocarditis</h3> <p>The following are the main underlying causes of NVE:</p> <ul> <li> <div class="topbullet">Rheumatic valvular disease (30% of NVE) - Primarily involves the mitral valve followed by the aortic valve</div></li> <li> <div class="topbullet">Congenital heart disease (15% of NVE) - Underlying etiologies include a patent ductus arteriosus, ventricular septal defect, tetralogy of Fallot, or any native or surgical high-flow lesion. </div></li> <li> <div class="topbullet">Mitral valve prolapse with an associated murmur (20% of NVE)</div></li> <li> <div class="topbullet">Degenerative heart disease - Including calcific aortic stenosis due to a bicuspid valve, Marfan syndrome, or syphilitic disease</div></li></ul> <p>Approximately 70% of infections in NVE are caused by <em>Streptococcus</em> species, including <em>S viridans, Streptococcus bovis</em>, and enterococci. <em>Staphylococcus</em> species cause 25% of cases and generally demonstrate a more aggressive acute course (see the images below).</p> <h3>Prosthetic valve endocarditis</h3> <p>Early PVE, which presents shortly after surgery, has a different bacteriology and prognosis than late PVE, which presents in a subacute fashion similar to NVE. </p> <p>Infection associated with aortic valve prostheses is particularly associated with local abscess and fistula formation, and valvular dehiscence. This may lead to shock, heart failure, heart block, shunting of blood to the right atrium, pericardial tamponade, and peripheral emboli to the central nervous system and elsewhere. </p> <p>Early PVE may be caused by a variety of pathogens, including <em>S aureus</em> and <em>S epidermidis</em>. These nosocomially acquired organisms are often methicillin-resistant (eg, MRSA).<sup><a href="javascript:showrefcontent('refrenceslayer');">[13] </a></sup>Late disease is most commonly caused by streptococci. Overall, CoNS are the most frequent cause of PVE (30%). </p> <p><em>S aureus</em> causes 17% of early PVE and 12% of late PVE. <em>Corynebacterium,</em> nonenterococcal streptococci, fungi (eg, <em>C albicans, Candida stellatoidea, Aspergillus</em> species), <em>Legionella,</em> and the HACEK (ie, <em>Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae</em>) organisms cause the remaining cases.</p> <h3>IVDA infective endocarditis</h3> <p>Diagnosis of endocarditis in IV drug users can be difficult and requires a high index of suspicion. Two thirds of patients have no previous history of heart disease or murmur on admission. A murmur may be absent in those with tricuspid disease, owing to the relatively small pressure gradient across this valve. Pulmonary manifestations may be prominent in patients with tricuspid infection: one third have pleuritic chest pain, and three quarters demonstrate chest radiographic abnormalities. </p> <p><em>S aureus</em> is the most common (< 50% of cases) etiologic organism in patients with IVDA IE. MRSA accounts for an increasing portion of <em>S aureus</em> infections and has been associated with previous hospitalizations, long-term addiction, and nonprescribed antibiotic use. Groups A, C, and G streptococci and enterococci are also recovered from patients with IVDA IE. </p> <p>Currently, gram-negative organisms are involved infrequently. <em>P aeruginosa</em><sup><a href="javascript:showrefcontent('refrenceslayer');">[14] </a></sup>and the HACEK family are the most common examples. </p> <h3>Nosocomial/healthcare-associated infective endocarditis</h3> <p>Endocarditis may be associated with new therapeutic modalities involving intravascular devices such as central or peripheral intravenous catheters, rhythm control devices such as <a href="http://emedicine.medscape.com/article/1971142-overview" target="_self">pacemakers</a> and defibrillators, hemodialysis shunts and catheters, and chemotherapeutic and hyperalimentation lines.<sup><a href="javascript:showrefcontent('refrenceslayer');">[15] </a></sup>These patients tend to have significant comorbidities, more advanced age, and predominant infection with <em>S aureus.</em> The mortality rate is high in this group. </p> <p>The organisms that cause NIE/HCIE obviously are related to the type of underlying bacteremia. The gram-positive cocci (ie, <em>S aureus,</em> CoNS, enterococci, nonenterococcal streptococci) are the most common pathogens.</p> <h3>Fungal endocarditis</h3> <p>Fungal endocarditis is found in intravenous drug users and intensive care unit patients who receive broad-spectrum antibiotics.<sup><a href="javascript:showrefcontent('refrenceslayer');">[16] </a></sup>Blood cultures are often negative, and diagnosis frequently is made after microscopic examination of large emboli. </p> <h3>Clinical features associated with different pathogens</h3> <p>Different causative organisms tend to give rise to varying clinical manifestations of IE, as shown in the Table below.</p> <p>Table 1. Clinical Features of Infective Endocarditis According to Causative Organism<a onclick=" wmdPageLink('cr-tbl_1');" href="javascript:reftableshow('layertabletw2aab6b2b3c23');"> (Open Table in a new window)</a></p> <div class="inlinetable"> <table id="tw2aab6b2b3c23" class="datatable widetable"> <tbody> <tr> <td valign="center" align="middle"><strong>Causative Organism(s) </strong></td> <td valign="center" align="middle"><strong>Clinical Features of IE </strong></td></tr> <tr> <td valign="top" align="left"><em>Staphylococcus aureus</em></td> <td valign="top"> <ul class="topbullet-para"> <li> <div>Overall, <em>S aureus</em> infection is the most common cause of IE, including PVE, acute IE, and IVDA IE.</div></li> <li> <div>Approximately 35-60.5% of staphylococcal bacteremias are complicated by IE.</div></li> <li> <div>More than half the cases are not associated with underlying valvular disease.</div></li> <li> <div>The mortality rate of <em>S aureus</em> IE is 40-50%.</div></li> <li> <div><em>S aureus</em> infection is the second most common cause of nosocomial BSIs, second only to CoNS infection.</div></li> <li> <div>The incidence of MRSA infections, both the hospital- and community-acquired varieties, has dramatically increased (50% of isolates). Sixty percent of individuals are intermittent carriers of MRSA or MSSA <em>.</em></div> </li> <li> <div>The primary risk factor for <em>S aureus</em> BSI is the presence of intravascular lines. Other risk factors include cancer, diabetes, corticosteroid use, IVDA, alcoholism, and renal failure. </div></li> <li> <div>The realization that approximately 50% of hospital- and community-acquired staphylococcal bacteremias arise from infected vascular catheters has led to the reclassification of staphylococcal BSIs. BSIs are acquired not only in the hospital but also in any type of health care facility (eg, nursing home, dialysis center). </div> </li> <li> <div>Of <em>S aureus</em> bacteremia cases in the United States, 7.8% (200,000) per year are associated with intravascular catheters.</div></li></ul></td></tr> <tr> <td valign="top" align="left"><em>Streptococcus viridans</em></td> <td valign="top"> <ul class="topbullet-para"> <li> <div>This organism accounts for approximately 50-60% of cases of subacute disease.</div></li> <li> <div>Most clinical signs and symptoms are mediated immunologically.</div></li></ul></td></tr> <tr> <td valign="top" align="left"><em>Streptococcus intermedius</em> group</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>These infections may be acute or subacute.</div></li> <li> <div><em>S intermedius</em> infection accounts for 15% of streptococcal IE cases.</div></li> <li> <div><em>S intermedius</em> is unique among the streptococci; it can actively invade tissue and can cause abscesses.</div></li></ul></td></tr> <tr> <td valign="top" align="left"><em>Abiotrophia</em></td> <td valign="top"> <ul class="topbullet-para"> <li> <div>Approximately 5% of subacute cases of IE are due to infection with <em>Abiotrophia</em> species.</div></li> <li> <div>They require metabolically active forms of vitamin B-6 for growth.</div></li> <li> <div>This type of IE is associated with large vegetations that lead to embolization and a high rate of posttreatment relapse.</div></li></ul></td></tr> <tr> <td valign="top" align="left">Group D streptococci</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>Most cases are subacute.</div></li> <li> <div>The source is the gastrointestinal or genitourinary tract.</div></li> <li> <div>It is the third most common cause of IE.</div></li> <li> <div>They pose major resistance problems for antibiotics.</div></li></ul></td></tr> <tr> <td valign="top" align="left">Nonenterococcal group D</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>The clinical course is subacute.</div></li> <li> <div>Infection often reflects underlying abnormalities of the large bowel (eg, ulcerative colitis, polyps, cancer).</div></li> <li> <div>The organisms are sensitive to penicillin.</div></li></ul></td></tr> <tr> <td valign="top" align="left">Group B streptococci</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>Acute disease develops in pregnant patients and older patients with underlying diseases (eg, cancer, diabetes, alcoholism).</div></li> <li> <div>The mortality rate is 40%.</div></li> <li> <div>Complications include metastatic infection, arterial thrombi, and congestive heart failure.</div></li> <li> <div>It often requires valve replacement for cure.</div></li></ul></td></tr> <tr> <td valign="top" align="left">Group A, C, and G streptococci</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>Acute disease resembles that of <em>S aureus</em> IE (30-70% mortality rate), with suppurative complications.</div></li> <li> <div>Group A organisms respond to penicillin alone.</div></li> <li> <div>Group C and G organisms require a combination of synergistic antibiotics (as with enterococci).</div></li></ul></td></tr> <tr> <td valign="top" align="left">Coagulase-negative <em>S aureus</em></td> <td valign="top"> <ul class="topbullet-para"> <li> <div>This causes subacute disease.</div></li> <li> <div>It behaves similarly to <em>S viridans</em> infection.</div></li> <li> <div>It accounts for approximately 30% of PVE cases and less than 5% of NVE cases.<sup><a href="javascript:showrefcontent('refrenceslayer');">[17] </a></sup></div></li></ul></td></tr> <tr> <td valign="top" align="left"><em>Pseudomonas aeruginosa</em></td> <td valign="top"> <ul class="topbullet-para"> <li> <div>This is usually acute, except when it involves the right side of the heart in IVDA IE.</div></li> <li> <div>Surgery is commonly required for cure.</div></li></ul></td></tr> <tr> <td valign="top" align="left">HACEK (ie, <em>Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae</em>)</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>These organisms usually cause subacute disease.</div></li> <li> <div>They account for approximately 5% of IE cases.</div></li> <li> <div>They are the most common gram-negative organisms isolated from patients with IE.</div></li> <li> <div>Complications may include massive arterial emboli and congestive heart failure.</div></li> <li> <div>Cure requires ampicillin, gentamicin, and surgery.</div></li></ul></td></tr> <tr> <td valign="top" align="left">Fungal</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>These usually cause subacute disease.</div></li> <li> <div>The most common organism of both fungal NVE and fungal PVE is <em>Candida albicans</em>.</div></li> <li> <div>Fungal IVDA IE is usually caused by <em>Candida parapsilosis</em> or <em>Candida tropicalis.</em></div></li> <li> <div><em>Aspergillus</em> species are observed in fungal PVE and NIE.</div></li></ul></td></tr> <tr> <td valign="top" align="left"><em>Bartonella</em></td> <td valign="top"> <ul class="topbullet-para"> <li> <div>The most commonly involved species is <em>Bartonella quintana.</em></div></li> <li> <div>IE typically develops in homeless males who have extremely substandard hygiene. <em>Bartonella</em> must be considered in cases of culture-negative endocarditis among homeless individuals.</div></li></ul></td></tr> <tr> <td valign="top" align="left">Multiple pathogens (polymicrobial)</td> <td valign="top"> <ul class="topbullet-para"> <li> <div><em>Pseudomonas and enterococci are the most common combination of organisms.</em></div></li> <li> <div>It is observed in cases of IVDA IE</div></li> <li> <div>The cardiac surgery mortality rate is twice that associated with single-agent IE.<sup><a href="javascript:showrefcontent('refrenceslayer');">[18] </a></sup></div></li></ul></td></tr></tbody></table></div> <h3>Risk factors</h3> <p>The most significant risk factor for IE is residual valvular damage caused by a previous attack of endocarditis.<sup><a href="javascript:showrefcontent('refrenceslayer');">[19, 15] </a></sup></p> <p>Many possible risk factors for the development of pacemaker IE have been described, including diabetes mellitus, age, and use of anticoagulants and corticosteroids. The evidence for these is conflicting. The major risk factor is probably surgical intervention to any part of the pacemaker system, especially elective battery replacements. The rate of infection associated with battery replacements is approximately 5 times that of the initial implantation (6.5% vs 1.4%). </p> <p>Other significant risk factors for pacemaker IE include the development of a postoperative hematoma, the inexperience of the surgeon, and a preceding temporary transvenous pacing. </p></div> <div style="DISPLAY:block" class="back_next_btn"> <div class="back_btn">Previous</div> <div class="next_btn"><a onclick="wmdTrack('cr-sn_next'); wmdPageview('http://emedicine.medscape.com/article/216650-overview#a0104', '1');" href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#a0104">Next Section: Pathophysiology </a></div> <div class="spacer"></div></div> <div class="spacer"></div></div> <div id="content_a0156" class="inactive"> <h2>Epidemiology</h2> <div class="refsection_content"> <p>In the United States, the incidence of IE is approximately 2-4 cases per 100,000 persons per year. This rate has not changed in the past 50 years.<sup><a href="javascript:showrefcontent('refrenceslayer');">[20] </a></sup>The incidence of IE in other countries is similar to that in the United States. </p> <p>Although endocarditis can occur in a person of any age, the mean age of patients has gradually risen over the past 50 years. Currently, more than 50% of patients are older than 50 years.<sup><a href="javascript:showrefcontent('refrenceslayer');">[15] </a></sup>Mendiratta et al, in their retrospective study of hospital discharges from 1993-2003 of patients aged 65 years and older with a primary or secondary diagnosis of IE, found that hospitalizations for IE increased 26%, from 3.19 per 10,000 elderly patients in 1993 to 3.95 per 10,000 in 2003.<sup><a href="javascript:showrefcontent('refrenceslayer');">[21] </a></sup></p> <p>IE is 3 times as common in males as in females. It has no racial predilection.</p></div> <div style="DISPLAY:block" class="back_next_btn"> <div class="back_btn">Previous</div> <div class="next_btn"><a onclick="wmdTrack('cr-sn_next'); wmdPageview('http://emedicine.medscape.com/article/216650-overview#a0104', '1');" href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#a0104">Next Section: Pathophysiology </a></div> <div class="spacer"></div></div> <div class="spacer"></div></div> <div id="content_aw2aab6b2b5" class="inactive"> <h2>Prognosis</h2> <div class="refsection_content"> <p>Prognosis largely depends on whether or not complications develop. If left untreated, IE is generally fatal. Early detection and appropriate treatment of this uncommon disease can be lifesaving. </p> <p>Cure rates for appropriately managed (including both medical and surgical therapies) NVE are as follows:</p> <ul> <li> <div class="topbullet">For <em>S viridans</em> and <em>S bovis</em> infection, the rate is 98%.</div></li> <li> <div class="topbullet">For enterococci and <em>S aureus</em> infection in individuals who abuse intravenous drugs, the rate is 90%.</div></li> <li> <div class="topbullet">For community-acquired <em>S aureus</em> infection in individuals who do not abuse intravenous drugs, the rate is 60-70%.</div></li> <li> <div class="topbullet">For infection with aerobic gram-negative organisms, the rate is 40-60%.</div></li> <li> <div class="topbullet">For infection with fungal organisms, the rate is lower than 50%.</div></li></ul> <p>For PVE, the cure rates are as follows:</p> <ul> <li> <div class="topbullet">Rates are 10-15% lower for each of the above categories, for both early and late PVE.</div></li> <li> <div class="topbullet">Surgery is required far more frequently.</div></li> <li> <div class="topbullet">Approximately 60% of early CoNS PVE cases and 70% of late CoNS PVE cases are curable.</div></li></ul> <p>Anecdotal reports describe the resolution of right-sided valvular infection caused by <em>S aureus</em> infection in individuals who abuse intravenous drugs after just a few days of oral antibiotics.</p> <p>The role of valvular surgery in reducing mortality among patients with IE has been unclear. Challenges to resolving this question include the necessity of performing multicentered studies with an apparent difficulty of ensuring that the patients' preoperative assessments and surgical approaches are comparable. The largest study to date indicates that in cases of IE complicated by heart failure, valvular surgery reduces the 1-year mortality rate.<sup><a href="javascript:showrefcontent('refrenceslayer');">[84] </a></sup></p> <p>Mortality rates in NVE range from 16-27%. Mortality rates in patients with PVE are higher. More than 50% of these infections occur within 2 months after surgery. The fatality rate of pacemaker IE ranges up to 34%.<sup><a href="javascript:showrefcontent('refrenceslayer');">[22] </a></sup></p> <p>Increased mortality rates are associated with increased age,<sup><a href="javascript:showrefcontent('refrenceslayer');">[23] </a></sup>infection involving the aortic valve, development of congestive heart failure, central nervous system (CNS) complications, and underlying disease such as diabetes mellitus. Catastrophic neurological events of all types due to IE are highly predictive of morbidity and mortality.<sup><a href="javascript:showrefcontent('refrenceslayer');">[24] </a></sup></p> <p>Mortality rates also vary with the infecting organism. Acute endocarditis due to <em>S aureus</em> is associated with a high mortality rate (30-40%), except when it is associated with IV drug use.<sup><a href="javascript:showrefcontent('refrenceslayer');">[10, 25] </a></sup>Endocarditis due to streptococci has a mortality rate of approximately 10%. </p> </div> <div style="DISPLAY:block" class="back_next_btn"> <div class="back_btn">Previous</div> <div class="next_btn"><a onclick="wmdTrack('cr-sn_next'); wmdPageview('http://emedicine.medscape.com/article/216650-overview#a0104', '1');" href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#a0104">Next Section: Pathophysiology </a></div> <div class="spacer"></div></div> <div class="spacer"></div></div> <div id="content_aw2aab6b2b6" class="inactive"> <h2>Patient Education</h2> <div class="refsection_content"> <p>Surveys indicate that an appallingly small number of patients who are at risk for developing IE have an understanding of antibiotic and nonpharmacologic (ie, appropriate oral hygiene) principles. Drug rehabilitation for patients who use IV drugs is critical.</p> <p>The United Kingdom's National Institute for Health and Clinical Excellence (NICE) addresses patient education in its 2008 guideline on prophylaxis against IE in adults and children undergoing interventional procedures. The NICE's guideline recommends that health care professionals teach patients about the symptoms of IE and the risks of nonmedical invasive procedures such as body piercing and tattooing, explain the benefits and risks of antibiotic prophylaxis and the reasons that it is no longer routine, and emphasize the need to maintain good oral health.<sup><a href="javascript:showrefcontent('refrenceslayer');">[26] </a></sup></p> <p>For patient education information, see the <a href="http://www.emedicinehealth.com/collections/CO1572.asp" target="_blank">Heart Center</a>, as well as <a href="http://www.emedicinehealth.com/Articles/11205-1.asp" target="_blank">Tetralogy of Fallot</a>.</p> </div> <div style="DISPLAY:block" class="back_next_btn"> <div class="back_btn">Previous</div> <div class="spacer"></div></div> <div style class="next_btn1">Proceed to <a onclick="wmdTrack('cr-sn_next');" href="https://mail.google.com/mail/html/compose/static_files/216650-clinical">Clinical Presentation</a></div> <div class="spacer"> </div></div> <div class="spacer"> </div> <div id="authordisclosures" class="inactive"> <div class="layerbg1"> <div class="closewindow"><a href="javascript:hiderefcontent('authordisclosures');"></a></div> <div id="authorinfo" class="scrolllayer"> <div class="layer_title">Contributor Information and Disclosures</div> <div class="layer_title2">Author</div> <p><strong>John L Brusch, MD, FACP</strong> Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance <br><br>John L Brusch, MD, FACP is a member of the following medical societies: <a href="http://www.acponline.org/" target="_blank">American College of Physicians</a> and <a href="http://www.idsociety.org/" target="_blank">Infectious Diseases Society of America</a><br> <br>Disclosure: Nothing to disclose. </p> <div class="layer_title2">Coauthor(s)</div> <p><strong>Steven A Conrad, MD, PhD</strong> Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center <br> <br>Steven A Conrad, MD, PhD is a member of the following medical societies: <a href="http://www.chestnet.org/" target="_blank">American College of Chest Physicians</a>, American College of Critical Care Medicine, <a href="http://www.acep.org/" target="_blank">American College of Emergency Physicians</a>, <a href="http://www.acponline.org/" target="_blank">American College of Physicians</a>, <a href="http://www.ishlt.org/" target="_blank">International Society for Heart and Lung Transplantation</a>, <a href="http://www.lsms.org/" target="_blank">Louisiana State Medical Society</a>, <a href="http://www.shocksociety.org/" target="_blank">Shock Society</a>, <a href="http://www.saem.org/" target="_blank">Society for Academic Emergency Medicine</a>, and <a href="http://www.sccm.org/" target="_blank">Society of Critical Care Medicine</a><br> <br>Disclosure: Nothing to disclose. </p> <p><strong>Keith A Marill, MD</strong> Faculty, Department of Emergency Medicine, Massachusetts General Hospital; Assistant Professor, Harvard Medical School <br><br>Keith A Marill, MD is a member of the following medical societies: <a href="http://www.aaem.org/" target="_blank">American Academy of Emergency Medicine</a> and <a href="http://www.saem.org/" target="_blank">Society for Academic Emergency Medicine</a><br> <br>Disclosure: Medtronic Ownership interest None; Cambridge Heart, Inc. Ownership interest None; General Electric Ownership interest None </p> <div class="layer_title2">Specialty Editor Board</div> <p><strong>Jon Mark Hirshon, MD, MPH</strong> Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine <br><br>Jon Mark Hirshon, MD, MPH is a member of the following medical societies: <a href="http://www.alphaomegaalpha.org/" target="_blank">Alpha Omega Alpha</a>, <a href="http://www.aaem.org/" target="_blank">American Academy of Emergency Medicine</a>, <a href="http://www.acep.org/" target="_blank">American College of Emergency Physicians</a>, <a href="http://www.apha.org/" target="_blank">American Public Health Association</a>, and <a href="http://www.saem.org/" target="_blank">Society for Academic Emergency Medicine</a><br> <br>Disclosure: Nothing to disclose. </p> <p><strong>Francisco Talavera, PharmD, PhD</strong> Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference <br><br>Disclosure: Medscape Salary Employment </p> <p><strong>Thomas M Kerkering, MD</strong> Chief of Infectious Diseases, Virginia Tech Carilion School of Medicine <br><br>Thomas M Kerkering, MD is a member of the following medical societies: <a href="http://www.alphaomegaalpha.org/" target="_blank">Alpha Omega Alpha</a>, <a href="http://www.acponline.org/" target="_blank">American College of Physicians</a>, <a href="http://www.apha.org/" target="_blank">American Public Health Association</a>, <a href="http://www.asm.org/" target="_blank">American Society for Microbiology</a>, <a href="http://www.astmh.org/" target="_blank">American Society of Tropical Medicine and Hygiene</a>, <a href="http://www.idsociety.org/" target="_blank">Infectious Diseases Society of America</a>, <a href="http://www.msv.org/" target="_blank">Medical Society of Virginia</a>, and <a href="http://www.wms.org/" target="_blank">Wilderness Medical Society</a><br> <br>Disclosure: Nothing to disclose. </p> <p><strong>Barry E Brenner, MD, PhD, FACEP</strong> Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine <br> <br>Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: <a href="http://www.alphaomegaalpha.org/" target="_blank">Alpha Omega Alpha</a>, <a href="http://www.aaem.org/" target="_blank">American Academy of Emergency Medicine</a>, <a href="http://www.chestnet.org/" target="_blank">American College of Chest Physicians</a>, <a href="http://www.acep.org/" target="_blank">American College of Emergency Physicians</a>, <a href="http://www.acponline.org/" target="_blank">American College of Physicians</a>, <a href="http://www.americanheart.org/presenter.jhtml?identifier=1200000" target="_blank">American Heart Association</a>, <a href="http://www.thoracic.org/" target="_blank">American Thoracic Society</a>, <a href="http://www.arkmed.org/cgi-bin/cgiwrap/arkmed/start.cgi/dev05/setup.html" target="_blank">Arkansas Medical Society</a>, <a href="http://www.nyam.org/" target="_blank">New York Academy of Medicine</a>, <a href="http://www.nyas.org/" target="_blank">New York Academy of Sciences</a>, and <a href="http://www.saem.org/" target="_blank">Society for Academic Emergency Medicine</a><br> <br>Disclosure: Nothing to disclose. </p> <div class="layer_title2">Chief Editor</div> <p><strong>Burke A Cunha, MD</strong> Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital <br><br>Burke A Cunha, MD is a member of the following medical societies: <a href="http://www.chestnet.org/" target="_blank">American College of Chest Physicians</a>, <a href="http://www.acponline.org/" target="_blank">American College of Physicians</a>, and <a href="http://www.idsociety.org/" target="_blank">Infectious Diseases Society of America</a><br> <br>Disclosure: Nothing to disclose. </p></div></div></div> <div id="refrenceslayer" class="inactive"> <div class="clinref_references"> <div class="closewindow"><a href="javascript:hiderefcontent('refrenceslayer');"></a></div> <div class="ref_layer"> <div class="layer_title">References</div> <ol> <li> <p>Brusch JL. 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Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. <em>Circulation</em>. Jun 14 2005;111(23):e394-434. <a href="http://reference.medscape.com/medline/abstract/15956145" target="_self">[Medline]</a>. </p> </li> <li> <p>Buckholz K, Larsen CT. Severity of gentamicin is nephrotoxic effect on patients with infective endocarditis: a prospective observation of cohort study of 373 patients. <em>Clinical Infect Dis</em>. 2009;48:65-71. </p> </li> <li> <p>Cunha BA. Persistent S. aureus acute bacteremia: clinical pathway for diagnosis and treatment. <em>Antibiot for Clin</em>. 2006;10:39-46. </p></li> <li> <p>Falagas ME, Manta KG, Ntziora F, Vardakas KZ. Linezolid for the treatment of patients with endocarditis: a systematic review of the published evidence. <em>J Antimicrob Chemother</em>. Aug 2006;58(2):273-80. <a href="http://reference.medscape.com/medline/abstract/16735427" target="_self">[Medline]</a>. </p> </li> <li> <p>Jones T, Yeaman MR, Sakoulas G, Yang SJ, Proctor RA, Sahl HG, et al. Failures in clinical treatment of Staphylococcus aureus Infection with daptomycin are associated with alterations in surface charge, membrane phospholipid asymmetry, and drug binding. <em>Antimicrob Agents Chemother</em>. Jan 2008;52(1):269-78. <a href="http://reference.medscape.com/medline/abstract/17954690" target="_self">[Medline]</a>. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223911/" target="_blank">[Full Text]</a>. </p> </li> <li> <p>Sakoulas G, Moise-Broder PA, Schentag J, Forrest A, Moellering RC Jr, Eliopoulos GM. Relationship of MIC and bactericidal activity to efficacy of vancomycin for treatment of methicillin-resistant Staphylococcus aureus bacteremia. <em>J Clin Microbiol</em>. Jun 2004;42(6):2398-402. <a href="http://reference.medscape.com/medline/abstract/15184410" target="_self">[Medline]</a>. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC427878/" target="_blank">[Full Text]</a>. </p> </li> <li> <p>Fowler VG Jr, Li J, Corey GR, Boley J, Marr KA, Gopal AK, et al. Role of echocardiography in evaluation of patients with Staphylococcus aureus bacteremia: experience in 103 patients. <em>J Am Coll Cardiol</em>. Oct 1997;30(4):1072-8. <a href="http://reference.medscape.com/medline/abstract/9316542" target="_self">[Medline]</a>. </p> </li> <li> <p>Fowler VG Jr, Miro JM, Hoen B, Cabell CH, Abrutyn E, Rubinstein E, et al. Staphylococcus aureus endocarditis: a consequence of medical progress. <em>JAMA</em>. Jun 22 2005;293(24):3012-21. <a href="http://reference.medscape.com/medline/abstract/15972563" target="_self">[Medline]</a>. </p> </li> <li> <p>Khatib R, Johnson LB, Fakih MG, Riederer K, Khosrovaneh A, Shamse Tabriz M, et al. Persistence in Staphylococcus aureus bacteremia: incidence, characteristics of patients and outcome. <em>Scand J Infect Dis</em>. 2006;38(1):7-14. <a href="http://reference.medscape.com/medline/abstract/16338832" target="_self">[Medline]</a>. </p> </li> <li> <p>Duval X, Selton-Suty C, Alla F, Salvador-Mazenq M, Bernard Y, Weber M, et al. Endocarditis in patients with a permanent pacemaker: a 1-year epidemiological survey on infective endocarditis due to valvular and/or pacemaker infection. <em>Clin Infect Dis</em>. Jul 1 2004;39(1):68-74. <a href="http://reference.medscape.com/medline/abstract/15206055" target="_self">[Medline]</a>. </p> </li> <li> <p>[Guideline] Olaison L, Pettersson G. Current best practices and guidelines indications for surgical intervention in infective endocarditis. <em>Infect Dis Clin North Am</em>. Jun 2002;16(2):453-75, xi. <a href="http://reference.medscape.com/medline/abstract/12092482" target="_self">[Medline]</a>. </p> </li> <li> <p>Mekontso Dessap A, Zahar JR, Voiriot G, Ali F, Aissa N, Kirsch M, et al. Influence of preoperative antibiotherapy on valve culture results and outcome of endocarditis requiring surgery. <em>J Infect</em>. Jul 2009;59(1):42-8. <a href="http://reference.medscape.com/medline/abstract/19481815" target="_self">[Medline]</a>. </p> </li> <li> <p>[Guideline] Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. <em>Circulation</em>. Oct 9 2007;116(15):1736-54. <a href="http://reference.medscape.com/medline/abstract/17446442" target="_self">[Medline]</a>. </p> </li> <li> <p>Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. <em>N Engl J Med</em>. Dec 28 2006;355(26):2725-32. <a href="http://reference.medscape.com/medline/abstract/17192537" target="_self">[Medline]</a>. </p> </li> <li> <p>Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. <em>JAMA</em>. Jun 11 1997;277(22):1794-801. <a href="http://reference.medscape.com/medline/abstract/9178793" target="_self">[Medline]</a>. </p> </li> <li> <p>Bach DS. Perspectives on the American College of Cardiology/American Heart Association guidelines for the prevention of infective endocarditis. <em>J Am Coll Cardiol</em>. May 19 2009;53(20):1852-4. <a href="http://reference.medscape.com/medline/abstract/19442883" target="_self">[Medline]</a>. </p> </li> <li> <p>Thornhill MH, Dayer MJ, Forde JM, et al. Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study. <em>BMJ</em>. May 3 2011;342:d2392. <a href="http://reference.medscape.com/medline/abstract/21540258" target="_self">[Medline]</a>. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3086390/" target="_blank">[Full Text]</a>. </p> </li> <li> <p>Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT, et al. ACC/AHA 2008 guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. <em>Circulation</em>. Aug 2008;118(8):887-96. </p> </li> <li> <p>Netzer RO, Altwegg SC, Zollinger E, Täuber M, Carrel T, Seiler C. Infective endocarditis: determinants of long term outcome. <em>Heart</em>. Jul 2002;88(1):61-6. <a href="http://reference.medscape.com/medline/abstract/12067947" target="_self">[Medline]</a>. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767177/" target="_blank">[Full Text]</a>. </p> </li> <li> <p>US Food and Drug Administration. FDA Drug Safety Communication: Serious CNS reactions possible when linezolid (Zyvox®) is given to patients taking certain psychiatric medications. Available at <a href="http://www.fda.gov/Drugs/DrugSafety/ucm265305.htm" target="_blank">http://www.fda.gov/Drugs/DrugSafety/ucm265305.htm</a>. Accessed July 27, 2011. </p> </li> <li> <p>Kiefer T, Park L, Tribouilloy C, Cortes C, Casillo R, Chu V, et al. Association between valvular surgery and mortality among patients with infective endocarditis complicated by heart failure. <em>JAMA</em>. Nov 23 2011;306(20):2239-47. <a href="http://reference.medscape.com/medline/abstract/22110106" target="_self">[Medline]</a>. </p> </li></ol></div></div></div> <div id="clinref_imageslidelayer"> <div id="whiteoutlayer" class="inactive"></div> <div id="clinref_imagecontainer" class="inactive"> <div class="layerbg"> <div class="closewindow"><a href="javascript:refimghide();"> </a></div> <div class="clinref_imageborder"> <div class="row"> <div class="imagelayer_rtcol"> <div id="refimage" class="image_layer"></div> <div id="reimageid1" class="inactive" title="http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-216650-1674.jpg"></div> <div id="reimageid2" class="inactive" title="http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-216650-1675.jpg"></div> <div id="reimageid3" class="inactive" title="http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-1641795-216650-1947368.jpg"></div> <div id="reimageid4" class="inactive" title="http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-1641795-216650-1947415.jpg"></div> <div id="reimageid5" class="inactive" title="http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-1641795-216650-1947428.jpg"></div> <div id="reimageid6" class="inactive" title="http://img.medscape.com/pi/emed/ckb/infectious_diseases/211212-1641795-216650-1947429.jpg"></div> <div class="slidebtn_bar"> <div id="previmagebtn"><a><img border="0" alt="Previous" src="http://img.medscape.com/pi/reference/slide_btn.png"></a></div> <div id="nextimagebtn"><a><img border="0" alt="Next" src="http://img.medscape.com/pi/reference/slide_btn.png"></a></div> <div id="refimg_num"></div> <div class="spacer"> </div></div> <div id="refimage_captions"> <div id="refimage_caption1" class="capt" title="1">Acute bacterial endocarditis caused by <em>Staphylococcus aureus</em> with perforation of the aortic valve and aortic valve vegetations. Courtesy of Janet Jones, MD, Laboratory Service, Wichita Veterans Administration Medical Center. </div> <div id="refimage_caption2" class="capt" title="2">Acute bacterial endocarditis caused by <em>Staphylococcus aureus</em> with aortic valve ring abscess extending into myocardium. Courtesy of Janet Jones, MD, Laboratory Service, Wichita Veterans Administration Medical Center. </div> <div id="refimage_caption3" class="capt" title="3">A middle-aged man with a history of intravenous drug use who presented with severe myalgias and a petechial rash. He was diagnosed with right-sided staphylococcal endocarditis. </div> <div id="refimage_caption4" class="capt" title="4">This is a magnified portion of a parasternal long axis view from a transthoracic echocardiogram. There is a small curvilinear vegetation on the mitral valve as indicated. The patient presented with a headache and fever, and CT scan of the brain revealed an occipital hemorrhage. The patient had a history of intravenous drug use and multiple blood cultures grew Staphylococcus aureus. </div> <div id="refimage_caption5" class="capt" title="5">A young adult with a history of intravenous drug use, endocarditis involving the tricuspid valve with Staphylococcus aureus, and multiple septic pulmonary emboli. Pulmonary lesions on chest radiograph are most prominent in the right upper lobe with both solid and cavitary appearance. </div> <div id="refimage_caption6" class="capt" title="6">A young adult with a history of intravenous drug use diagnosed with right-sided staphylococcal endocarditis and multiple embolic pyogenic abscesses on chest radiograph. </div> </div> <div class="spacer"></div></div> <div class="imagelayer_ad"> <div id="adtagrightcol_imglayer"></div></div> <div class="spacer"></div></div></div></div></div> <div id="refimage_zoomlayer" class="inactive"> <div class="closewindow"><a href="javascript:hiderefcontent('refimage_zoomlayer');"></a></div> <div id="clinref_zoomimage"></div></div></div> <div id="clinref_tablelayer" class="inactive"> <div class="tablelayerbg"> <div class="closewindow"><a href="javascript:reftablehide();"></a></div> <div class="tablelayer_bg"> <div id="tablelayer_right"> <div id="adtagrightcol_tablelayer"></div></div> <div id="tablelayer_left"> <div id="tablelist_layer" class="active"> <div class="tablelist"> <ul> <li><a onclick=" wmdPageLink('cr-tbl_1');" href="javascript:reflisttableshow('layertabletw2aab6b2b3c23');">Table 1. Clinical Features of Infective Endocarditis According to Causative Organism</a></li></ul> </div></div> <div id="tablecontent_layer" class="inactive"> <div id="layertabletw2aab6b2b3c23" class="tablelayer_content"> <div class="table_title">Table 1. Clinical Features of Infective Endocarditis According to Causative Organism</div> <div class="table_scrolllayer"> <table id="tw2aab6b2b3c23" class="datatable"> <tbody> <tr> <td valign="center" align="middle"><strong>Causative Organism(s) </strong></td> <td valign="center" align="middle"><strong>Clinical Features of IE </strong></td></tr> <tr> <td valign="top" align="left"><em>Staphylococcus aureus</em></td> <td valign="top"> <ul class="topbullet-para"> <li> <div>Overall, <em>S aureus</em> infection is the most common cause of IE, including PVE, acute IE, and IVDA IE.</div></li> <li> <div>Approximately 35-60.5% of staphylococcal bacteremias are complicated by IE.</div></li> <li> <div>More than half the cases are not associated with underlying valvular disease.</div></li> <li> <div>The mortality rate of <em>S aureus</em> IE is 40-50%.</div></li> <li> <div><em>S aureus</em> infection is the second most common cause of nosocomial BSIs, second only to CoNS infection.</div></li> <li> <div>The incidence of MRSA infections, both the hospital- and community-acquired varieties, has dramatically increased (50% of isolates). Sixty percent of individuals are intermittent carriers of MRSA or MSSA <em>.</em></div> </li> <li> <div>The primary risk factor for <em>S aureus</em> BSI is the presence of intravascular lines. Other risk factors include cancer, diabetes, corticosteroid use, IVDA, alcoholism, and renal failure. </div></li> <li> <div>The realization that approximately 50% of hospital- and community-acquired staphylococcal bacteremias arise from infected vascular catheters has led to the reclassification of staphylococcal BSIs. BSIs are acquired not only in the hospital but also in any type of health care facility (eg, nursing home, dialysis center). </div> </li> <li> <div>Of <em>S aureus</em> bacteremia cases in the United States, 7.8% (200,000) per year are associated with intravascular catheters.</div></li></ul></td></tr> <tr> <td valign="top" align="left"><em>Streptococcus viridans</em></td> <td valign="top"> <ul class="topbullet-para"> <li> <div>This organism accounts for approximately 50-60% of cases of subacute disease.</div></li> <li> <div>Most clinical signs and symptoms are mediated immunologically.</div></li></ul></td></tr> <tr> <td valign="top" align="left"><em>Streptococcus intermedius</em> group</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>These infections may be acute or subacute.</div></li> <li> <div><em>S intermedius</em> infection accounts for 15% of streptococcal IE cases.</div></li> <li> <div><em>S intermedius</em> is unique among the streptococci; it can actively invade tissue and can cause abscesses.</div></li></ul></td></tr> <tr> <td valign="top" align="left"><em>Abiotrophia</em></td> <td valign="top"> <ul class="topbullet-para"> <li> <div>Approximately 5% of subacute cases of IE are due to infection with <em>Abiotrophia</em> species.</div></li> <li> <div>They require metabolically active forms of vitamin B-6 for growth.</div></li> <li> <div>This type of IE is associated with large vegetations that lead to embolization and a high rate of posttreatment relapse.</div></li></ul></td></tr> <tr> <td valign="top" align="left">Group D streptococci</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>Most cases are subacute.</div></li> <li> <div>The source is the gastrointestinal or genitourinary tract.</div></li> <li> <div>It is the third most common cause of IE.</div></li> <li> <div>They pose major resistance problems for antibiotics.</div></li></ul></td></tr> <tr> <td valign="top" align="left">Nonenterococcal group D</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>The clinical course is subacute.</div></li> <li> <div>Infection often reflects underlying abnormalities of the large bowel (eg, ulcerative colitis, polyps, cancer).</div></li> <li> <div>The organisms are sensitive to penicillin.</div></li></ul></td></tr> <tr> <td valign="top" align="left">Group B streptococci</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>Acute disease develops in pregnant patients and older patients with underlying diseases (eg, cancer, diabetes, alcoholism).</div></li> <li> <div>The mortality rate is 40%.</div></li> <li> <div>Complications include metastatic infection, arterial thrombi, and congestive heart failure.</div></li> <li> <div>It often requires valve replacement for cure.</div></li></ul></td></tr> <tr> <td valign="top" align="left">Group A, C, and G streptococci</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>Acute disease resembles that of <em>S aureus</em> IE (30-70% mortality rate), with suppurative complications.</div></li> <li> <div>Group A organisms respond to penicillin alone.</div></li> <li> <div>Group C and G organisms require a combination of synergistic antibiotics (as with enterococci).</div></li></ul></td></tr> <tr> <td valign="top" align="left">Coagulase-negative <em>S aureus</em></td> <td valign="top"> <ul class="topbullet-para"> <li> <div>This causes subacute disease.</div></li> <li> <div>It behaves similarly to <em>S viridans</em> infection.</div></li> <li> <div>It accounts for approximately 30% of PVE cases and less than 5% of NVE cases.<sup><a href="javascript:showrefcontent('refrenceslayer');">[17] </a></sup></div></li></ul></td></tr> <tr> <td valign="top" align="left"><em>Pseudomonas aeruginosa</em></td> <td valign="top"> <ul class="topbullet-para"> <li> <div>This is usually acute, except when it involves the right side of the heart in IVDA IE.</div></li> <li> <div>Surgery is commonly required for cure.</div></li></ul></td></tr> <tr> <td valign="top" align="left">HACEK (ie, <em>Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae</em>)</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>These organisms usually cause subacute disease.</div></li> <li> <div>They account for approximately 5% of IE cases.</div></li> <li> <div>They are the most common gram-negative organisms isolated from patients with IE.</div></li> <li> <div>Complications may include massive arterial emboli and congestive heart failure.</div></li> <li> <div>Cure requires ampicillin, gentamicin, and surgery.</div></li></ul></td></tr> <tr> <td valign="top" align="left">Fungal</td> <td valign="top"> <ul class="topbullet-para"> <li> <div>These usually cause subacute disease.</div></li> <li> <div>The most common organism of both fungal NVE and fungal PVE is <em>Candida albicans</em>.</div></li> <li> <div>Fungal IVDA IE is usually caused by <em>Candida parapsilosis</em> or <em>Candida tropicalis.</em></div></li> <li> <div><em>Aspergillus</em> species are observed in fungal PVE and NIE.</div></li></ul></td></tr> <tr> <td valign="top" align="left"><em>Bartonella</em></td> <td valign="top"> <ul class="topbullet-para"> <li> <div>The most commonly involved species is <em>Bartonella quintana.</em></div></li> <li> <div>IE typically develops in homeless males who have extremely substandard hygiene. <em>Bartonella</em> must be considered in cases of culture-negative endocarditis among homeless individuals.</div></li></ul></td></tr> <tr> <td valign="top" align="left">Multiple pathogens (polymicrobial)</td> <td valign="top"> <ul class="topbullet-para"> <li> <div><em>Pseudomonas and enterococci are the most common combination of organisms.</em></div></li> <li> <div>It is observed in cases of IVDA IE</div></li> <li> <div>The cardiac surgery mortality rate is twice that associated with single-agent IE.<sup><a href="javascript:showrefcontent('refrenceslayer');">[18] </a></sup></div></li></ul></td></tr></tbody></table></div></div> <div class="table_layer_bar"> <div id="prevtablebtn"><a><img border="0" alt="Previous" src="http://img.medscape.com/pi/reference/slide_btn.png"></a></div> <div id="nexttablebtn"><a><img border="0" alt="Next" src="http://img.medscape.com/pi/reference/slide_btn.png"></a></div> <div id="reftable_num"></div> <div class="spacer"> </div></div> <div id="link_tablelist"><a href="javascript:viewtablelist()">View Table List</a></div></div></div> <div class="spacer"> </div></div></div></div> <div class="spacer"> </div> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com1tag:blogger.com,1999:blog-2345113505836037298.post-13509110018392344522012-05-19T20:55:00.001-07:002012-05-19T20:55:14.600-07:00como me veo yosE han dado cuenta que las personas mas conspirativas son las que toleran menos las criticas y reclaman confianza tolerancia y paciencia cuando cuando se trata de ellos mismos. Que las personas mas intolerantes son las que que menos se exigen asi mismos y se toleran toda clase de cosas incluso la <a href="http://mediocridad.la/" target="_blank">mediocridad.la</a> negligencia la falta de conocimiento. Pueden ver cosas en los demas que no ven en ellos mismos. Tienen definitivamente un problema de percepcion. Pero no contentos con eso tratan de convencer o forzar a los demas para que los vean como ellos quieren que los vean. Como ellos se ven asimismos. Una vision que no concuerda con la realidad que no pueden soportar. Necesitan in ventar una ficcion. Y fuerzan a los demas a vivir dentro de esa ficcion. Como la anorexia nervosa que un desorden de la percepcion. Hay una sreie de desordenes parecidos. Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-59663944828716627602012-03-02T07:33:00.001-08:002012-03-02T07:33:46.465-08:00amandatina para TEC grave<p class="articleType">Original Article</p> <h1>Placebo-Controlled Trial of Amantadine for Severe Traumatic Brain Injury</h1> <p class="authors">Joseph T. Giacino, Ph.D., John Whyte, M.D., Ph.D., Emilia Bagiella, Ph.D., Kathleen Kalmar, Ph.D., Nancy Childs, M.D., Allen Khademi, M.D., Bernd Eifert, M.D., David Long, M.D., Douglas I. Katz, M.D., Sooja Cho, M.D., Stuart A. Yablon, M.D., Marianne Luther, M.D., Flora M. Hammond, M.D., Annette Nordenbo, M.D., Paul Novak, O.T.R., Walt Mercer, Ph.D., Petra Maurer-Karattup, Dr.Rer.Nat., and Mark Sherer, Ph.D.</p> <p class="citationLine"><span class="citation">N Engl J Med 2012; 366:819-826</span><a href="http://www.nejm.org/toc/nejm/366/9/">March 1, 2012</a></p> <dl class="articleTabs tabPanel lastChild"> <dt id="abstractTab" class="active abstract firstChild sideBySide inactive">Abstract</dt> <dt id="articleTab" class="article sideBySide">Article</dt> <dt id="referencesTab" class="references sideBySide inactive">References</dt> <dd style id="abstract"> <div class="left section"> <div class="section"></div> <div class="section"> <h3 id="abstractBackground">Background</h3> <p>Amantadine hydrochloride is one of the most commonly prescribed medications for patients with prolonged disorders of consciousness after traumatic brain injury. Preliminary studies have suggested that amantadine may promote functional recovery.</p> <p class="fullTextLink"><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#Background" rel="gotofulltext">Full Text of Background...</a></p></div> <div class="section"></div> <div class="section"> <h3 id="abstractMethods">Methods</h3> <p>We enrolled 184 patients who were in a vegetative or minimally conscious state 4 to 16 weeks after traumatic brain injury and who were receiving inpatient rehabilitation. Patients were randomly assigned to receive amantadine or placebo for 4 weeks and were followed for 2 weeks after the treatment was discontinued. The rate of functional recovery on the Disability Rating Scale (DRS; range, 0 to 29, with higher scores indicating greater disability) was compared over the 4 weeks of treatment (primary outcome) and during the 2-week washout period with the use of mixed-effects regression models.</p> <p class="fullTextLink"><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#Methods" rel="gotofulltext">Full Text of Methods...</a></p></div> <div class="section"></div> <div class="section"> <h3 id="abstractResults">Results</h3> <p>During the 4-week treatment period, recovery was significantly faster in the amantadine group than in the placebo group, as measured by the DRS score (difference in slope, 0.24 points per week; P=0.007), indicating a benefit with respect to the primary outcome measure. In a prespecified subgroup analysis, the treatment effect was similar for patients in a vegetative state and those in a minimally conscious state. The rate of improvement in the amantadine group slowed during the 2 weeks after treatment (weeks 5 and 6) and was significantly slower than the rate in the placebo group (difference in slope, 0.30 points per week; P=0.02). The overall improvement in DRS scores between baseline and week 6 (2 weeks after treatment was discontinued) was similar in the two groups. There were no significant differences in the incidence of serious adverse events.</p> <p class="fullTextLink"><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#Results" rel="gotofulltext">Full Text of Results...</a></p></div> <div class="section"></div> <div class="section"> <h3 id="abstractConclusions">Conclusions</h3> <p>Amantadine accelerated the pace of functional recovery during active treatment in patients with post-traumatic disorders of consciousness. (Funded by the National Institute on Disability and Rehabilitation Research; ClinicalTrials.gov number, <a class="ref" href="http://clinicaltrials.gov/show/NCT00970944" target="url">NCT00970944</a>.)</p> <p class="fullTextLink"><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#Discussion" rel="gotofulltext">Full Text of Discussion...</a></p></div> <div class="section"></div> <p class="fullTextLink"><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#Top" rel="gotofulltext">Read the Full Article...</a></p></div> <div class="right section"> <div class="articleMedia"> <h3 class="title">Media in This Article</h3> <div class="mediaRefs"> <div class="mediaRef"><span class="fig"><span class="figureTitle">Figure 1</span><a class="figureLink viewType-Layer viewClass-ImageViewerLayer event-articleThumb" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=f01"><img alt="" src="http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-9/nejmoa1102609/production/images/small/nejmoa1102609_f1.gif"></a><span class="figureCaption">Mean Disability Rating Scale (DRS) Scores during the 6-Week Assessment Period, According to Study Group.</span></span></div> <div class="mediaRef"><span class="fig"><span class="figureTitle">Figure 2</span><a class="figureLink viewType-Layer viewClass-ImageViewerLayer event-articleThumb" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=f02"><img alt="" src="http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-9/nejmoa1102609/production/images/small/nejmoa1102609_f2.gif"></a><span class="figureCaption">Post hoc Analysis of the Distribution of DRS Scores by Outcome Category.</span></span></div> </div></div></div></dd> <dd style="DISPLAY:block" id="article"> <div class="section"> <p>Severe traumatic brain injury is a catastrophic event that frequently has devastating familial, economic, and societal consequences. Traumatic brain injury is the most common cause of death and disability in persons between 15 and 30 years of age.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref1" rel="#refLayer">1</a></span> The most severe injuries can result in prolonged disorders of consciousness. Approximately 10 to 15% of patients with severe traumatic brain injury are discharged from acute care in a vegetative state,<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref2" rel="#refLayer">2</a></span> a condition in which there is wakefulness without behavioral evidence of conscious awareness.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref3" rel="#refLayer">3</a></span> The estimated prevalence of a minimally conscious state,<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref4" rel="#refLayer">4</a></span> which is distinguished from a vegetative state by the presence of at least one clearly discernible behavioral sign of consciousness, is 8 times as high as the prevalence of a vegetative state.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref5" rel="#refLayer">5</a></span> Of patients who are in a vegetative state for at least 4 weeks, approximately 50% will regain consciousness by 1 year.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref2" rel="#refLayer">2</a></span> Outcomes are generally more favorable for patients who are in a minimally conscious state, although approximately 50% remain severely disabled at 1 year.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref6" rel="#refLayer">6-9</a></span> </p> <p>No intervention has been shown in rigorous studies to alter the pace of recovery or improve the functional outcome. Neuropharmacologic therapies are commonly used off label to enhance arousal and behavioral responsiveness, on the premise that injury induced derangements in dopaminergic and noradrenergic neurotransmitter systems can be improved through supplementation.</p> <p>Amantadine hydrochloride is one of the most commonly prescribed medications for patients with disorders of consciousness who are undergoing inpatient neurorehabilitation.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref10" rel="#refLayer">10</a></span> The mechanism of action is unclear, although amantadine appears to act as an <em>N</em>-methyl-D-aspartate antagonist and indirect dopamine agonist.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref11" rel="#refLayer">11</a></span> The results of two randomized trials involving patients with traumatic disorders of consciousness suggested that amantadine was effective,<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref12" rel="#refLayer">12,13</a></span> although methodologic limitations, including small samples and unbalanced groups, precluded definitive conclusions.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref14" rel="#refLayer">14,15</a></span> </p> <p>In 1998, a consortium of brain-injury rehabilitation centers conducted an observational pilot study designed to establish the rate of spontaneous recovery from vegetative and minimally conscious states and provide the basis for a multicenter clinical trial.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref10" rel="#refLayer">10</a></span> A multiple-regression analysis exploring the effect of cognition-enhancing medications at 16 weeks after injury on scores on the Disability Rating Scale (DRS),<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref16" rel="#refLayer">16</a></span> a measure of functional outcome that is specific to traumatic brain injury, showed better scores at 16 weeks after injury in patients who received amantadine than in those who did not.</p> <p>On the basis of these findings, we designed the current multicenter, prospective, double-blind, randomized, placebo-controlled trial to determine the effectiveness of amantadine in promoting recovery from a post-traumatic vegetative or minimally conscious state. We hypothesized that 4 weeks of treatment with amantadine administered between 4 and 16 weeks after injury in patients with traumatic disorders of consciousness would improve the rate of functional recovery during the treatment interval, that the improvement would be maintained 2 weeks after drug washout, and that amantadine would be well tolerated.</p> </div> <div class="section"> <h3 id="articleMethods">Methods</h3> <div class="subSection"> <h3 id="articlePatients and Sites">Patients and Sites</h3> <p>We conducted this study at 11 clinical sites in three countries. Eligible patients were 16 to 65 years of age, had sustained a nonpenetrating traumatic brain injury 4 to 16 weeks before enrollment, and were receiving usual inpatient rehabilitation at each site. Additional eligibility criteria were a vegetative state or a minimally conscious state, as indicated by a DRS score greater than 11, and an inability both to follow commands consistently and to engage in functional communication, as assessed by the score on the Coma Recovery Scale–Revised (CRS-R).<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref17" rel="#refLayer">17</a></span> </p> <p>The DRS includes measures of eye opening, verbalization, and motor response (derived from the Glasgow Coma Scale); cognitive understanding of feeding, dressing, and grooming; degree of assistance and supervision required; and employability.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref16" rel="#refLayer">16</a></span> Scores range from 0 to 29, with higher values indicating greater disability (see the <a href="http://www.nejm.org/doi/suppl/10.1056/NEJMoa1102609/suppl_file/nejmoa1102609_appendix.pdf">Supplementary Appendix</a>, available with the full text of this article at NEJM.org, for details). The CRS-R is a standardized neurobehavioral assessment tool comprising six hierarchically organized subscales (i.e., auditory, visual, motor, oromotor–verbal, communication, and arousal); scores range from 0 to 23, with higher scores indicating a higher level of neurobehavioral function.</p> <p>Exclusion criteria were any disability related to the central nervous system that predated the traumatic brain injury, medical instability, pregnancy, serious renal disease (estimated creatinine clearance, less than 60 ml per minute), more than one seizure in the previous month, prior treatment with amantadine, and allergy to amantadine. In the case of patients who were undergoing evaluation for ventricular shunt placement or receiving a psychoactive medication, enrollment was deferred until shunt placement had been completed or psychoactive medications discontinued.</p> <p>Demographic characteristics and baseline functional scores on the DRS and CRS-R were submitted to the data coordinating center through an online portal. Treatment was assigned within centers in random blocks of four or six, with stratification for diagnosis (vegetative state vs. minimally conscious state) and interval between injury and enrollment (28 to 70 days vs. 71 to 112 days), which are factors shown to be predictive of outcomes.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref3" rel="#refLayer">3,6,10</a></span> </p> </div> <div class="subSection"> <h3 id="articleStudy Oversight">Study Oversight</h3> <p>The protocol was approved by the institutional review boards at all participating sites, and written informed consent was obtained from each patient's legally authorized representative. Independent oversight was provided by an external data and safety monitoring board. All data were stored and analyzed by a data coordinating center at Columbia University. The study was conducted in adherence to the <a href="http://www.nejm.org/doi/suppl/10.1056/NEJMoa1102609/suppl_file/nejmoa1102609_protocol.pdf">protocol</a>, available at NEJM.org. The first and second authors designed the study. All the authors vouch for the accuracy and completeness of the data and for the analysis. The National Institute on Disability and Rehabilitation Research provided all financial support for this study, including funds to purchase amantadine.</p> </div> <div class="subSection"> <h3 id="articleStudy Procedures">Study Procedures</h3> <p>Amantadine and a visually identical placebo were supplied by four compounding pharmacies serving the different study regions. On randomization, the data coordinating center assigned coded medication bottles to patients enrolled at each clinical site. The patients began receiving treatment at a dose of 100 mg twice daily on the day after randomization, with this dose continued for 14 days. The dose was increased to 150 mg twice daily at week 3 and to 200 mg twice daily at week 4 if the DRS score had not improved by at least 2 points from baseline (see Table S1 in the <a href="http://www.nejm.org/doi/suppl/10.1056/NEJMoa1102609/suppl_file/nejmoa1102609_appendix.pdf">Supplementary Appendix</a> for a breakdown of the drug doses received by patients in each study group). After the week 4 assessment, the study drug was tapered over a period of 2 to 3 days, with assessment of the patients continued through week 6. Additional procedural details are provided in the study protocol.</p> <p>To minimize exposure to confounding psychoactive medications during the treatment phase, a list of suggested treatments for commonly observed medical problems was compiled. This list was ordered roughly from the least to the most potentially confounding treatment. Treating physicians were requested to follow the order in this list, when possible, in choosing treatments.</p> </div> <div class="subSection"> <h3 id="articleOutcomes">Outcomes</h3> <p>The primary outcome was the rate of improvement in the DRS score during the 4 weeks of treatment. DRS scores were collected at baseline and weekly through week 6 on the basis of consensus ratings compiled by the interdisciplinary treatment team.</p> <p>To gauge the clinical significance of the effects of amantadine, clinically relevant behavioral benchmarks were assessed by study personnel using the CRS-R. We used the CRS-R as a qualitative measure to better understand the effects of the study drug on key behaviors associated with a vegetative state, a minimally conscious state, and emergence from a minimally conscious state.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref17" rel="#refLayer">17</a></span> We also assessed whether the rate of recovery was altered in the amantadine group during the 2-week washout period. All DRS and CRS-R assessments were conducted by study personnel who were unaware of the group assignments. Adverse events were documented throughout the 6-week assessment period and were coded with respect to their severity, whether they were expected, and whether they were thought by the investigator to be related or possibly related to the study drug. Exposure to other psychoactive drugs was recorded for all patients throughout the 6-week period. All outcome assessments and the final data analysis were conducted without knowledge of group assignments.</p> </div> <div class="subSection"> <h3 id="articleStatistical Analysis">Statistical Analysis</h3> <p>The planned sample size of 184 was estimated, on the basis of our previously described pilot study,<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref10" rel="#refLayer">10</a></span> to provide 80% power to detect a difference in the rate of change in the DRS score of 0.3 points per week, or 1.2 points by the end of the 4-week treatment interval. This sample size also provided 90% power to detect an unforeseen adverse event with an incidence of at least 2.5% and allowed estimation of the incidence of adverse events to an accuracy of ±10%. Two blinded interim analyses were conducted after the enrollment of 60 and 120 participants, with the use of the O'Brien–Fleming boundaries and with alpha levels set at 0.0005 and 0.014, respectively. An alpha level of 0.045 was set for the final analysis.</p> <p>We used t-tests for continuous variables and a chi-square analysis for categorical variables for comparison of the study groups at baseline. We used mixed-effect regression models with random intercepts to test the primary and secondary hypotheses of a difference in the rate of change in the DRS score between the amantadine and placebo groups overall and in stratified subgroups.</p> <p>The first hypothesis (primary outcome) was assessed by comparing the slope of change in the DRS score over the 4-week treatment period between the two groups, with a negative slope reflecting functional improvement. We conducted a post hoc descriptive analysis of behavioral recovery as defined by the six CRS-R behavioral benchmarks associated with the highest level of cognitive processing on each subscale. Because this analysis was not prespecified in the protocol and was conducted for descriptive purposes only, a statistical comparison of the percentage of patients within each group who were able to engage in these behaviors was not conducted.</p> <p>The second hypothesis (durability of the treatment effect) was assessed by comparing the slope of change in the DRS score between weeks 4 and 6 in the two groups. Preplanned subgroup analyses were conducted to determine the consistency of the results across the strata of diagnosis (vegetative state vs. minimally conscious state) and interval between injury and enrollment (28 to 70 days vs. 71 to 112 days). An analysis of residuals was conducted to determine model fit. Fisher's exact test was used to compare the proportions of patients who had adverse events in the two groups. The Wilcoxon signed-rank test was used to compare non-normally distributed variables. All analyses were conducted according to the intention-to-treat principle.</p> </div></div> <div class="section"></div> <div class="section"> <h3 id="articleResults">Results</h3> <div class="subSection"> <h3 id="articleStudy Participants">Study Participants</h3> <p>Of 1170 patients who were screened for eligibility, 350 met all eligibility criteria and 184 were enrolled (Figure S2 in the <a href="http://www.nejm.org/doi/suppl/10.1056/NEJMoa1102609/suppl_file/nejmoa1102609_appendix.pdf">Supplementary Appendix</a>). Of these 184 patients, all but 3 (2 assigned to the placebo group and 1 to the amantadine group) completed the study. The amantadine and placebo groups were well matched with respect to major demographic variables and prognostic factors, including the DRS score at baseline, interval between injury and enrollment, and diagnosis at enrollment (<a class="viewType-Layer viewClass-ImageViewerLayer" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=t01">Table 1</a><span class="table"><span class="figureTitle">Table 1</span><a class="figureLink viewType-Layer viewClass-ImageViewerLayer event-articleThumb" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=t01"><img alt="" src="http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-9/nejmoa1102609/production/images/small/nejmoa1102609_t1.gif"></a><span class="figureCaption">Demographic and Clinical Characteristics at Baseline.</span></span>). Of the 184 patients, 154 (84%) missed no more than 4 of the 56 total doses of study medication. The remaining 30 patients (16%) missed between 5 and 52 doses, in most cases owing to transfer to an acute care facility where it was not feasible or was medically inadvisable to continue the study treatment. Approximately one third of the patients received potentially confounding medications (Table S3 in the <a href="http://www.nejm.org/doi/suppl/10.1056/NEJMoa1102609/suppl_file/nejmoa1102609_appendix.pdf">Supplementary Appendix</a>). Exposure to stimulants and open-label amantadine was uncommon. Antiepileptic drug use was more frequent in the amantadine group (P=0.04), whereas use of narcotic analgesic agents was more frequent in the placebo group (P=0.08).</p> </div> <div class="subSection"> <h3 id="articleOutcomes">Outcomes</h3> <p>Both groups had significant improvement in the DRS score over the 4-week treatment interval, but the amantadine group had significantly faster recovery (difference in slope, −0.24 points per week; P=0.007) (<a class="viewType-Layer viewClass-ImageViewerLayer" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=f01">Figure 1</a><span class="fig"><span class="figureTitle">Figure 1</span><a class="figureLink viewType-Layer viewClass-ImageViewerLayer event-articleThumb" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=f01"><img alt="" src="http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-9/nejmoa1102609/production/images/small/nejmoa1102609_f1.gif"></a><span class="figureCaption">Mean Disability Rating Scale (DRS) Scores during the 6-Week Assessment Period, According to Study Group.</span></span>) and had fewer dose increases at weeks 2 and 3. Although in both study groups, patients who were enrolled earlier after injury versus later (i.e., 28 to 70 days vs. 71 to 112 days) and those who were in a minimally conscious state rather than a vegetative state at enrollment had faster recovery rates, the treatment effect was consistent across subgroups. The advantage of exposure to amantadine was most pronounced for patients who were enrolled later as compared with those who were enrolled earlier (effect size, −0.40 points vs. −0.19 points). The effect size was similar between diagnostic subgroups (vegetative state, −0.25 points; minimally conscious state, −0.24 points). However, all subgroup effect sizes fell within the 95% confidence interval for the overall effect (95% confidence interval, −0.41 to −0.07 points) (Figure S4 and S5 in the <a href="http://www.nejm.org/doi/suppl/10.1056/NEJMoa1102609/suppl_file/nejmoa1102609_appendix.pdf">Supplementary Appendix</a>).</p> <p>More patients in the amantadine group than in the placebo group had favorable outcomes on the DRS, fewer remained in a vegetative state (<a class="viewType-Layer viewClass-ImageViewerLayer" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=f02">Figure 2</a><span class="fig"><span class="figureTitle">Figure 2</span><a class="figureLink viewType-Layer viewClass-ImageViewerLayer event-articleThumb" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=f02"><img alt="" src="http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-9/nejmoa1102609/production/images/small/nejmoa1102609_f2.gif"></a><span class="figureCaption">Post hoc Analysis of the Distribution of DRS Scores by Outcome Category.</span></span>), and a greater percentage had recovery of key behavioral benchmarks on the CRS-R at the end of the 4-week treatment period. Statistical comparison of the behavioral benchmarks was not prespecified and therefore was not performed (<a class="viewType-Layer viewClass-ImageViewerLayer" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=f03">Figure 3</a><span class="fig"><span class="figureTitle">Figure 3</span><a class="figureLink viewType-Layer viewClass-ImageViewerLayer event-articleThumb" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=f03"><img alt="" src="http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-9/nejmoa1102609/production/images/small/nejmoa1102609_f3.gif"></a><span class="figureCaption">Frequency of Recovery of Key Behavioral Benchmarks on the Coma Recovery Scale–Revised (CRS-R).</span></span>).</p> <p>During the 2-week washout period, only the placebo group had significant improvement in the DRS score (slope, −0.44 points per week; P<0.001 for the change from the beginning of week 5 to the end of week 6). Although behavioral improvements were generally maintained in the amantadine group, the pace of recovery was significantly slower in the amantadine group (slope, −0.14 points per week; between-group difference in slope, 0.30 points; P=0.02) (<a class="viewType-Layer viewClass-ImageViewerLayer" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=f01">Figure 1</a>). The percentage of patients who were able to engage in each of the six clinically relevant behaviors was higher in the amantadine group than in the placebo group at 4 weeks, but the difference was smaller at the 6-week follow-up assessment (<a class="viewType-Layer viewClass-ImageViewerLayer" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=f03">Figure 3</a>).</p> </div> <div class="subSection"> <h3 id="articleAdverse Events">Adverse Events</h3> <p>As expected, medical complications were common (median number of adverse events per patient, 2), with no significant difference in the incidence of adverse events between groups (P>0.20) (<a class="viewType-Layer viewClass-ImageViewerLayer" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=t02">Table 2</a><span class="table"><span class="figureTitle">Table 2</span><a class="figureLink viewType-Layer viewClass-ImageViewerLayer event-articleThumb" href="http://www.nejm.org/action/showImage?doi=10.1056%2FNEJMoa1102609&iid=t02"><img alt="" src="http://www.nejm.org/na102/home/ACS/publisher/mms/journals/content/nejm/2012/nejm_2012.366.issue-9/nejmoa1102609/production/images/small/nejmoa1102609_t2.gif"></a><span class="figureCaption">Adverse Events, According to Treatment Group.</span></span>). During the course of the trial, one patient in the amantadine group died from cardiac arrest (see Table S6 in the <a href="http://www.nejm.org/doi/suppl/10.1056/NEJMoa1102609/suppl_file/nejmoa1102609_appendix.pdf">Supplementary Appendix</a> for a list of all serious adverse events).</p> </div></div> <div class="section"></div> <div class="section"> <h3 id="articleDiscussion">Discussion</h3> <p>In this international, multicenter, randomized, controlled trial involving patients with post-traumatic disorders of consciousness, we found that the administration of amantadine between 4 and 16 weeks after injury significantly improved the rate of functional recovery over the 4-week period of treatment, as compared with placebo. In keeping with evidence on the rate of change during inpatient rehabilitation,<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref10" rel="#refLayer">10,18</a></span> both groups had improvement during the 4-week period. However, the rate of recovery was more rapid in the amantadine group, affecting functionally meaningful behaviors such as consistent responses to commands, intelligible speech, reliable yes-or-no communication, and functional-object use.</p> <p>The benefit of amantadine appeared to be consistent, regardless of the interval since injury or whether patients were in a vegetative state or a minimally conscious state at enrollment. Although gains were generally well maintained in the amantadine group after the washout period, the rate of recovery attenuated substantially after treatment was discontinued, and scores on the DRS were largely indistinguishable between the amantadine and placebo groups at the 6-week follow-up assessment. During the 6-week observation period, exposure to amantadine did not increase the risk of adverse medical, neurologic, or behavioral events, including those of greatest concern to clinicians treating this population (e.g., seizure). These findings suggest that amantadine can be used safely at doses between 200 mg and 400 mg in patients with severe traumatic brain injury.</p> <p>Our findings are consistent with observational reports<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref12" rel="#refLayer">12,19</a></span> suggesting the acceleration of recovery in patients who are receiving amantadine and the deceleration or loss of function after treatment is discontinued. The acute phase of recovery from severe traumatic brain injury is characterized by a brief period of neuronal excitability followed by a longer period of hypoexcitability, involving depletion of multiple neurotransmitters, including dopamine. Amantadine may promote dopaminergic activity by facilitating presynaptic release and blocking reuptake postsynaptically.<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref20" rel="#refLayer">20,21</a></span> The favorable neurobehavioral effects of amantadine may reflect enhanced neurotransmission in the dopamine-dependent nigrostriatal, mesolimbic, and frontostriatal circuits that are responsible for mediating arousal, drive, and attentional functions.</p> <p>Two case studies that used serial <sup>18</sup>F-fluorodeoxyglucose–positron-emission tomography to evaluate the effects of amantadine showed significant increases in prefrontal cortical metabolism<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref22" rel="#refLayer">22,23</a></span> and a nonsignificant increase in striatal D2 dopamine–receptor availability, supporting this proposed mechanism of action. The extent to which the treatment effect was mediated by general improvements in arousal cannot be discerned from this study because arousal functions generally recover in parallel with cognition.</p> <p>Our study has some limitations. The sample comprised patients admitted to inpatient rehabilitation centers, raising the possibility of selection bias because decisions about admission to a rehabilitation center may be influenced by the probability of further improvement. In addition, nonwhites were underrepresented, potentially limiting the generalizability of the results to nonwhite populations. Second, practical and ethical constraints required the use of a brief treatment interval and a short term assessment of the outcome, because we anticipated that caregivers would withdraw patients who were not making gains in order to try other treatments. Thus, our findings do not address the effects of prolonged treatment on long-term outcomes. Third, we did not restrict standard rehabilitation interventions, so we cannot determine the degree to which the benefits of amantadine are independent of or synergistic with such standard treatments. Fourth, despite attempts to limit the use of potentially confounding psychoactive drugs, such drugs were used frequently. However, exposure to other psychoactive drugs would be expected either to block the benefits of amantadine in treated patients or to provide alternative mechanisms for similar benefits in the placebo group, thereby reducing rather than exaggerating the magnitude of the difference between the groups. Finally, we did not use continuous electroencephalographic monitoring to detect seizures; however, a high incidence of amantadine-induced subclinical seizures would be expected to slow rather than accelerate functional recovery.</p> <p>We conclude that amantadine is effective in accelerating the pace of recovery during acute rehabilitation in patients with prolonged post-traumatic disturbances in consciousness. Exposure to amantadine is associated with more rapid emergence of cognitively mediated behaviors that serve as the foundation for functional independence. The rate of recovery in the amantadine group slowed and between-group behavioral differences diminished during the washout period, suggesting that the response is drug-dependent. Whether treatment with amantadine, as compared with placebo, improves the long-term outcome or simply accelerates recovery en route to an equivalent level of function remains unknown. In view of health care cost constraints and declining lengths of stay for inpatient rehabilitation,<span class="ref"><a class="showRefLayer" href="http://www.nejm.org/doi/full/10.1056/NEJMoa1102609?query=TOC#ref24" rel="#refLayer">24</a></span> amantadine-induced acceleration of recovery may represent an important advance. Future research should focus on determining the pathophysiological characteristics of patients who have a response to amantadine, the most effective dosage and duration of treatment and timing of its initiation, and the effectiveness of amantadine in patients with nontraumatic brain injuries.</p> </div> <div class="section"></div> <p>Supported by a grant from the National Institute on Disability and Rehabilitation Research (H133A031713).</p> <p><a href="http://www.nejm.org/doi/suppl/10.1056/NEJMoa1102609/suppl_file/nejmoa1102609_disclosures.pdf">Disclosure forms</a> provided by the authors are available with the full text of this article at NEJM.org.</p> <p>Drs. Giacino and Whyte contributed equally to this article.</p> <div class="section"> <div class="sourceInfo"> <h3>Source Information</h3> <p>From the JFK Johnson Rehabilitation Institute, Edison, NJ (J.T.G., K.K., A.K.); Spaulding Rehabilitation Hospital and Department of Physical Medicine and Rehabilitation, Harvard Medical School (J.T.G.), and Department of Neurology, Boston University School of Medicine (D.I.K.) — all in Boston; Moss Rehabilitation Research Institute, Albert Einstein Healthcare Network, Elkins Park (J.W., S.C.), and Brain Injury Program, Bryn Mawr Rehab Hospital, Malvern (D.L.) — both in Pennsylvania; Department of Biostatistics, Mailman School of Public Health, Columbia University, New York (E.B.); Texas NeuroRehab Center, Austin (N.C., W.M.); SRH Fachkrankenhaus Neresheim, Neresheim (B.E., P.M.-K.), and Schön Klinik Bad Aibling, Bad Aibling (M.L.) — both in Germany; Braintree Rehabilitation Hospital, Braintree, MA (D.I.K.); Methodist Rehabilitation Center, Jackson, MS (S.A.Y., M.S.); Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, Canada (S.A.Y.); Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Charlotte, NC (F.M.H.); Indiana University School of Medicine, Indianapolis (F.M.H.); Department of Neurorehabilitation, Traumatic Brain Injury Unit at Copenhagen University Hospital, Glostrup, and Hvidovre Hospital, Hvidovre — both in Denmark (A.N.); Sunnyview Rehabilitation Hospital, Schenectady, NY (P.N.); and TIRR Memorial Hermann, Houston (M.S.).</p> <p>Address reprint requests to Dr. Giacino at the Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, 125 Nashua St., Boston, MA 02114, or at <a class="email" href="mailto:jgiacino@partners.org">jgiacino@partners.org</a>. </p> </div></div></dd></dl> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com1tag:blogger.com,1999:blog-2345113505836037298.post-69490056641583289422011-12-23T07:36:00.001-08:002011-12-23T07:36:34.075-08:00Re: Saludos Navideños<div>y donde estas?</div> <div>con razon que no vas a jugar fulbito</div> <div> cmori<br><br></div> <div class="gmail_quote">El 22 de diciembre de 2011 15:53, Juan Carlos Carril Alvarez <span dir="ltr"><<a href="mailto:carrilalvarezjc@hotmail.com">carrilalvarezjc@hotmail.com</a>></span> escribió:<br> <blockquote style="BORDER-LEFT:#ccc 1px solid;MARGIN:0px 0px 0px 0.8ex;PADDING-LEFT:1ex" class="gmail_quote"> <div> <div dir="ltr">Buenas tardes amigos : en esta oportunidad les envio un fuerte abrazo y saludos por estas fiestas navideñas , espero que lo pasen con mucha felicidad y amor para uds y sus familias y que a pesar de la distancia los llevo muy presente , saludos para el resto de amigos de la Familia Casimirina .<br> Un saludo muy fuerte para uds.<br><font color="#888888"> <br> Juan Carlos Carril Alvarez<br></font></div></div></blockquote></div><br> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-52847803099012949132011-12-19T07:41:00.001-08:002011-12-19T07:41:26.743-08:00vasopresina puede disminuir dosis de NA<a href="http://icmjournal.esicm.org/journal/134/38/1/2407_10.1007_s00134-011-2407-x/2011/Vasopressin_for_treatment_of_vasodilatory_shock_a.pdf.html">http://icmjournal.esicm.org/journal/134/38/1/2407_10.1007_s00134-011-2407-x/2011/Vasopressin_for_treatment_of_vasodilatory_shock_a.pdf.html</a> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-12655029634265057432011-12-19T07:07:00.001-08:002011-12-19T07:07:36.586-08:00fibrilacion auricular Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-35312245983123862522011-12-19T07:05:00.001-08:002011-12-19T07:05:31.788-08:00warfarina<a href="http://circ.ahajournals.org/content/124/23/e652.full.pdf+html">http://circ.ahajournals.org/content/124/23/e652.full.pdf+html</a> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-63469761610497428742011-11-20T13:51:00.001-08:002011-11-20T13:51:47.565-08:00ketorolaco<div class="viewFullArticleAndPdf"> <div class="viewFullArticleAndPdfOptions">digemid HA retirado ketorolaco 60 mg endovenoso no sabemos con que criterios. El asunto es que se recomienda para crisis de migraña siendo muy efectivo y mucho mas barato que los triptanos.Sn embargo en casimiro ulloa hay ketorolaco de 30 mg ev.</div> <div class="viewFullArticleAndPdfOptions">Y que? no puede comprar directamente esterptokinasa en el extranjero</div> <div class="viewFullArticleAndPdfOptions"> cmori</div> <div class="viewFullArticleAndPdfOptions"> </div> <div class="viewFullArticleAndPdfOptions"> </div> <div class="viewFullArticleAndPdfOptions"><a class="viewFullTextLink" title="Link to article fulltext" href="http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2009.01422.x/full" shape="rect">View Full Article (HTML)</a> <a class="pdfLink" title="Article in pdf format" href="http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2009.01422.x/pdf" shape="rect">Get PDF (54K)</a></div> <div class="viewFullArticleAndPdfOptions"> </div> <div class="viewFullArticleAndPdfOptions"> <div class="viewFullArticleAndPdf"> <div class="viewFullArticleAndPdfOptions"><a class="viewFullTextLink" title="Link to article fulltext" href="http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2009.01422.x/full" shape="rect">View Full Article (HTML)</a> <a class="pdfLink" title="Article in pdf format" href="http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4610.2009.01422.x/pdf" shape="rect">Get PDF (54K)</a></div> </div> <div id="fulltext"> <div id="abstract"> <h3 class="firstPageHeading">First page of article</h3> <div class="firstPageContainer"><img style="WIDTH: 752px" alt="First page of 2008: The Year in Review" src="http://onlinelibrary.wiley.com/store/10.1111/j.1526-4610.2009.01422.x/asset/j.1526-4610.2009.01422.x_p1.png?v=1&s=c1eb66dc0c732069af842863e0ba7781b2c1f314"></div> </div></div></div> <div class="viewFullArticleAndPdfOptions"> </div> <div class="viewFullArticleAndPdfOptions"> </div></div> <div id="fulltext"> <div id="abstract"> <h3 class="firstPageHeading">First page of article</h3> <div class="firstPageContainer"><img style="WIDTH: 752px" alt="First page of 2008: The Year in Review" src="http://onlinelibrary.wiley.com/store/10.1111/j.1526-4610.2009.01422.x/asset/j.1526-4610.2009.01422.x_p1.png?v=1&s=c1eb66dc0c732069af842863e0ba7781b2c1f314"></div> </div></div> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-48866547644552246892011-11-12T04:15:00.001-08:002011-11-12T04:42:58.979-08:00no hay estrepto<div dir="ltr" style="text-align: left;" trbidi="on">El TASK FORCE de infarto de miocardio dice que si un infartocon supradesnivel del ST es pequeno se debe usar estreptoquinaza, si es grande alteplase si es extenso o esta shocado el paciente angioplastia. Sin embargo el hospital solo tiene alteplase. Refieren que la esterptokinasa ha sido retirada del mercado?. Acaso el estado no la puede comprar directamente. Acaso solo los ricos se pueden trombolizar. El alteplase esta costando 5000 soles. Y una angioplastia puede llegar a costar hasta 20,000 25,000 dolares</div>Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-6425009794204626172011-11-08T13:27:00.001-08:002011-11-08T13:27:26.574-08:00VI CURSO DE CARDIOLOGIA INTERVENCIONISTA<p><br> </p> <p>VI CURSO INTERNACIONAL DE INTERVENCIONISMO CARDIOVASCULAR</p> <p><br> <br>Organizado por la Sociedad Peruana de Cardiología<br>Sábado 19 de Noviembre de 2011<br>Plaza del Bosque Hotel<br> <br>INSCRIPCION DE CORTESIA</p> <p> </p> <p> </p> <p><br>P R O G R A M A<br> <br>08:45 - 09:00 Inauguración por el Presidente de la Sociedad Peruana de Cardiología<br> Dr. Mario Zubiate <br> <br>MODERADOR Dra. Bertha Gonzáles<br> <br>09:00 -09.30 Inflamación, ateroesclerosis y aterotrombosis <br> Dr. Félix Medina<br> <br>09:30 - 10:00 Terapia coadyuvante en intervencionismo <br> Dr. Aldo Castañeda<br> <br>10:00 – 10:30 Stent medicados y no medicados<br> Dr. Jorge Casana<br> <br>10:30 – 11:00 Intervencionismo periférico<br> Dr. Bernardo Treistman (USA)<br> <br>11:00 – 11:30 Carótidas y circulación intracraneal<br> Dr. Michel Mawad (USA)<br> <br>11:30 – 11:45 Preguntas<br> <br>11:45 – 12:00 Break<br> <br>MODERADOR Dr. Federico Osores<br> <br>12:00 – 12:30 Intervención Percutánea SCASTNE <br>Dr. Ricardo Coloma<br> <br>12:30 – 13:00 Intervención Percutánea SCASTE<br> Dr. Enrique Bustos<br> <br>13:00 – 13:30 Lesiones en bifurcaciones <br> Dr. José Ercilla<br> <br>13:30-15:30 Almuerzo<br> <br> <br>MODERADOR Dr. Plinio Obregón<br> <br>15:30 – 16:00 Intervención Percutánea en Tronco de Coronaria Izquierda <br> Dr. Walter Mogrovejo<br> <br>16.00 -16:30 Intervención en Múltiples vasos<br>Dr. Orestes Salazar<br> <br>16:30 – 17:00 Intervención Coronaria Percutánea Transradial <br> Dr. Luis Mejía<br> <br>17:00 – 17:15 Preguntas<br> <br>17:15 – 17:30 Break<br> <br>MODERADOR Dr. Carlos Sánchez <br> <br>17:30 – 18:00 Infarto Miocárdico en el periprocedimiento y protección <br> de embolismos<br> Dr. César Conde<br> <br>18:00 – 18:30 Intervención en territorios vasculares distales<br> Dr. Rodolfo Rojas<br> <br>18:30 – 18:45 Preguntas<br> <br>18:45 – 19:45 SIMPOSIUM <br> Prótesis valvular aórtica por vía percutánea<br> Dr. <br> <br>19:45 Clausura por el Vocal de Acción Científica<br> Dr. Guillermo Bustamante</p> <p> </p> <p><br>CONFIRMAR ASISTENCIA, SE ADJUNTA FICHA DE INSCRIPCION.</p> <p><br>E-MAIL: <a href="mailto:sopecard@hotmail.com">sopecard@hotmail.com</a> </p> <p><br>TELEFONOS: 4216999 - 4415932<br></p> <div class="gmail_quote">---------- Mensaje reenviado ----------<br>De: <b class="gmail_sendername">Sociedad Peruana de Cardiologia</b> <span dir="ltr"><<a href="mailto:sopecard@hotmail.com">sopecard@hotmail.com</a>></span><br> Fecha: 7 de noviembre de 2011 13:07<br>Asunto: VI CURSO DE CARDIOLOGIA INTERVENCIONISTA<br>Para: Sociedad Peruana de Cardiologia <<a href="mailto:sopecard@hotmail.com">sopecard@hotmail.com</a>><br><br><br> <div> <div dir="ltr"> <div> <div dir="ltr"> <div> <div dir="ltr"> <div> <div dir="ltr"> <div> <div dir="ltr"> <div> <div dir="ltr"> <p style="TEXT-ALIGN: center" align="center"><span lang="ES"><br></span></p> <div style="TEXT-ALIGN: justify"><b style="TEXT-ALIGN: left; FONT-SIZE: 13px"><span style="FONT-FAMILY: 'Bookman Old Style','serif'; FONT-SIZE: 14pt" lang="ES">VI CURSO INTERNACIONAL DE INTERVENCIONISMO CARDIOVASCULAR</span></b></div> <br> <p style="TEXT-ALIGN: center; FONT-SIZE: 10pt" align="center"><b><span style="FONT-FAMILY: 'Bookman Old Style','serif'; FONT-SIZE: 14pt" lang="ES"> </span></b></p> <p style="TEXT-ALIGN: left" align="center"><b><span style="FONT-FAMILY: 'Bookman Old Style', serif" lang="ES">Organizado por la Sociedad Peruana de Cardiología</span></b></p> <p style="TEXT-ALIGN: left" align="center"><b><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES">Sábado 19 de Noviembre de 2011</span></b></p> <p style="TEXT-ALIGN: left; TEXT-INDENT: 36pt; MARGIN-LEFT: 108pt"><span style="FONT-FAMILY: 'Bookman Old Style', serif" lang="ES"><b>Plaza del Bosque Hotel</b><font size="2"></font></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 108pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"> </span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 108pt"><span style="FONT-FAMILY: 'Bookman Old Style', serif" lang="ES"><b><font color="#ff0000">INSCRIPCION DE CORTESIA</font></b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 108pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><br></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 108pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><br></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 108pt; FONT-SIZE: 10pt"><b><u><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><br></span></u></b></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 108pt; FONT-SIZE: 10pt"><b><u><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES">P R O G R A M A</span></u></b></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="MARGIN-LEFT: 106.2pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>08:45 - 09:00 <span style="WHITE-SPACE: pre-wrap"></span>Inauguración por el Presidente de la Sociedad Peruana de Cardiología</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"></span>Dr. Mario Zubiate </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>MODERADOR <span style="WHITE-SPACE: pre-wrap"></span>Dra. Bertha Gonzáles</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>09:00 -09.30<span style="WHITE-SPACE: pre-wrap"> </span>Inflamación, ateroesclerosis y aterotrombosis </b></span></p> <p style="MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"> </span>Dr. Félix Medina</b></span></p> <p style="MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>09:30 - 10:00<span style="WHITE-SPACE: pre-wrap"> </span>Terapia coadyuvante en intervencionismo </b></span></p> <p style="MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"></span>Dr. Aldo Castañeda</b></span></p> <p style="MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>10:00 – 10:30 <span style="WHITE-SPACE: pre-wrap"></span>Stent medicados y no medicados</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"></span>Dr. Jorge Casana</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>10:30 – 11:00 <span style="WHITE-SPACE: pre-wrap"></span>Intervencionismo periférico</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"></span>Dr. Bernardo Treistman (USA)</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>11:00 – 11:30<span style="WHITE-SPACE: pre-wrap"> </span>Carótidas y circulación intracraneal</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"></span>Dr. Michel Mawad (USA)</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>11:30 – 11:45 Preguntas</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>11:45 – 12:00 Break</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>MODERADOR <span style="WHITE-SPACE: pre-wrap"></span>Dr. Federico Osores</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>12:00 – 12:30 <span style="WHITE-SPACE: pre-wrap"></span>Intervención Percutánea SCASTNE </b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b><span style="WHITE-SPACE: pre-wrap"></span>Dr. Ricardo Coloma</b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>12:30 – 13:00<span style="WHITE-SPACE: pre-wrap"> </span><span style="WHITE-SPACE: pre-wrap"></span>Intervención Percutánea SCASTE</b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b><span style="WHITE-SPACE: pre-wrap"></span>Dr. Enrique Bustos</b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>13:00 – 13:30 <span style="WHITE-SPACE: pre-wrap"></span>Lesiones en bifurcaciones </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"></span>Dr. José Ercilla</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>13:30-15:30<span style="WHITE-SPACE: pre-wrap"> </span>Almuerzo</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>MODERADOR <span style="WHITE-SPACE: pre-wrap"></span>Dr. Plinio Obregón</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="MARGIN-LEFT: 108pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>15:30 – 16:00 <span style="WHITE-SPACE: pre-wrap"></span>Intervención Percutánea en Tronco de Coronaria Izquierda </b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b><span style="WHITE-SPACE: pre-wrap"></span>Dr. Walter Mogrovejo</b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>16.00 -16:30<span style="WHITE-SPACE: pre-wrap"> </span>Intervención en Múltiples vasos</b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b><span style="WHITE-SPACE: pre-wrap"></span>Dr. Orestes Salazar</b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>16:30 – 17:00<span style="WHITE-SPACE: pre-wrap"> </span><span style="WHITE-SPACE: pre-wrap"></span>Intervención Coronaria Percutánea Transradial </b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"> </span>Dr. Luis Mejía</b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>17:00 – 17:15<span style="WHITE-SPACE: pre-wrap"> </span><span style="WHITE-SPACE: pre-wrap"></span>Preguntas</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>17:15 – 17:30 <span style="WHITE-SPACE: pre-wrap"></span>Break</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>MODERADOR <span style="WHITE-SPACE: pre-wrap"></span>Dr. Carlos Sánchez <a name="1337f36f9b1218cd__GoBack"></a></b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>17:30 – 18:00<span style="WHITE-SPACE: pre-wrap"> </span>Infarto Miocárdico en el periprocedimiento y protección </b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"></span>de embolismos</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"></span>Dr. César Conde</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>18:00 – 18:30<span style="WHITE-SPACE: pre-wrap"> </span>Intervención en territorios vasculares distales</b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"> </span>Dr. Rodolfo Rojas</b></span></p> <p style="TEXT-INDENT: 36pt; MARGIN-LEFT: 72pt; FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>18:30 – 18:45<span style="WHITE-SPACE: pre-wrap"> </span>Preguntas</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b>18:45 – 19:45<span style="WHITE-SPACE: pre-wrap"> </span>SIMPOSIUM </b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"> </span>Prótesis valvular aórtica por vía percutánea</b></span></p> <p style="FONT-SIZE: 10pt"><span lang="ES"><b> <span style="WHITE-SPACE: pre-wrap"></span> Dr. </b></span></p> <p style="FONT-SIZE: 10pt"><span lang="ES"><b> </b></span></p> <p style="FONT-SIZE: 10pt"><b><span lang="ES">19:45 <span style="WHITE-SPACE: pre-wrap"> </span></span><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES">Clausura por el Vocal de Acción Científica</span></b></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b><span style="WHITE-SPACE: pre-wrap"></span> Dr. Guillermo Bustamante</b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b><br></b></span></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b><br></b></span></p> <p><font color="#1f497d" face="'Bookman Old Style', serif"><b>CONFIRMAR ASISTENCIA, SE ADJUNTA FICHA DE INSCRIPCION.</b></font></p> <p><font color="#1f497d" face="'Bookman Old Style', serif"><b><br></b></font></p> <p><font color="#1f497d" face="'Bookman Old Style', serif"><b>E-MAIL: <a href="mailto:sopecard@hotmail.com" target="_blank">sopecard@hotmail.com</a> </b></font></p> <p><font color="#1f497d" face="'Bookman Old Style', serif"><b><br></b></font></p> <p><font color="#1f497d" face="'Bookman Old Style', serif"><b>TELEFONOS: 4216999 - 4415932</b></font></p> <p style="FONT-SIZE: 10pt"><font face="'Bookman Old Style', serif"><b><br></b></font></p> <p style="FONT-SIZE: 10pt"><font face="'Bookman Old Style', serif"><b><br></b></font></p> <p style="FONT-SIZE: 10pt"><font face="'Bookman Old Style', serif"><b><br></b></font></p> <p style="FONT-SIZE: 10pt"><font face="'Bookman Old Style', serif"><b><br></b></font></p> <p style="FONT-SIZE: 10pt"><span style="FONT-FAMILY: 'Bookman Old Style','serif'" lang="ES"><b><br></b></span></p><br></div></div></div></div></div></div></div></div></div></div></div></div></div><br> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-91469885280707834302011-10-30T10:00:00.001-07:002011-10-30T10:00:12.461-07:00Pediatrics in Review & NeoReviews all 2011 issues<h1 id="firstHeading" class="firstHeading">Soplo cardiaco</h1> <div id="bodyContent"> <div id="siteSub">De Wikipedia, la enciclopedia libre</div> <div id="contentSub"></div> <div id="jump-to-nav">Saltar a: <a href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#mw-head">navegación</a>, <a href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#p-search">búsqueda</a> </div> <div dir="ltr" lang="es" class="mw-content-ltr"> <p>Los <b>soplos cardiacos</b> (o <b>soplos del corazón</b>) son ruidos patológicos que se perciben a la <a title="Auscultación" href="https://mail.google.com/wiki/Auscultaci%C3%B3n">auscultación</a> con el uso del <a title="Estetoscopio" href="https://mail.google.com/wiki/Estetoscopio">estetoscopio</a> y se originan por aumento de flujo a través de una <a title="Válvula cardiaca" href="https://mail.google.com/wiki/V%C3%A1lvula_cardiaca">válvula cardiaca</a> normal, por alteraciones de dichas válvulas (<a title="Estenosis" href="https://mail.google.com/wiki/Estenosis">estenosis</a>, insuficiencia, doble lesión), por ciertas anomalías intracardiacas (comunicación interventricular) o extracardiacas (estenosis arteriales, ductus arterioso persistente, <a title="Fístula arteriovenosa" href="https://mail.google.com/wiki/F%C3%ADstula_arteriovenosa">fístulas arteriovenosas</a>).</p> <table id="toc" class="toc"> <tbody> <tr> <td> <div id="toctitle"> <h2>Contenido</h2></div> <ul> <li class="toclevel-1 tocsection-1"><a href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#Clasificaci.C3.B3n"><span class="tocnumber">1</span> <span class="toctext">Clasificación</span></a></li> <li class="toclevel-1 tocsection-2"><a href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#Clasificaci.C3.B3n_seg.C3.BAn_intensidad"><span class="tocnumber">2</span> <span class="toctext">Clasificación según intensidad</span></a></li> <li class="toclevel-1 tocsection-3"><a href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#V.C3.A9ase_tambi.C3.A9n"><span class="tocnumber">3</span> <span class="toctext">Véase también</span></a></li> <li class="toclevel-1 tocsection-4"><a href="https://mail.google.com/mail/html/compose/static_files/blank_quirks.html#Enlaces_externos"><span class="tocnumber">4</span> <span class="toctext">Enlaces externos</span></a></li> </ul></td></tr></tbody></table> <h2><span class="editsection">[<a title="Editar sección: Clasificación" href="https://mail.google.com/w/index.php?title=Soplo_cardiaco&action=edit&section=1">editar</a>]</span> <span id="Clasificaci.C3.B3n" class="mw-headline">Clasificación</span></h2> <div class="thumb tright"> <div style="WIDTH: 222px" class="thumbinner"><a class="image" href="https://mail.google.com/wiki/Archivo:Phonocardiograms_from_normal_and_abnormal_heart_sounds.png"><img class="thumbimage" alt="" src="https://upload.wikimedia.org/wikipedia/commons/thumb/4/4a/Phonocardiograms_from_normal_and_abnormal_heart_sounds.png/220px-Phonocardiograms_from_normal_and_abnormal_heart_sounds.png" width="220" height="299"></a> <div class="thumbcaption"> <div class="magnify"><a class="internal" title="Aumentar" href="https://mail.google.com/wiki/Archivo:Phonocardiograms_from_normal_and_abnormal_heart_sounds.png"><img alt="" src="https://bits.wikimedia.org/skins-1.18/common/images/magnify-clip.png" width="15" height="11"></a></div> Auscultograma con sonidos normales y anormales</div></div></div> <p>Los soplos pueden ser clasificados por 7 diferentes características: Tiempo, forma, posición, irradiación, intensidad, calidad y tono.</p> <ul> <li>El tiempo se refiere a si es sistólico o diastólico.</li> <li>La forma se refiere al patrón de intensidad que tiene el soplo. Puede ser, constante, en crescendo, decrescendo o una mezcla de estos dos últimos.</li> <li>La localización se refiere al lugar en donde el soplo tiene su mayor intensidad. Existen 6 lugares de auscultación en la cara anterior del tórax: <ul> <li>Segundo espacio intercostal derecho</li> <li>Segundo a quinto espacio intercostal izquierdo</li> <li>Quinto espacio intercostal en línea medioclavicular izquierdo.</li></ul></li> <li>La irradiación se refiere al lugar hacia donde el soplo se irradia. En general, el sonido se irradia siguiendo la dirección del flujo sanguíneo.</li> <li>La intensidad se refiere a la potencia del sonido, el cual va de 0 a 6 (se escribe con números romanos Ejemplo: II/VI)</li> <li>El tono puede variar según sea bajo o alto</li> <li>La calidad se refiere a las características especiales que pueda tener cada soplo (por ejemplo, musical, en rodada, soplante etc...)</li></ul> <h2><span class="editsection">[<a title="Editar sección: Clasificación según intensidad" href="https://mail.google.com/w/index.php?title=Soplo_cardiaco&action=edit&section=2">editar</a>]</span> <span id="Clasificaci.C3.B3n_seg.C3.BAn_intensidad" class="mw-headline">Clasificación según intensidad</span></h2> <table class="wikitable"> <tbody> <tr> <th><b>Grading of Murmurs</b><span class="reference"><sup id="ref_Abnormal_sounds" class="plainlinksneverexpand"><a class="external autonumber" href="https://es.wikipedia.org/wiki/Soplo_cardiaco#notapie_Abnormal_sounds" rel="nofollow"><font size="2">[1]</font></a></sup></span> <span style="COLOR: red; FONT-SIZE: 85%">La plantilla <tt>{{<a title="Plantilla:Ref" href="https://mail.google.com/wiki/Plantilla:Ref">ref</a>}}</tt> está obsoleta, véase el <a title="Wikipedia:Referencias" href="https://mail.google.com/wiki/Wikipedia:Referencias#Referencias_bibliogr.C3.A1ficas">nuevo sistema de referencias</a>.</span></th> </tr> <tr> <td><b>Grado</b></td> <td><b>Descripción</b></td></tr> <tr> <td>Grado 1</td> <td>Muy tenue</td></tr> <tr> <td>Grado 2</td> <td>Suave</td></tr> <tr> <td>Grado 3</td> <td>Audible en todo la región precordial</td></tr> <tr> <td>Grado 4</td> <td>Ruidoso, con frémito palpable</td></tr> <tr> <td>Grado 5</td> <td>Muy ruidoso, con frémito palpable. Puede ser escuchado con el estetoscopio alejado de la piel.</td></tr> <tr> <td>Grado 6</td> <td>Muy ruidoso, con frémito palpable. Puede ser audible con el estetoscopio totalmente alejado del pecho del paciente.</td></tr></tbody></table> <p><br></p> <h2><span class="editsection">[<a title="Editar sección: Véase también" href="https://mail.google.com/w/index.php?title=Soplo_cardiaco&action=edit&section=3">editar</a>]</span> <span id="V.C3.A9ase_tambi.C3.A9n" class="mw-headline">Véase también</span></h2> <br><br></div></div> <div class="gmail_quote">---------- Forwarded message ----------<br>From: <b class="gmail_sendername">Edwin Villacorta</b> <span dir="ltr"><<a href="mailto:evillitaz@yahoo.com">evillitaz@yahoo.com</a>></span><br>Date: 2011/10/29<br> Subject: [SALUD_LORETO] Rv: [medicpass] Pediatrics in Review & NeoReviews all 2011 issues<br>To: Salud Loreto <<a href="mailto:salud_loreto@yahoogroups.com">salud_loreto@yahoogroups.com</a>><br><br><br><u></u> <div style="BACKGROUND-COLOR: #fff"><span> </span> <div> <div> <div> <p></p> <table border="0" cellspacing="0" cellpadding="0"> <tbody> <tr> <td valign="top"><br><br> <div style="COLOR: rgb(255,0,127)"><strong>Edwin Villacorta Vigo</strong></div> <div style="COLOR: rgb(0,0,191); FONT-WEIGHT: bold"><font size="2">MEDICO PEDIATRA<br><br></font><font color="#bf00bf"><strong>MIS VIDEOS EN YOUTUBE<br><a href="http://www.youtube.com/evillitaz#p/u" rel="nofollow" target="_blank">http://www.youtube.com/evillitaz#p/u</a></strong></font><br> <br><a href="http://www.youtube.com/results?search_query=evillitaz123&aq=f" rel="nofollow" target="_blank">http://www.youtube.com/results?search_query=evillitaz123&aq=f</a><br></div> <div> </div> <div><font color="#bf00bf"><strong>Mis galerias de FOTOS <br></strong></font><a style="FONT-WEIGHT: bold" href="http://facebook.com/evillitaz" rel="nofollow" target="_blank"><font size="4">http://facebook.com/evillitaz</font></a><br> <font color="#bf00bf"><strong><a href="http://evillitaz.hi5.com/" rel="nofollow" target="_blank">http://evillitaz.hi5.com</a><br><a href="http://www.youtube.com/evillitaz#p/u" rel="nofollow" target="_blank"></a></strong></font><br> <a href="http://es.groups.yahoo.com/group/SALUD_LORETO/" rel="nofollow" target="_blank">MIEMBRO DE <strong style="COLOR: rgb(0,127,127)">SALUD LORETO</strong></a> <br></div> <div><a href="http://es.groups.yahoo.com/group/SALUD_LORETO/" rel="nofollow" target="_blank">http://es.groups.yahoo.com/group/SALUD_LORETO/</a></div><br><br>--- El <b>sáb, 10/29/11, tamer ibrahim <i><<a href="mailto:drtameribrahim@gmail.com" target="_blank">drtameribrahim@gmail.com</a>></i></b> escribió:<br> <blockquote style="BORDER-LEFT: rgb(16,16,255) 2px solid"><br> <div> <div dir="ltr"> <p><font color="#ff00ff" size="4" face="comic sans ms"><strong>NeoReviews</strong></font></p> <p><font color="#ff00ff" size="4" face="comic sans ms"><strong>Pediatrics in Review</strong></font></p> <p><font size="3" face="comic sans ms"><strong> <font style="BACKGROUND-COLOR: #ffff80" color="#ff007f">all 2011 issues</font></strong></font></p> <p><font face="comic sans ms"></font> </p> <p><font style="BACKGROUND-COLOR: #ffff40" color="#ff007f" size="4" face="comic sans ms"><u><strong>Download from our sharing folder:</strong></u></font></p> <p><a href="http://neoreviews.4shared.com/" rel="nofollow" target="_blank"><font face="comic sans ms">http://NeoReviews.4shared.com/</font></a></p> <p><a href="http://pediatricsinreview.4shared.com/" rel="nofollow" target="_blank"><font face="comic sans ms">http://PediatricsInReview.4shared.com/</font></a></p></div> <p></p>-- <br><br><a href="http://groups-beta.google.com/group/medicpass" rel="nofollow" target="_blank"></a></div></blockquote></td></tr></tbody></table> <p></p></div></div></div></div></div> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-60112076383012310122011-10-30T08:29:00.001-07:002011-11-03T12:29:27.274-07:00no mires la paja en el ojo ajeno cuando tienes la viga en el tuyo<div dir="ltr" style="text-align: left;" trbidi="on"><div style="text-align: justify;"><span style="font-size: medium;">es un rasgo del ser humano ver en los demas los errores o defectos que no ve en el mismo. O reconocer defectos en los demas que no ve en si mismo. El corrupto llama corrupto al corrupto. El escapero de la guardia llama escapero al otro escapero. El que no esta capacitado llama incapacitado al otro incapacitado. El impuntual llama impuntual al otro impuntual. Cree que porque guarda las apariencias no es como el otro. No importa si te portas bien en realidad. Lo que importa es aparentar que lo haces, ser solapa. Es pegado al pie de la letra con las reglas pero solo cuando le conviene. Solo para aparentar para enganar a los demas que lo es o para enganarse a si mismo que lo es. Cuando sus amigos cometen faltas graves se sale y viola las normas. Ahi no es pegado a las reglas. Doble moral. Honestidad de barro.En algunos casos la inclinacion a ver errores en los demas que uno tambien tiene es obsesiva alcanzando el nivel neurotico. Cuando alguien con estas caracteristicas tiene poder delegado por alguna institucion se generan muchos problemas. El tiene problemas para ser un lider. Y las instituciones sin lideres tendran problemas. Todos tenemos afan de reconocimiento. Dicen que eso es mas fuerte que el hambre o el deseo de libertad. Por eso florecen los nacionalismos sobre todo en sociedades con individuos no individualistas. </span></div><div style="text-align: justify;"><span style="font-size: medium;">El critica y sanciona al que llega tarde pero el se escapa de la guardia. Es muy peruano, el cree que tiene privilegios, que esta por encima de las reglas pero no los demas. O protege a sus amigos que lo hacen. O protege a sus amigos que cometen graves faltas de negligencia que le cuestan la vida a personas. Al mismo tiempo te critica cuando tu cometes una negligencia que no le cuesta la vida a nadie. Por supuesto que en ambos casos no hay disculpa. Te critica y raja de ti porque llegas tarde. Pero el llega cochino al hospital impresentable. Por supuesto que ambos casos no tienen disculpa.</span></div><div style="text-align: justify;"><span style="font-size: medium;">Te critica porque llegas tarde pero el es un medico parasito. Siempre esta buscando que lo programen en areas de poco trabajo o poco stress. Siempre esta buscando diluir sus responsabilidades trabajar menos lo menos posible comprometiendo en sus propias responsabilidades a otros medicos cuando el podria y debiera resolver sus problemas solo. Te critica cuando tu cometes un error medico pero el nunca hace nada para no cometer errores. El continuamente comete errores por omision que a veces cuestan vidas pero el no lo ve o no quiere verlo. Total en Peru no existen auditorias de nada para que preocuparse. A veces llega al nivel sociopatico cinico de creer que los demas no se dan cuenta de como es o como actua. El cree que porque los demas son educados y lo sobrellevan no se dan cuenta. Claro este ya es otro nivel, el nivel sociopatico. El nivel del cinico del manipulador, del que trata de matarte moralmente porque es demasiado cobarde para hacerlo fisicamente.</span></div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;"><br />
</div><div style="text-align: justify;"><span style="font-size: medium;">cmori</span></div></div>Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-10675658233720315092011-10-26T13:11:00.000-07:002011-10-26T13:11:40.355-07:00ENSAYOS Y MAS ENSAYOS Y OTROS: mi desorden favorito:TDAH - trastorno por déficit ...<a href="http://ensayyyyo.blogspot.com/2011/10/mi-desorden-favoritotdah-trastorno-por.html?spref=bl">ENSAYOS Y MAS ENSAYOS Y OTROS: mi desorden favorito:TDAH - trastorno por déficit ...</a>: [Más abajo se incluyen archivos adjuntos de =?iso-8859-1?Q?M=E1ximo_Cuadros?=] Clinical Practice Guideline for the Diagnosis, Evalu...Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-8005086416591950112011-10-04T14:37:00.001-07:002011-10-04T14:37:32.787-07:00Revisan el Tratamiento de Control del Asma en los Niños [Archivo adjunto 1]<p>[Más abajo se incluyen archivos adjuntos de johnny sandoval garay]<br> <br>Adjunto revisión original<br> Atentamente<br> Johny Sandoval Garay<br> Pediatra<br> RNE 21209</p> <p><br>----- Mensaje reenviado -----<br>De: "<a href="mailto:wolfmdped@yahoo.com">wolfmdped@yahoo.com</a>" <<a href="mailto:wolfmdped@yahoo.com">wolfmdped@yahoo.com</a>><br>Para: Salud Loreto <<a href="mailto:SALUD_LORETO@yahoogroups.com">SALUD_LORETO@yahoogroups.com</a>><br> Enviado: martes 4 de octubre de 2011 14:54<br>Asunto: [SALUD_LORETO] Revisan el Tratamiento de Control del Asma en los Niños</p> <p><br> <br>Saludos amigos,</p> <p><a href="http://www.bago.com/BagoArg/Biblio/pediatweb581.htm">http://www.bago.com/BagoArg/Biblio/pediatweb581.htm</a></p> <p>Enviado desde mi BlackBerry de Claro.</p> <p> </p> <p> </p> <p>__._,_.___<br>Archivos adjuntos de johnny sandoval garay<br>Archivo 1 de 1 <br> Pediatric_Asthma_Controller_Therapy.2.pdf<br><br></p> <div class="gmail_quote">---------- Mensaje reenviado ----------<br>De: <b class="gmail_sendername">johnny sandoval garay</b> <span dir="ltr"><<a href="mailto:johnysanga@yahoo.es">johnysanga@yahoo.es</a>></span><br> Fecha: 4 de octubre de 2011 15:52<br>Asunto: Rv: [SALUD_LORETO] Revisan el Tratamiento de Control del Asma en los Niños [Archivo adjunto 1]<br>Para: salud loreto <<a href="mailto:Salud_loreto@yahoogroups.com">Salud_loreto@yahoogroups.com</a>>, Pediatras <<a href="mailto:PEDIATRIA_PERU@yahoogroups.com">PEDIATRIA_PERU@yahoogroups.com</a>>, ramirez felix mechato <<a href="mailto:beto1355@hotmail.com">beto1355@hotmail.com</a>>, Huanca David <<a href="mailto:dhuancap@gmail.com">dhuancap@gmail.com</a>>, Santos Aida Saby Borcic <<a href="mailto:aidaborcic@hotmail.com">aidaborcic@hotmail.com</a>>, Roncal Marco <<a href="mailto:antonioroncal@yahoo.com">antonioroncal@yahoo.com</a>>, Calle Carlos Enrique Checa <<a href="mailto:drcarloscheca@yahoo.es">drcarloscheca@yahoo.es</a>>, Flores Vigo Admer <<a href="mailto:aflovi100@gmail.com">aflovi100@gmail.com</a>>, Valera Lazo Tomas <<a href="mailto:tomasvalera25@hotmail.com">tomasvalera25@hotmail.com</a>>, Pardo Marìa <<a href="mailto:maripardo74@hotmail.com">maripardo74@hotmail.com</a>>, Roncal Marco <<a href="mailto:marcoroncal@yahoo.es">marcoroncal@yahoo.es</a>>, Rojas David <<a href="mailto:darogue1111@yahoo.es">darogue1111@yahoo.es</a>>, Vite Juarez Nora <<a href="mailto:noravitejuarez@hotmail.com">noravitejuarez@hotmail.com</a>>, Martinez Delgado Humberto <<a href="mailto:beto1244@hotmail.com">beto1244@hotmail.com</a>>, OMAR JHON <<a href="mailto:jhomgavi11@hotmail.com">jhomgavi11@hotmail.com</a>>, Guffanti Giancarlo <<a href="mailto:gjguffantia@hotmail.com">gjguffantia@hotmail.com</a>>, Contreras Carreño Jose julian <<a href="mailto:pepeju8@hotmail.com">pepeju8@hotmail.com</a>>, prado julio <<a href="mailto:juliopradoa.q.p@hotmail.com">juliopradoa.q.p@hotmail.com</a>>, gonzalesS luis <<a href="mailto:Lgdlav@yahoo.com">Lgdlav@yahoo.com</a>>, gonzales luis <<a href="mailto:lgdlav@yahoo.com">lgdlav@yahoo.com</a>>, Baltazar Luis <<a href="mailto:luisbar2000@hotmail.com">luisbar2000@hotmail.com</a>>, flores nube <<a href="mailto:nubeflores@hotmail.com">nubeflores@hotmail.com</a>>, "<a href="mailto:carmen.armas@hotmail.com">carmen.armas@hotmail.com</a>" <<a href="mailto:carmen.armas@hotmail.com">carmen.armas@hotmail.com</a>>, LAVI ROSARIO REATEGUI <<a href="mailto:charlav3@hotmail.com">charlav3@hotmail.com</a>>, Millones LLorca Luz Melina <<a href="mailto:sheccid_224@hotmail.com">sheccid_224@hotmail.com</a>>, more clara <<a href="mailto:cl_more@hotmail.com">cl_more@hotmail.com</a>>, Fernandez Loperz Graciela Angela <<a href="mailto:graciela_enf@hotmail.com">graciela_enf@hotmail.com</a>>, Cordova Dersy <<a href="mailto:dersy160975@hotmail.com">dersy160975@hotmail.com</a>>, Calderon Patricia <<a href="mailto:recalmen_40@hotmail.com">recalmen_40@hotmail.com</a>>, Maribel <<a href="mailto:rosamari78@hotmail.com">rosamari78@hotmail.com</a>>, Alcedo Mariella <<a href="mailto:ela_ac@hotmail.com">ela_ac@hotmail.com</a>>, Susana <<a href="mailto:susan1180@hotmail.com">susan1180@hotmail.com</a>>, Bertha <<a href="mailto:enferberlu_2@hotmail.com">enferberlu_2@hotmail.com</a>>, Dioselinda <<a href="mailto:yossy882@hotmail.com">yossy882@hotmail.com</a>>, Chapoñan Claudia <<a href="mailto:sagi18_73@hotmail.com">sagi18_73@hotmail.com</a>>, Sarita <<a href="mailto:saritac19@hotmail.com">saritac19@hotmail.com</a>>, Rubio Rubio Sonia <<a href="mailto:soniarubiorubio@yahoo.com">soniarubiorubio@yahoo.com</a>>, Lorena <<a href="mailto:loemi01@hotmail.com">loemi01@hotmail.com</a>>, Simbaña Rivera Aurora <<a href="mailto:asir755@hotmail.com">asir755@hotmail.com</a>>, ITURRIA Deysi <<a href="mailto:empera_2010@hotmail.com">empera_2010@hotmail.com</a>>, Tecnica Rosa <<a href="mailto:rosa_rpv55@hotmail.com">rosa_rpv55@hotmail.com</a>>, Briceño Infante Cecilia Elvira <<a href="mailto:miel_y_jazmin@hotmail.com">miel_y_jazmin@hotmail.com</a>>, Pouicon Roxana <<a href="mailto:roxy312@hotmail.com">roxy312@hotmail.com</a>>, "<a href="mailto:tatiaagu@hotmail.com">tatiaagu@hotmail.com</a>" <<a href="mailto:tatiaagu@hotmail.com">tatiaagu@hotmail.com</a>><br> <br><br><u></u> <div style="BACKGROUND-COLOR: #fff"><span> </span> <div> <div> <div><span style="DISPLAY: block; MARGIN-BOTTOM: 20px; FONT-SIZE: 12px; FONT-WEIGHT: 700">[Más abajo se incluyen <a style="TEXT-DECORATION: none" href="https://mail.google.com/mail/?ui=2&view=js&name=main,tlist&ver=Om3Gq9PGwPQ.es.&am=!UWhoknh25chVJL3uu6i3Qkn-U3fZ21s7hK5KfkGhrpUhaod_QAG7lAigYd6Vz0zo#132d0b56415337a6_TopText">archivos adjuntos</a> de johnny sandoval garay]</span> <p> <div style="BACKGROUND-COLOR: #fff; FONT-FAMILY: times new roman, new york, times, serif; COLOR: #000; FONT-SIZE: 12pt"> <div><span>Adjunto revisión original</span></div> <div><span> Atentamente</span></div> <div><span> Johny Sandoval Garay</span></div> <div><span> Pediatra</span></div> <div><span> RNE 21209</span></div> <div><br></div> <div style="FONT-FAMILY: times new roman, new york, times, serif; FONT-SIZE: 12pt"> <div style="FONT-FAMILY: times new roman, new york, times, serif; FONT-SIZE: 12pt"><font size="2" face="Arial">----- Mensaje reenviado -----<br><b><span style="FONT-WEIGHT: bold">De:</span></b> "<a href="mailto:wolfmdped@yahoo.com" target="_blank">wolfmdped@yahoo.com</a>" <<a href="mailto:wolfmdped@yahoo.com" target="_blank">wolfmdped@yahoo.com</a>><br> <b><span style="FONT-WEIGHT: bold">Para:</span></b> Salud Loreto <<a href="mailto:SALUD_LORETO@yahoogroups.com" target="_blank">SALUD_LORETO@yahoogroups.com</a>><br><b><span style="FONT-WEIGHT: bold">Enviado:</span></b> martes 4 de octubre de 2011 14:54<br> <b><span style="FONT-WEIGHT: bold">Asunto:</span></b> [SALUD_LORETO] Revisan el Tratamiento de Control del Asma en los Niños<br></font><br> <div><span> </span> <div> <div>Saludos amigos,<br><br><a href="http://www.bago.com/BagoArg/Biblio/pediatweb581.htm" rel="nofollow" target="_blank">http://www.bago.com/BagoArg/Biblio/pediatweb581.htm</a><br><br>Enviado desde mi BlackBerry de Claro.<br> <br></div></div></div><br><br></div></div></div> <p></p></p></div> <div style="MIN-HEIGHT: 0px; COLOR: #fff">__._,_.___</div><a name="132d0b56415337a6_TopText"> <p style="PADDING-BOTTOM: 3px; MARGIN: 0px; PADDING-LEFT: 0px; PADDING-RIGHT: 0px; CLEAR: both; PADDING-TOP: 0px"><span style="COLOR: #628c2a; FONT-SIZE: 13px; FONT-WEIGHT: 700">Archivos adjuntos de johnny sandoval garay</span></p> </a> <p style="PADDING-BOTTOM: 0px; MARGIN: 0px 0px 2px; PADDING-LEFT: 0px; PADDING-RIGHT: 0px; PADDING-TOP: 10px"><span style="COLOR: #628c2a; FONT-WEIGHT: 700">Archivo 1 de 1 </span></p> <div> <div style="MARGIN: 2px 0px; WHITE-SPACE: nowrap; FLOAT: left; CLEAR: both"> <div><img style="VERTICAL-ALIGN: middle; MARGIN-RIGHT: 5px"> <a style="TEXT-DECORATION: none" title="Pediatric_Asthma_Controller_Therapy.2.pdf" href="http://xa.yimg.com/kq/groups/17358357/640473124/name/Pediatric_Asthma_Controller_Therapy.2.pdf" target="_blank">Pediatric_Asthma_Controller_Therapy.2.pdf</a></div> </div></div> <div style="WHITE-SPACE: nowrap; MARGIN-BOTTOM: 10px; COLOR: #666; CLEAR: both; PADDING-TOP: 15px"> </div></div></div></div></div> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-84175561357384136072011-09-26T10:26:00.001-07:002011-09-26T10:26:43.806-07:00Guías salud mental MINSA-PERU<br>Maximo Cuadros Chavez posted in cibermedicos.<br>Maximo Cuadros Chavez12:02pm Sep 26 <br>Guías salud mental MINSA-PERU<br><a href="http://www.minsa.gob.pe/portada/est_san/saludmental.htm">http://www.minsa.gob.pe/portada/est_san/saludmental.htm</a><br> Enviado desde mi BlackBerry de Movistar<br> <div class="gmail_quote">---------- Mensaje reenviado ----------<br>De: <b class="gmail_sendername">Maximo Cuadros Chavez</b> <span dir="ltr"><<a href="mailto:notification%2Byfo6tzj9@facebookmail.com">notification+yfo6tzj9@facebookmail.com</a>></span><br> Fecha: 26 de septiembre de 2011 12:02<br>Asunto: [cibermedicos] Guías salud mental MINSA-PERU<br>Para: cibermedicos <<a href="mailto:internetymedicos@groups.facebook.com">internetymedicos@groups.facebook.com</a>><br> <br><br><u></u> <div style="PADDING-BOTTOM: 0px; MARGIN: 0px; PADDING-LEFT: 0px; PADDING-RIGHT: 0px; PADDING-TOP: 0px" dir="ltr"> <table border="0" cellspacing="0" cellpadding="8" width="98%"> <tbody> <tr> <td style="FONT-FAMILY: 'lucida grande',tahoma,verdana,arial,sans-serif" bgcolor="#ffffff" width="100%"> <table border="0" cellspacing="0" cellpadding="0" width="500"> <tbody> <tr> <td style="PADDING-BOTTOM: 0px; PADDING-LEFT: 10px; PADDING-RIGHT: 0px; FONT-FAMILY: 'lucida grande',tahoma,verdana,arial,sans-serif; COLOR: #000000; FONT-SIZE: 11px; PADDING-TOP: 10px" valign="top" colspan="2"> <table style="COLOR: #000000; FONT-SIZE: 11px" width="100%"> <tbody> <tr> <td style="FONT-FAMILY: 'lucida grande',tahoma,verdana,arial,sans-serif; COLOR: #000000; FONT-SIZE: 11px" valign="top" width="100%" align="left"> <div style="BORDER-BOTTOM: #e9e9e9 1px solid; PADDING-BOTTOM: 7px; PADDING-LEFT: 0px; WIDTH: 100%; PADDING-RIGHT: 0px; COLOR: #666666; PADDING-TOP: 0px">Maximo Cuadros Chavez <a style="COLOR: #3b5998; TEXT-DECORATION: underline" href="http://www.facebook.com/n/?groups%2Finternetymedicos%2F&id=232366363466498&mid=4eaad5bG5ae37904G2c38d61G96&bcode=nwBazsHy&n_m=clagui57%40gmail.com" target="_blank">posted in cibermedicos</a>.</div> <div style="MARGIN-BOTTOM: 15px"> <table style="WIDTH: 100%; PADDING-TOP: 7px" cellspacing="0" cellpadding="0"> <tbody> <tr> <td style="PADDING-BOTTOM: 5px; PADDING-LEFT: 0px; WIDTH: 57px; PADDING-RIGHT: 5px; PADDING-TOP: 3px" valign="top"><a style="COLOR: #3b5998; TEXT-DECORATION: none" href="http://www.facebook.com/n/?profile.php&id=100001101314342&mid=4eaad5bG5ae37904G2c38d61G96&bcode=nwBazsHy&n_m=clagui57%40gmail.com" target="_blank"><img style="BORDER-BOTTOM: 0px; BORDER-LEFT: 0px; MIN-HEIGHT: 50px; WIDTH: 50px; BORDER-TOP: 0px; BORDER-RIGHT: 0px" alt="Guías salud mental MINSA-PERU..." src="http://profile.ak.fbcdn.net/hprofile-ak-snc4/27419_100001101314342_6017_q.jpg"></a></td> <td style="PADDING-BOTTOM: 5px; PADDING-LEFT: 0px; PADDING-RIGHT: 5px; FONT-FAMILY: 'lucida grande',tahoma,verdana,arial,sans-serif; PADDING-TOP: 5px" valign="top" align="left"> <table style="PADDING-BOTTOM: 5px; WIDTH: 100%" cellspacing="0" cellpadding="0"> <tbody> <tr> <td style="FONT-FAMILY: 'lucida grande',tahoma,verdana,arial,sans-serif; COLOR: #000000; FONT-SIZE: 11px"><a style="COLOR: #3b5998; FONT-WEIGHT: bold; TEXT-DECORATION: none" href="http://www.facebook.com/n/?profile.php&id=100001101314342&mid=4eaad5bG5ae37904G2c38d61G96&bcode=nwBazsHy&n_m=clagui57%40gmail.com" target="_blank">Maximo Cuadros Chavez</a></td> <td style="TEXT-ALIGN: right; PADDING-RIGHT: 5px; FONT-FAMILY: 'lucida grande',tahoma,verdana,arial,sans-serif; COLOR: #999999; FONT-SIZE: 11px">12:02pm Sep 26 </td></tr></tbody></table> <div style="PADDING-BOTTOM: 7px; WIDTH: 458px; WORD-WRAP: break-word; COLOR: #000000; FONT-SIZE: 11px">Guías salud mental MINSA-PERU<br><a style="COLOR: #3b5998; TEXT-DECORATION: none" href="http://www.facebook.com/l/NAQAzMSyn/www.minsa.gob.pe/portada/est_san/saludmental.htm" target="_blank">http://www.minsa.gob.pe/portada/est_san/saludmental.htm</a><br> Enviado desde mi BlackBerry de Movistar</div></td></tr></tbody></table></div></td></tr></tbody></table><span><img style="BORDER-BOTTOM: 0px; BORDER-LEFT: 0px; MIN-HEIGHT: 1px; WIDTH: 1px; BORDER-TOP: 0px; BORDER-RIGHT: 0px" src="http://www.facebook.com/email_open_log_pic.php?mid=4eaad5bG5ae37904G2c38d61G96"><u></u></span><br> </td></tr> <tr> <td style="PADDING-BOTTOM: 15px; LINE-HEIGHT: 18px; PADDING-LEFT: 10px; PADDING-RIGHT: 5px; FONT-FAMILY: 'lucida grande',tahoma,verdana,arial,sans-serif; COLOR: #666666; FONT-SIZE: 12px; BORDER-TOP: #e9e9e9 1px solid; PADDING-TOP: 10px" colspan="2"> <a style="COLOR: #3b5998; TEXT-DECORATION: none" href="http://www.facebook.com/n/?groups%2Finternetymedicos%2F&id=232366363466498&mid=4eaad5bG5ae37904G2c38d61G96&bcode=nwBazsHy&n_m=clagui57%40gmail.com" target="_blank">View Post on Facebook</a> · <a style="COLOR: #3b5998; TEXT-DECORATION: none" href="http://www.facebook.com/n/?groups%2Finternetymedicos%2F&view=notifications&mid=4eaad5bG5ae37904G2c38d61G96&bcode=nwBazsHy&n_m=clagui57%40gmail.com" target="_blank">Edit Email Settings</a> · Reply to this email to add a comment.<br> </td></tr></tbody></table></td></tr></tbody></table></div></div><br> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-42323673168720333632011-09-19T05:05:00.001-07:002011-09-19T05:05:16.133-07:00Acute Myocardial Ischaemia Update 2011<p><br>Acute Myocardial Ischaemia Update 2011</p> <p>Link<br><a href="http://www.mediafire.com/?mavm1nd4yttdaxc">http://www.mediafire.com/?mavm1nd4yttdaxc</a></p> <p><br>Murillo Santucci Cesar de Assunção<br>Unidade de Terapia Intensiva adulto<br>Disciplina de Anestesiologia, Dor e Terapia Intensiva<br>Escola Paulista de Medicina<br>Rua Napoleão de Barros,715<br>Vila Clementino - São Paulo - CEP: 04024-002<br> Tel/Fax: +55-11-55757768<br>Tel/Fax: +55-11- 55764069<br><a href="mailto:m.assuncao@unifesp.br">m.assuncao@unifesp.br</a><br><a href="mailto:murilloassuncao@gmail.com">murilloassuncao@gmail.com</a><br><br></p> <div class="gmail_quote">---------- Forwarded message ----------<br>From: <b class="gmail_sendername">Murillo Santucci Cesar de Assunção</b> <span dir="ltr"><<a href="mailto:murilloa@uol.com.br">murilloa@uol.com.br</a>></span><br> Date: 2011/9/19<br>Subject: [interno_residente_medico_PERU] Acute Myocardial Ischaemia Update 2011<br>To: UTI - Anestesiologia UNIFESP <<a href="mailto:uti-anestesiologia@yahoogrupos.com.br">uti-anestesiologia@yahoogrupos.com.br</a>><br> <br><br> <div style="WORD-WRAP: break-word"> <div style="WORD-WRAP: break-word"><span style="LINE-HEIGHT: 19px; BORDER-COLLAPSE: collapse; FONT-FAMILY: Verdana, Helvetica, Arial, sans-serif; COLOR: rgb(68,68,68); FONT-SIZE: 12px"> <div style="BORDER-BOTTOM: rgb(232,232,232) 1px dashed; LINE-HEIGHT: normal; WORD-WRAP: break-word; MARGIN-BOTTOM: 8px"> <h1 style="PADDING-BOTTOM: 0px; LINE-HEIGHT: normal; MARGIN: 8px 0px; PADDING-LEFT: 0px; PADDING-RIGHT: 0px; WORD-WRAP: break-word; FONT-SIZE: 1.17em; PADDING-TOP: 0px">Acute Myocardial Ischaemia Update 2011</h1></div> <div style="LINE-HEIGHT: normal; MIN-HEIGHT: 100px; WORD-WRAP: break-word"> <table style="LINE-HEIGHT: normal; WIDTH: 758px; BORDER-COLLAPSE: collapse; WORD-WRAP: break-word; EMPTY-CELLS: show; TABLE-LAYOUT: fixed; MARGIN-LEFT: 1px" cellspacing="0" cellpadding="0"> <tbody style="LINE-HEIGHT: normal; WORD-WRAP: break-word"> <tr style="LINE-HEIGHT: normal; WORD-WRAP: break-word"> <td style="LINE-HEIGHT: 1.6em; WORD-WRAP: break-word; COLOR: rgb(68,68,68); FONT-SIZE: 14px"><img style="LINE-HEIGHT: normal; WORD-WRAP: break-word" alt="pact.jpg" src="cid:E0F799BE-B4CE-4302-8EA2-C0599D201F04@EINSTEIN" width="799" height="95"> <br style="LINE-HEIGHT: normal; WORD-WRAP: break-word"> <strong style="TEXT-ALIGN: left; LINE-HEIGHT: normal; FONT-STYLE: normal; WORD-WRAP: break-word; FONT-WEIGHT: bold"><font style="LINE-HEIGHT: normal; WORD-WRAP: break-word" size="5"><font style="LINE-HEIGHT: normal; WORD-WRAP: break-word" color="seagreen">Acute Myocardial Ischaemia Update 2011<br style="LINE-HEIGHT: normal; WORD-WRAP: break-word"> </font></font></strong><br style="LINE-HEIGHT: normal; WORD-WRAP: break-word">Link<br style="LINE-HEIGHT: normal; WORD-WRAP: break-word"><a style="LINE-HEIGHT: normal; WORD-WRAP: break-word; COLOR: rgb(0,102,153); TEXT-DECORATION: none" href="http://www.mediafire.com/?mavm1nd4yttdaxc" target="_blank">http://www.mediafire.com/?mavm1nd4yttdaxc</a></td> </tr></tbody></table></div> <div style="LINE-HEIGHT: normal; WORD-WRAP: break-word"></div> <div style="LINE-HEIGHT: normal; MARGIN: 20px auto; MIN-HEIGHT: 50px; WIDTH: 110px; DISPLAY: block; WORD-WRAP: break-word; CLEAR: both"></div></span> <div><span style="TEXT-TRANSFORM: none; TEXT-INDENT: 0px; BORDER-COLLAPSE: separate; FONT: medium Cambria; WHITE-SPACE: normal; LETTER-SPACING: normal; WORD-SPACING: 0px"><span style="TEXT-TRANSFORM: none; TEXT-INDENT: 0px; BORDER-COLLAPSE: separate; FONT: medium Cambria; WHITE-SPACE: normal; LETTER-SPACING: normal; WORD-SPACING: 0px"><span style="TEXT-TRANSFORM: none; TEXT-INDENT: 0px; BORDER-COLLAPSE: separate; FONT: medium Cambria; WHITE-SPACE: normal; LETTER-SPACING: normal; WORD-SPACING: 0px"> <div style="WORD-WRAP: break-word"><span style="TEXT-TRANSFORM: none; TEXT-INDENT: 0px; BORDER-COLLAPSE: separate; FONT: medium Cambria; WHITE-SPACE: normal; LETTER-SPACING: normal; WORD-SPACING: 0px"> <div style="WORD-WRAP: break-word"><span style="TEXT-TRANSFORM: none; TEXT-INDENT: 0px; BORDER-COLLAPSE: separate; FONT: medium Cambria; WHITE-SPACE: normal; LETTER-SPACING: normal; WORD-SPACING: 0px"> <div style="WORD-WRAP: break-word"><span style="TEXT-TRANSFORM: none; TEXT-INDENT: 0px; BORDER-COLLAPSE: separate; FONT: medium Cambria; WHITE-SPACE: normal; LETTER-SPACING: normal; WORD-SPACING: 0px"> <div style="WORD-WRAP: break-word"><span style="TEXT-TRANSFORM: none; TEXT-INDENT: 0px; BORDER-COLLAPSE: separate; FONT: medium Cambria; WHITE-SPACE: normal; LETTER-SPACING: normal; WORD-SPACING: 0px"> <div style="WORD-WRAP: break-word"><span style="TEXT-TRANSFORM: none; TEXT-INDENT: 0px; BORDER-COLLAPSE: separate; FONT: medium Cambria; WHITE-SPACE: normal; LETTER-SPACING: normal; WORD-SPACING: 0px"> <div style="WORD-WRAP: break-word"> <div>Murillo Santucci Cesar de Assunção</div> <div>Unidade de Terapia Intensiva adulto</div> <div>Disciplina de Anestesiologia, Dor e Terapia Intensiva</div> <div>Escola Paulista de Medicina</div> <div>Rua Napoleão de Barros,715</div> <div>Vila Clementino - São Paulo - CEP: 04024-002</div> <div>Tel/Fax: +55-11-55757768</div> <div>Tel/Fax: +55-11- 55764069</div> <div><a href="mailto:m.assuncao@unifesp.br" target="_blank">m.assuncao@unifesp.br</a></div> <div><a href="mailto:murilloassuncao@gmail.com" target="_blank">murilloassuncao@gmail.com</a></div><br><br></div></span></div></span></div></span></div></span></div></span></div></span></span></span></div><br></div></div> </div><br> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-50624480231792223842011-09-11T18:05:00.001-07:002011-09-11T18:05:43.849-07:00] Captado por una cámara del transito.. Reflexión!!!<br><br> <div class="gmail_quote">---------- Mensaje reenviado ----------<br>De: <b class="gmail_sendername">Mauricio Oyuela Pavón</b> <span dir="ltr"><<a href="mailto:dr.maoy.blackberry@gmail.com">dr.maoy.blackberry@gmail.com</a>></span><br> Fecha: 8 de septiembre de 2011 23:15<br>Asunto: [SALUD_LORETO] Captado por una cámara del transito.. Reflexión!!!<br>Para: Salud Loreto <<a href="mailto:salud_loreto@yahoogroups.com">salud_loreto@yahoogroups.com</a>><br> <br><br><u></u> <div style="BACKGROUND-COLOR: #fff"><span> </span> <div> <div> <div> <p> <div class="gmail_quote"> <div> <div style="BACKGROUND-COLOR: #fff; FONT-FAMILY: verdana, helvetica, sans-serif; COLOR: #000; FONT-SIZE: 12pt"> <div style="FONT-FAMILY: verdana, helvetica, sans-serif; FONT-SIZE: 12pt"> <div style="FONT-FAMILY: times new roman, new york, times, serif; FONT-SIZE: 12pt"><font size="2" face="Arial"><b><br></b></font> <div> <div dir="ltr"> <div> <div> <div><font size="3" face="Times New Roman"><span style="FONT-SIZE: 12pt"> </span></font><br> <div> <div><font size="5" face="Tahoma"><span style="FONT-FAMILY: Tahoma; FONT-SIZE: 16pt">La vida es solo un soplo, adios a los resentimientos, hay que aprovechar las segundas oportunidades, y mantenerce en paz con DIOS y las personas que quieres.</span></font><font size="2" face="Tahoma"><span style="FONT-FAMILY: Tahoma; FONT-SIZE: 10pt"></span></font></div> </div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div style="BACKGROUND: white"><font color="black" size="2" face="Arial"><span style="FONT-FAMILY: Arial; COLOR: black; FONT-SIZE: 10pt"><a href="http://es.mc283.mail.yahoo.com/mc/compose?to=gontha12002%40yahoo.com" rel="nofollow" target="_blank"></a></span></font></div> </div> <div> <div> <div> <div> <div style="BACKGROUND: white"><font color="black" size="3" face="Times New Roman"><span style="COLOR: black; FONT-SIZE: 12pt"> </span></font></div> <div> <div> <div> <div style="BACKGROUND: white"><font color="black" size="5" face="Tahoma"><span style="FONT-FAMILY: Tahoma; COLOR: black; FONT-SIZE: 18pt">ESPERA QUE CARGE PARA QUE LO OBSERVES BIEN</span></font><font color="navy" size="4" face="Tahoma"><span style="FONT-FAMILY: Tahoma; COLOR: navy; FONT-SIZE: 14pt"> </span></font><font color="black" size="4" face="Arial"><span style="FONT-FAMILY: Arial; COLOR: black; FONT-SIZE: 14pt"> </span></font></div> </div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <div> <table border="0" cellpadding="0" width="100%"> <tbody> <tr> <td valign="top" width="100%"> <div><font size="2" face="Tahoma"><span style="FONT-FAMILY: Tahoma; FONT-SIZE: 10pt"><br>Son 3 segundos para que nuestra vida termine, y sin tener la culpa.<font color="teal"><span style="COLOR: teal"> </span></font></span></font><br> <font size="2" face="Tahoma"><span style="FONT-FAMILY: Tahoma; FONT-SIZE: 10pt"><br></span></font><img border="0" src="cid:1.860449456@web25405.mail.ukl.yahoo.com" width="352" height="240"><br><br><b><font size="4" face="Arial Narrow"><span style="FONT-FAMILY: 'Arial Narrow'; FONT-SIZE: 13.5pt; FONT-WEIGHT: bold">La vida es tan corta para levantarnos en la mañana con tristezas Así es que, comienza tu día con una oración, ama a tu familia que se preocupa por ti sinceramente, atesora a tus amigos, Olvida a los que te hacen daño, manténte en paz con Dios por sobre todo.<font color="blue"><span style="COLOR: blue"> </span></font>Y cree que las cosas suceden por una razón. Si te dan una oportunidad<font color="#ff8100"><span style="COLOR: #ff8100"> </span></font>aprovéchala, existen las segundas oportunidades, si hiciste algo mal reivindícate y no lo vuelvas a hacer.<font color="blue"><span style="COLOR: blue"> </span></font>Nadie dice que será fácil. Solo te puedo asegurar que valdrá la pena.<font color="#ff8100"><span style="COLOR: #ff8100"> </span></font></span></font></b></div> </td></tr></tbody></table></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div></div> </div></div></div> <div> <div> <div> <div> <div style="BACKGROUND: white"><font color="black" size="3" face="Times New Roman"><span style="COLOR: black; FONT-SIZE: 12pt"> </span></font></div></div></div></div></div></div></div></div></div><u></u><u></u></div></div> </div></div></div></div><br> <p></p></p></div> <div style="MIN-HEIGHT: 0px; COLOR: #fff">__._,_.___</div> <div style="WHITE-SPACE: nowrap; MARGIN-BOTTOM: 10px; COLOR: #666; CLEAR: both; PADDING-TOP: 15px"> </div></div></div></div></div> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-19439279459638268912011-08-25T09:35:00.001-07:002011-08-25T09:35:54.988-07:00A proposito de das casos de sindrome neuroleptico maligno<div class="refsection_content"> <p>The most important intervention is to discontinue all antipsychotics. In most cases, symptoms will resolve in 1-2 weeks. Neuroleptic malignant syndrome precipitated by long-acting depot injections of antipsychotics can last as long as a month. During the course of neuroleptic malignant syndrome, use supportive care aggressively. The value of other interventions, such as dantrolene, amantadine, bromocriptine, and electroconvulsive therapy, is uncertain.<sup><a href="javascript:showrefcontent('refrenceslayer');">[23] </a></sup></p> <ul> <li> <div class="topbullet">Supportive measures are aimed at preventing further complications and maintaining organ function. <ul> <li>Patients should receive circulatory and ventilatory support as needed.</li> <li>Cooling blankets and antipyretics can be used to control temperature.</li> <li>Aggressive fluid resuscitation and alkalization of urine can help prevent acute renal failure and enhance excretion of muscle breakdown products. </li></ul></div></li> <li> <div class="topbullet">Electroconvulsive therapy has been proposed as a treatment based on its effectiveness in acute lethal catatonia. Some data suggest that electroconvulsive therapy is effective for neuroleptic malignant syndrome, but serious treatment-related complications have occurred (see Complications). Specifically, patients with neuroleptic malignant syndrome have developed cardiac arrest and ventricular fibrillation after electroconvulsive therapy. </div> </li></ul></div> <div style="DISPLAY: none" class="back_next_btn"> <div class="spacer"></div></div> <div class="next_btn1">Proceed to <a onclick="wmdTrack('cr-sn_next');" href="https://mail.google.com/mail/html/compose/static_files/288482-medication">Medication</a></div> <div class="spacer"> </div> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-47016909328131457442011-08-18T16:24:00.001-07:002011-08-18T16:24:47.899-07:00BASIC LIFE SUPPORT (BLS)<p>Sociem Ucv Trujillo posted in cibermedicos.Sociem Ucv Trujillo5:18pm Aug 18 </p> <p>BASIC LIFE SUPPORT (BLS)<br>Acreditación Nacional e Internacional: <br>Certificado y Tarjeta de Acreditación Internacional BLS de American Heart Association válida por dos años (será otorgada a quienes aprueben satisfactoriamente las evaluaciones teórico-prácticas).<br> Certificado de asistencia al curso otorgado por el Centro de Entrenamiento Internacional - UPCH.<br>UPCH<br><a href="http://www.upch.edu.pe/">www.upch.edu.pe</a></p> <p>Dirigido a: Profesionales de la Salud y Personal Prehospitalario (Médico General y/o Especialista</p> <p> </p> <p>View Post on Facebook<br><br></p> <div class="gmail_quote">---------- Mensaje reenviado ----------<br>De: <b class="gmail_sendername">Sociem Ucv Trujillo</b> <span dir="ltr"><<a href="mailto:notification%2Byfo6tzj9@facebookmail.com">notification+yfo6tzj9@facebookmail.com</a>></span><br> Fecha: 18 de agosto de 2011 17:18<br>Asunto: [cibermedicos] BASIC LIFE SUPPORT (BLS)<br>Para: cibermedicos <<a href="mailto:internetymedicos@groups.facebook.com">internetymedicos@groups.facebook.com</a>><br><br><br> <u></u> <div style="PADDING-BOTTOM: 0px; MARGIN: 0px; PADDING-LEFT: 0px; PADDING-RIGHT: 0px; PADDING-TOP: 0px" dir="ltr"> <table border="0" cellspacing="0" cellpadding="8" width="98%"> <tbody> <tr> <td style="FONT-FAMILY: 'lucida grande', tahoma, verdana, arial, sans-serif" bgcolor="#ffffff" width="100%"> <table border="0" cellspacing="0" cellpadding="0" width="500"> <tbody> <tr> <td style="PADDING-BOTTOM: 0px; PADDING-LEFT: 10px; PADDING-RIGHT: 0px; FONT-FAMILY: 'lucida grande', tahoma, verdana, arial, sans-serif; COLOR: #000000; FONT-SIZE: 11px; PADDING-TOP: 10px" valign="top" colspan="2"> <table style="COLOR: #000000; FONT-SIZE: 11px" width="100%"> <tbody> <tr> <td style="FONT-FAMILY: 'lucida grande', tahoma, verdana, arial, sans-serif; COLOR: #000000; FONT-SIZE: 11px" valign="top" width="100%" align="left"> <div style="BORDER-BOTTOM: #e9e9e9 1px solid; PADDING-BOTTOM: 7px; PADDING-LEFT: 0px; WIDTH: 100%; PADDING-RIGHT: 0px; COLOR: #666666; PADDING-TOP: 0px">Sociem Ucv Trujillo <a style="COLOR: #3b5998; TEXT-DECORATION: underline" href="http://www.facebook.com/n/?groups%2Finternetymedicos%2F&view=permalink&id=217738431595958&mid=4b78cebG5ae37904G2ad4ae4G96&bcode=gITwf9Ya&n_m=clagui57%40gmail.com" target="_blank">posted in cibermedicos</a>.</div> <div style="MARGIN-BOTTOM: 15px"> <table style="WIDTH: 100%; PADDING-TOP: 7px" cellspacing="0" cellpadding="0"> <tbody> <tr> <td style="PADDING-BOTTOM: 5px; PADDING-LEFT: 0px; WIDTH: 57px; PADDING-RIGHT: 5px; PADDING-TOP: 3px" valign="top"><a style="COLOR: #3b5998; TEXT-DECORATION: none" href="http://www.facebook.com/n/?profile.php&id=100000975834215&mid=4b78cebG5ae37904G2ad4ae4G96&bcode=gITwf9Ya&n_m=clagui57%40gmail.com" target="_blank"><img style="BORDER-BOTTOM: 0px; BORDER-LEFT: 0px; MIN-HEIGHT: 50px; WIDTH: 50px; BORDER-TOP: 0px; BORDER-RIGHT: 0px" alt="BASIC LIFE SUPPORT (BLS) Acreditación Nacional e Internacional: Certificado y Tarjeta de Acreditación Internacional BLS de American Heart Association válida por dos años (será otorgada a quienes aprueben satisfactoriamente las evaluaciones teórico-prácticas). Certificado de asistencia al curso otorgado por el Centro de Entrenamiento Internacional - UPCH." src="http://profile.ak.fbcdn.net/hprofile-ak-snc4/186295_100000975834215_7993790_q.jpg"></a></td> <td style="PADDING-BOTTOM: 5px; PADDING-LEFT: 0px; PADDING-RIGHT: 5px; FONT-FAMILY: 'lucida grande', tahoma, verdana, arial, sans-serif; PADDING-TOP: 5px" valign="top" align="left"> <table style="PADDING-BOTTOM: 5px; WIDTH: 100%" cellspacing="0" cellpadding="0"> <tbody> <tr> <td style="FONT-FAMILY: 'lucida grande', tahoma, verdana, arial, sans-serif; COLOR: #000000; FONT-SIZE: 11px"><a style="COLOR: #3b5998; FONT-WEIGHT: bold; TEXT-DECORATION: none" href="http://www.facebook.com/n/?profile.php&id=100000975834215&mid=4b78cebG5ae37904G2ad4ae4G96&bcode=gITwf9Ya&n_m=clagui57%40gmail.com" target="_blank">Sociem Ucv Trujillo</a></td> <td style="TEXT-ALIGN: right; PADDING-RIGHT: 5px; FONT-FAMILY: 'lucida grande', tahoma, verdana, arial, sans-serif; COLOR: #999999; FONT-SIZE: 11px">5:18pm Aug 18 </td></tr></tbody></table> <div style="PADDING-BOTTOM: 7px; COLOR: #000000; FONT-SIZE: 11px">BASIC LIFE SUPPORT (BLS)<br>Acreditación Nacional e Internacional: <br>Certificado y Tarjeta de Acreditación Internacional BLS de American Heart Association válida por dos años (será otorgada a quienes aprueben satisfactoriamente las evaluaciones teórico-prácticas).<br> Certificado de asistencia al curso otorgado por el Centro de Entrenamiento Internacional - UPCH.</div> <div style="PADDING-BOTTOM: 10px; PADDING-LEFT: 0px; PADDING-RIGHT: 0px; COLOR: #000000; FONT-SIZE: 11px; PADDING-TOP: 10px"> <div style="BORDER-LEFT: #ccc 2px solid; PADDING-BOTTOM: 0px; MARGIN: 10px 0px; PADDING-LEFT: 10px; PADDING-RIGHT: 0px; COLOR: #808080; PADDING-TOP: 0px"> <div><a style="COLOR: #3b5998; FONT-WEIGHT: bold; TEXT-DECORATION: none" href="http://www.facebook.com/l/mAQChyPdOAQDj5HqJCQp66OLUZTwTgntni1fM04wnFI6VKg/www.upch.edu.pe/famed/general/emc/emc2010/centro-entrenamiento/basic.asp" target="_blank">UPCH</a></div> <div><a style="COLOR: #3b5998; TEXT-DECORATION: none" href="http://www.facebook.com/l/QAQC04Mz8AQD1OTCITyf5byf6_a_syVxb7805QDwpX274aQ/www.upch.edu.pe/famed/general/emc/emc2010/centro-entrenamiento/basic.asp" target="_blank"> <table style="BORDER-COLLAPSE: collapse; MARGIN-BOTTOM: 10px" border="0" cellspacing="0" cellpadding="0" width="100%"> <tbody> <tr> <td style="BORDER-BOTTOM: medium none; BORDER-LEFT: medium none; PADDING-BOTTOM: 0px; PADDING-LEFT: 0px; PADDING-RIGHT: 0px; FONT-FAMILY: 'Lucida Grande', 'Lucida Sans', Tahoma, Verdana, Arial, sans-serif; COLOR: #333333; FONT-SIZE: 11px; BORDER-TOP: medium none; FONT-WEIGHT: bold; BORDER-RIGHT: medium none; PADDING-TOP: 0px"> www.upch.edu.pe</td></tr></tbody></table></a></div> <div><span>Dirigido a: Profesionales de la Salud y Personal Prehospitalario (Médico General y/o Especialista</span></div></div></div></td></tr></tbody></table></div></td></tr></tbody></table><br></td></tr> <tr> <td style="PADDING-BOTTOM: 15px; LINE-HEIGHT: 18px; PADDING-LEFT: 10px; PADDING-RIGHT: 5px; FONT-FAMILY: 'lucida grande', tahoma, verdana, arial, sans-serif; COLOR: #666666; FONT-SIZE: 12px; BORDER-TOP: #e9e9e9 1px solid; PADDING-TOP: 10px" colspan="2"> <a style="COLOR: #3b5998; TEXT-DECORATION: none" href="http://www.facebook.com/n/?groups%2Finternetymedicos%2F&view=permalink&id=217738431595958&mid=4b78cebG5ae37904G2ad4ae4G96&bcode=gITwf9Ya&n_m=clagui57%40gmail.com" target="_blank">View Post on Facebook</a> · <a style="COLOR: #3b5998; TEXT-DECORATION: none" href="http://www.facebook.com/n/?groups%2Finternetymedicos%2F&view=notifications&mid=4b78cebG5ae37904G2ad4ae4G96&bcode=gITwf9Ya&n_m=clagui57%40gmail.com" target="_blank">Edit Email Settings</a> · Reply to this email to add a comment.<br> </td></tr></tbody></table></td></tr></tbody></table></div></div><br> Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0tag:blogger.com,1999:blog-2345113505836037298.post-68987833923935597402011-07-28T08:25:00.001-07:002011-08-08T00:21:37.189-07:00Yo no soy sicopata, soy solapa<div dir="ltr" style="text-align: left;" trbidi="on"><div closure_uid_pnqnpm="100" style="text-align: justify;">el sicopata sabe que es correcto y que es incorrecto pero nada lo detiene para hacer algo incorrecto si con eso consigue lo que desea para su satisfaccion. Ha aprendido que determinadas cosas no son correctas para la sociedad intelectualmente hablando, incluso sabe porque pero no comprende porque.No todos salen por las noches a matar mujeres despues de violarlas. No todos matan. Aunque tu no sabes en que momento pueden llegar a hacerlo. Si lo hacen no es porque te odien sino porque eres un obstaculo para conseguir algo que ellos quieren. Son parasitos siempre viven de los demas. Siempre estaran buscando quien les haga su trabajo o quien asuma su responsabilidad. Lo que ellos evitan. Claro racionalizaran de alguna manera su comportamiento. Te acusaran de que no lo quieres ayudar cuando en realidad lo que estan buscando es que tu hagas su trabajo. Cree que tiene normas especiales. Las suyas ´por supuesto. Tu no puedes violar las normas pero el si. Cuando el lo hace tiene una justificacion.Por supuesto si no pueden comprender porque algo es incorrecto no tendran remordimiento alguno. Es manipulador y por excelencia, abusa del poder cuando lo tiene. Detras de cada persona que abusa del poder que se le otorga hay un potencial sicopata. No todos matan pero puede intentar matarte moralmente. Por eso detras de cada calumniador hay un posible sicopata. Generalmente no se amilana con argumentos, razonamientos. Se amilana con la amenaza fisica. Es cobarde.Hoy dia puede haber estado conspirando ´para que te boten del trabajo. Y manana con toda frialdad te ruega que se lo des en otro sitio. Detras de cada doble cara hay un potencial sicopata. Aunque no necesariamente. Este puede ser un rasgo aislado de la personalidad. Pero si juntas latrocinio con doble cara lo mas probable es que lo sea. Por eso se amontonan alrededor del poder politico economico en donde pueden obtener poder y sacar provecho. No digo que cada politico sea un potencial sicopata. Pero probablemente muchos de ellos lo sean. Muchos lobistas lo son. Muchos seudoempresarios quer desprestigian la insititucion de la empresa privada. Pero en el estado tambien abundan. Pero la gente suele ser mas tolerante con el syco del estad opor paradigmas politicos .Ustedes los conocen ahora mejor. Claro como el no rompe las leyes y normas el se siente, bien los demas estan mal. Acusa de ladrones acosadores a todo el que puede cuando el lo es.</div><div style="text-align: justify;">Suelen ser simpaticos y aceptados por muchos menos por los que los conocen verdaderamente. Tiene un atractivo superficial. Puede ser corteses te ayudan y hasta protegen pero solo lo hacen para ganar tu voluntad. Para tenerte como aliado incondicional. Si son fuertes se rodean generalmente de gente sin valores pero debiles. El debil amoral tiene afinidad por el psyco. Es su lider. Es capaz de hacer loq ue el no puede. Por que al final de cuentas el debil inmoral pero no psyco tiene remordimientos. Tiene conciencia el psyco de que es psyco?. Como podria tenerla si no puede comprender que lo que hace esta mal. Sabe que esta mal pero no puede comprender porque?</div><div closure_uid_pnqnpm="112" style="text-align: justify;">c mori</div><br />
<div><h3 class="post-title entry-title">La Discapacidad del Psicópata. Problema poco entendido. </h3><div class="post-header"><div class="post-header-line-1"></div></div><div class="post-body entry-content" id="post-body-1857012322135837609">Edwin Villacorta posted in MEDICOS.Edwin Villacorta11:42pm May 14 <br />
La Discapacidad del Psicópata.<br />
<br />
Habrá que agradecer a Jonathan Demme que la palabra "psicópata" nos traiga a la memoria la cara del doctor Hannibal Lecter, el asesino inteligente, refinado y cruel de El silencio de los corderos. Sin embargo, muy pocos psicópatas, son tan listos y fotogénicos como Anthony Hopkins ni todos se manchan las manos de sangre. <br />
El psicópata es un enfermo que tiende a buscar su propio placer por encima de cualquier otra consideración. La mayoría tiene un aspecto anodino, una inteligencia media y una conducta normal. Pero sólo aparentemente normal, pues realmente son personas impulsivas, manipuladoras y, sobre todo, incapaces de comprender el porqué de las normas sociales y de sentir la más mínima empatía hacia sus semejantes. <br />
Sencillamente, no las entienden: si quieren algo, lo cogerán; si alguien les molesta, lo apartarán; y si una norma de convivencia se interpone entre ellos y sus deseos, la burlarán. Lo harán sin acritud, como si no hubieran roto un plato en su vida, y si alguien recrimina su conducta, le mirarán como a un marciano, antes de seguir su camino. Y es que, pese a conocer la diferencia entre lo correcto y lo incorrecto, no entenderán el reproche. <br />
Este perfil es más sencillo de reconocer en la sociedad y seguro que muchos lectores ya tendrán en la cabeza varios candidatos en su entorno cercano. Los hay, a montones: desde líderes políticos a consejeros delegados, desde maltratadores a acosadores laborales… casi todo aquel que se aprovecha de una posición de fuerza suele tener un cuadro de psicopatía en mayor o menor grado que es muy difícil de denunciar ante una sociedad acostumbrada a creer que los verdaderos psicópatas son personas que devoran los hígados de sus víctimas con un poco de Chianti. <br />
La ciencia se ha preguntado a menudo si la conducta de estos enfermos es adaptativa -condicionada por la supervivencia en el entorno- o debida a algún tipo de anomalía genética. Por lo general, la búsqueda de causas fisiológicas asociadas a las conductas ha tenido consecuencias nefastas en la historia, al recurrir a un determinismo muy cómodo, pero imposible de aceptar por cualquier sociedad convencida de que las personas deben ser dueñas de sus destinos, al margen de lo que quiera imponerles tal o cual gen. <br />
Más interesantes son los experimentos que a través de las reacciones de los investigados permiten extraer conclusiones sobre un determinado asunto. De este tipo es el estudio de dos investigadores de la Universidad de Nuevo México (EEUU) publicado por la revista Psichological Science. Elsa Ermer and Kent Kiehl se preguntaron si los psicópatas carecían de alguna facultad mental para comprender las normas sociales y el alcance de un riesgo. <br />
Así que recurrieron a un grupo de 67 prisioneros voluntarios, algunos de los cuales contaban con un cuadro más o menos claro de psicopatía, y usaron un sencillo juego de cartas con reglas para someterles a tres tipos de pruebas: relacionadas con el razonamiento lógico descriptivo ( "Si una persona es de California, será paciente" ), con el contrato social ("Si me coges la moto, tendrás que lavarla") y con la precaución y las medidas preventivas ("Si trabajas con tuberculosos, deberás ponerte mascarilla" ). <br />
Los psicópatas demostraron una incapacidad manifiesta para entender las reglas del contrato social y las preventivas, pero acertaron con las descriptivas en la misma medida en que lo hicieron los presos no psicópatas. Es decir, un sencilla norma social como "si me coges el coche, luego ponle gasolina" era para ellos un enigma equiparable al que pasa por la cabeza de un niño ante las leyes de la termodinámica. <br />
Este experimento indujo a pensar a Ermer y Kiehl que su hipótesis era correcta: los enfermos eran incapaces de entender las reglas sociales o el fraude que conlleva una trampa, así como el verdadero alcance de un riesgo, pero por lo demás eran capaces de razonar prácticamente igual que el resto de personas analizadas. <br />
El proceso que lleva a un joven a comprender por qué no está bien quitarle el bastón a una anciana que cruza un paso de cebra, a un jefe a reconocer la injusticia cometida con uno de sus empleados o a un marido a avergonzarse por haber sentido ganas de golpear a su mujer, no funciona en toda la sociedad. En los tres casos existe una relación asimétrica, una imposición del fuerte sobre el débil y, al final, el reconocimiento de un orden social vulnerado y la capacidad de las personas para ponerse en el lugar de los otros, la misma empatía que nunca podrá sentir un psicópata. Las mismas normas que nunca acabará de comprender. <br />
La cuestión ahora es saber si la sociedad podrá comprender, por su parte, que la psicopatía es una enfermedad y no sólo una pesadilla o un argumento de ficción. Comprenderlo y asumirlo, sin recurrir al determinismo genético ni refugiarse sólo en el Código Penal, será tan difícil como necesario para arreglar muchos de nuestros problemas actuales. La ciencia será la mejor guía en el camino a encontrar un tratamiento adecuado, pero la empatía de la sociedad hacia los psicópatas, también. Quid pro quo<br />
<div class="gmail_quote">---------- Mensaje reenviado ----------<br />
De: <b class="gmail_sendername">Edwin Villacorta</b> <span dir="ltr"><<a href="mailto:notification%2Byfo6tzj9@facebookmail.com"><span style="color: #ff9900;">notification+yfo6tzj9@facebookmail.com</span></a>></span><br />
Fecha: 14 de mayo de 2011 23:43<br />
Asunto: [MEDICOS] La Discapacidad del Psicópata. Habrá que...<br />
Para: Claudio Mori Gonzales <<a href="mailto:clagui57@gmail.com"><span style="color: #ff9900;">clagui57@gmail.com</span></a>><br />
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</div></div></div></div>Claudio Mori Gonzaleshttp://www.blogger.com/profile/16446075772477324704noreply@blogger.com0