Effect of geography on the use of ultrafiltration during cardiac surgery with cardiopulmonary bypass

BACKGROUND

Ultrafiltration (UF) is a common practice during cardiopulmonary bypass (CPB) where it is used as a blood management strategy to reduce red blood cell (RBC) transfusion, minimize adverse effects of hemodilution, and reduce proinflammatory mediators. However, its clinical utilization has been shown to vary throughout the continents.

PURPOSE

The purpose of this investigation was to assess the distribution of UF use across the United States.

DATA COLLECTION

Data on UF use during cardiac surgery was obtained from a national (United States) perfusion database for adult cardiac procedures performed from January 2016 through December 2018.

STUDY SAMPLE

Four geographical regions were established: Northeast (NE), South (SO), Midwest (MW) and West (WE). The primary endpoint was the use of UF with secondary endpoints UF volume, CPB and anesthesia asanguineous volumes, intraoperative allogeneic RBC transfusion, nadir hematocrit and urine output (UO). 92,859 adult cardiac cases from 191 hospitals were reviewed.

RESULTS

The NE and the WE had similar usages of UF (59.9% and 59.7% respectively), which were higher than the MW and the SO (38.6% and 34.9%, p < .001). When UF was utilized, the median [IQR] volume removed was highest in the NE (1900 [1200-2800]mL), and similar in all other regions (WE 1500 [850-2400 mL, MW 1500 [900-2300]mL and SO 1500 [950-2200]mL, p < .001. Median total UO was lowest in the NE 400 [210,650]mL vs all other regions (p < .001), and remained so when indexed by patient weight and operative time (NE-0.8 [0.5, 1.3]mL/kg/hour, MW-1.1 [0.7, 1.8] mL/kg/hour, SO-1.3 [0.8, 2.0]mL/kg/hour, WE-1.1 [0.7, 1.3]mL/kg/hour, p < .001. Intraoperative RBC transfusion rate was highest in the SO (21.3%) and WE (20.5%), while similar rates seen in the NE (16.2%) and MW (17.6%), p < .001.

CONCLUSIONS

Across the United States there is geographic variation on the use of UF. Further research is warranted to investigate why these practice variations exist and to better understand and determine their reasons for use.

Establishment of a national quality improvement process on oxygen delivery index during cardiopulmonary bypass

Targeted oxygen delivery during cardiopulmonary bypass (CPB) has received significant attention due to its influence on patient outcomes, especially in mitigating acute kidney injury. While it has gained popularity in select institutions, there remains a gap in establishing it globally across multiple centers. The purpose of this investigation was to describe the development of a quality improvement process of targeted oxygen delivery during CPB across hospitals throughout the United States. A systematic approach to utilize oxygen delivery index (DO2i) as a key performance indicator within hospitals serviced by a national provider of perfusion services. The process included a review of the current literature on DO2i, which yielded a target nadir value (272 mL/min/m2) and an area under the curve (DO2i272AUC) cut off of 632. All data is displayed on a dashboard with results categorized across multiple levels from system-wide to individual clinician performance. From January 2020 through December 2022, DO2i data from 91 hospitals and 11,165 coronary artery bypass graft procedures were collected. During this period the monthly proportion of DO2i measurements above the target nadir DO2i272 ranged from 60.5% to 78.4% with a mean+/-SD of 70.8 +/- 4.2%. Binary logistic regression for the first 7 months following monthly DO2i performance reporting has shown a statistically significant positive linear trend in the probability of achieving the target DO2i272 (p < .001), with a crude increase of approximately 7.8% for DO2i272AUC, and a 73.8% success rate (p < .001). A survey was sent to all individuals measuring oxygen delivery during CPB to assess why a target DO2i272 could not be reached. The two most common responses were an 'inability to improve CPB flow rates' and 'restrictive allogeneic red blood cell transfusion policies'. This study demonstrates that targeting a minimum level of oxygen delivery can serve as a key performance indicator during CPB using a structured quality improvement process.

Two known therapies could be useful as adjuvant therapy in critical patients infected by COVID-19

Pneumonia caused by coronavirus, which originated in Wuhan, China, in late 2019, has been spread around the world already becoming a pandemic. Unfortunately, there is not yet a specific vaccine or effective antiviral drug for treating COVID-19. Many of these patients deteriorate rapidly and require intubation and are mechanically ventilated, which is causing the collapse of the health system in many countries due to lack of ventilators and intensive care beds. In this document we review two simple adjuvant therapies to administer, without side effects, and low cost that could be useful for the treatment of acute severe coronavirus infection associated with acute respiratory syndrome (SARS-CoV-2). VitaminC, a potent antioxidant, has emerged as a relevant therapy due to its potential benefits when administered intravenous. The potential effect of vitaminC in reducing inflammation in the lungs could play a key role in lung injury caused by coronavirus infection. Another potential effective therapy is ozone: it has been extensively studied and used for many years and its effectiveness has been demonstrated so far in multiples studies. Nevertheless, our goal is not to make an exhaustive review of these therapies but spread the beneficial effects themselves. Obviously clinical trials are necessaries, but due to the potential benefit of these two therapies we highly recommended to add to the therapeutic arsenal.

Fire-induced pine woodland to shrubland transitions in Southern Europe may promote shifts in soil fertility

Since the mid of the last century, fire recurrence has increased in the Iberian Peninsula and in the overall Mediterranean basin due to changes in land use and climate. The warmer and drier climate projected for this region will further increase the risk of wildfire occurrence and recurrence. Although the impact of wildfires on soil nutrient content in this region has been extensively studied, still few works have assessed this impact on the basis of fire recurrence. This study assesses the changes in soil organic C and nutrient status of mineral soils in two Southern European areas, Várzea (Northern Portugal) and Valencia (Eastern Spain), affected by different levels of fire recurrence and where short fire intervals have promoted a transition from pine woodlands to shrublands. At the short-term (<1year), the amount of soil organic matter was higher in burned than in unburned soils while its quality (represented as labile to total organic matter) was actually lower. In any case, total and labile soil organic matter showed decreasing trends with increasing fire recurrence (one to four fires). At the long-term (>5years), a decline in overall soil fertility with fire recurrence was also observed, with a drop between pine woodlands (one fire) and shrublands (two and three fires), particularly in the soil microsites between shrubs. Our results suggest that the current trend of increasing fire recurrence in Southern Europe may result in losses or alterations of soil organic matter, particularly when fire promotes a transition from pine woodland to shrubland. The results also point to labile organic matter fractions in the intershrub spaces as potential early warning indicators for shifts in soil fertility in response to fire recurrence.

Force Outputs during Squats Performed Using a Rotational Inertia Device under Stable versus Unstable Conditions with Different Loads

The purpose of the study was to compare the force outputs achieved during a squat exercise using a rotational inertia device in stable versus unstable conditions with different loads and in concentric and eccentric phases. Thirteen male athletes (mean ± SD: age 23.7 ± 3.0 years, height 1.80 ± 0.08 m, body mass 77.4 ± 7.9 kg) were assessed while squatting, performing one set of three repetitions with four different loads under stable and unstable conditions at maximum concentric effort. Overall, there were no significant differences between the stable and unstable conditions at each of the loads for any of the dependent variables. Mean force showed significant differences between some of the loads in stable and unstable conditions (P < 0.010) and peak force output differed between all loads for each condition (P < 0.045). Mean force outputs were greater in the concentric than in the eccentric phase under both conditions and with all loads (P < 0.001). There were no significant differences in peak force between concentric and eccentric phases at any load in either stable or unstable conditions. In conclusion, squatting with a rotational inertia device allowed the generation of similar force outputs under stable and unstable conditions at each of the four loads. The study also provides empirical evidence of the different force outputs achieved by adjusting load conditions on the rotational inertia device when performing squats, especially in the case of peak force. Concentric force outputs were significantly higher than eccentric outputs, except for peak force under both conditions. These findings support the use of the rotational inertia device to train the squatting exercise under unstable conditions for strength and conditioning trainers. The device could also be included in injury prevention programs for muscle lesions and ankle and knee joint injuries.

Investigating Histone Acetylation Stoichiometry and Turnover Rate

Histone acetylation is a dynamic epigenetic modification that functions in the regulation of DNA-templated reactions, such as transcription. This lysine modification is reversibly controlled by histone (lysine) acetyltransferases and deacetylases. Here, we present methods employing isotopic labeling and mass spectrometry (MS) to comprehensively investigate histone acetylation dynamics. Turnover rates of histone acetylation are determined by measuring the kinetics of labeling from (13)C-labeled precursors of acetyl-CoA, which incorporates (13)C-carbon onto histones via the acetyltransferase reaction. Overall histone acetylation states are assessed from complete protease digestion to single amino acids, which is followed by MS analysis. Determination of site-specific acetylation stoichiometry is achieved by chemically acetylating endogenous histones with isotopic acetic anhydride, followed by trypsin digestion and LC-MS analysis. Combining metabolic labeling with stoichiometric analysis permits determination of both acetylation level and acetylation dynamics. When comparing genetic, diet, or environmental perturbations, these methods permit both a global and site-specific evaluation of how histone acetylation is dynamically regulated.

Green liquor dregs effect on Kraft mill secondary sludge composting

Increased Kraft pulp mill production generates increased solid wastes. In response, composting has emerged as an interesting alternative for disposal of these solid wastes. A central composite factor design was used to investigate the influence of incubation conditions (dregs addition and operation time) on chemical and biological parameters, determining the best in-vessel conditions in order to develop a correct composting design. Dregs helped reduce the pH drop that occurs at the beginning of the process. Biological activities presented high values during the active phase, followed by a decrease with stable final values along with N-NH(4)(+) and N-NO(3)(-) trend, which were indicative of mature compost. Dregs addition had not significant effect on the biological activities during composting of Kraft mill sludge. However, moderate amounts of dregs (between 5% and 8%) at operation time of 60-70 days would be the best compromise.

Using a second-order polynomial model to determine the optimum dregs/bark ratio for industrial-biosolid composting: the initial conditioning stage

Increasing pulp industry production has generated additional solid waste (i.e. biological sludge, dregs, etc.) and therefore an increasing disposal problem. On the other hand, composting is emerging as an interesting alternative for the disposal of residues. The objective of this study was to evaluate the physical and chemical properties of sludge, dregs and bark and the effect on their initial conditioning stage prior to composting, using pine chips as bulking agent. After their characterization, these solid wastes were combined in different mixture proportions defined by a 32 experimental design based on the response surface methodology (RSM), in which 18 observations were required for the independent variables (dregs and bark) and the C: N ratio, moisture content and pH were the dependent variables. The characterization indicated that the dregs have alkaline properties with the presence of some essential plant nutrients, such as phosphorous (0.37%), potassium (0.76%), magnesium (1.4%) and calcium (27%). The combination of the macronutrients (phosphorous: 0.39%, potassium: 0.24%, calcium: 1.7%, magnesium: 0.44%) and micronutrients such as ferrous material (0.47%) and zinc (0.12%) found in the sludge suggest a promising alternative despite the potential problem due to the high pH of the dregs. The RSM design indicated a feasible region that satisfied the optimal dregs: bark ratio of 0.25 without exceeding the addition of 12.5% dregs, due to the alkaline properties of these inorganic wastes and the quadratic influence over the C:N ratio. The experimental results indicated that the composting process of dregs, bark and sludge is technically suitable, although the use of a rapidly available C source needs to be evaluated.

Degradation of recalcitrant compounds by catechol-driven Fenton reaction

Dihydroxybenzenes are able to reduce Fe(III) and promote the Fenton reaction in the presence of H2O2. The catechol/Fe(III)/H2O2 system has been successfully used to degrade different compounds, being more efficient than the Fe(II)-Fenton reaction. In this paper the possibilities for using the catechol-driven Fenton reaction to degrade recalcitrant compounds such as the Fe(III)-EDTA complex and veratryl alcohol are reviewed.

A hybrid supervisory system to support WWTP operation: implementation and validation

Integrated operation of Wastewater Treatment Plants is still far from being solved. A reasonable proposal should link advanced and robust control algorithms to some knowledge-based techniques, allocating the detailed engineering to numerical computations, while delegating the logical analysis and reasoning to supervisory intelligent systems. This paper describes the development and implementation of a knowledge-based Hybrid Supervisory System to support the operation of a real Wastewater Treatment Plant. The system integrates different reasoning modules, overcoming the limitations in the use of each single technique, while providing an agent based architecture with additional modularity and independence. It is structured into three separated levels: data gathering, diagnosis, and decision support. The different tasks of the system are performed in a seven-step cycle: data gathering and update, diagnosis, supervision, prediction, communication, actuation, and evaluation phase. In spite of certain reservations of the scientific community about the use of these techniques, the system is successfully performing real-time support to the operation of the Granollers facility since September 1999. Results of the first four-month validation period are shown and discussed. An example of the system behavior is also shown in the paper. The conclusions indicate the key steps which are necessary to transfer the system to another facility.

Dihydroxybenzenes: driven Fenton reactions

Different compounds that reduce Fe(III) and that simultaneously increase the oxidation potential of the H2O2/Fe2+ system, have been evaluated. In this work, the improving of Fenton reactions by 2,3-dihydroxybenzoic acid (2,3-DHBA), 3,4-dihydroxybenzoic acid (3,4-DHBA) or 1,2-dihydroxybenzene (CAT) were studied. The three compounds are able to reduce Fe(III) to Fe(II), but the kinetic results depend on the method used to determine the Fe(II) ion. The dihydroxybenzenes (DHBs) degrades veratryl alcohol (VA), a lignin model compound, to a greater extent than observed in a typical Fenton reaction. The rate of VA degradation was associated with the duration of the chemiluminescence (CAT > 2,3-DHBA > 3,4-DHBA) and not with the sum of integrated counts. The treatment of a cellulose pulp bleaching effluent with DHBs/Fe(III)/H2O2 was evaluated by analyzing their depolymerization at pH 4 and 7 through molecular mass distribution determinations.

Reactive dyes decolouration by TiO2 photo-assisted catalysis

The photocatalytic degradation of three reactive azo dyes (yellow-2, orange-16 and red-2) and one anthraquinone reactive dye (blue-19) was studied. The reactions were carried out in a reactor with recirculation using TiO2 immobilised on glass Raschig rings (system A) and compared with a batch system using the catalyst in aqueous suspension (system B). Both reaction systems were irradiated with a 125 W, lambda > 254 nm lamp. The suspended TiO2 system was also studied using a 125 W 360 nm lamp (system C). Kinetic studies indicated a rapid colour removal, following the order B > A > C. The same trend was observed in COD and TOC removal profiles. The energy consumption per order of magnitude of catalytic degradation of the dyes was lower in the batch reactor (system B) than in the reactor with recirculation and immobilised TiO2 (system A).

Synthesis of E-9-Dodecen-1-yl Acetate Using Organomanganese Reagents

The Grignard reagent obtained from 2-(6-bromohexyloxy)-tetrahydropyrane, by treatment with anhydrous manganese(II) chloride was transformed to the corresponding organomanganese reagent, which was coupled with E-1-bromo-3-hexeneby treatment with anhydrous manganese chloride. Further deprotection and acetylation furnished E-9-dodecen-1-yl acetate. A second procedure involved the coupling of E-3-hexenylmanganese bromide and 6-bromohexyl acetate. Coupling reactions were carried out at 0 °C, using tetrahydrofurane and N-methylpyrrolidone as co-solvent.

General practice. Hit and miss

A survey of practices in a primary care group in outer London found many were poorly prepared for implementing clinical governance. More than half consisted of one doctor, and a quarter of practices were not computerised. Only a third had a staff development plan. Only a minority had sought patients' views about new services. Although three-quarters of practices were using guidelines, few had been trained in the use of protocols and guidelines.

Advanced oxidation of a pulp mill bleaching wastewater

The degradation, by several advanced oxidation reactions, of a pulp mill ECF bleaching effluent, was studied. The initial biodegradability of the organic matter present in the effluent, estimated as the BOD5/COD, was low (0.3). When the effluent was submitted to ozonation and to five different advanced oxidation systems (O3/UV, O3/UV/ZnO, O3/UV/TiO2, O2/UV/ZnO, O2/UV/TiO2), the biodegradability increase significantly. After five minutes of reaction, the O3/UV system appears as the most efficient in to transform the organic matter to more biodegradable forms. A similar effect was observed when the effluent was submitted to an activated sludge treatment. The COD, TOC and toxicity reduction correlated well with the biodegradability enhancement after AOPs treatments.

Iron-binding catechols oxidating lignin and chlorolignin

Iron-chelating low-molecular-weight compounds or catecholate siderophores have been suggested to be involved in wood biodegradation. To help in understanding the mechanism involved in the enzyme-like activity of catecholate siderophores, the oxidative properties of 2,3-dihydroxybenzoic acid (DHBA) and 3, 4-dihydroxyphenylacetic acid (DHPAA) chelated with iron were studied. The pH and catechol/Fe(III) ratios were optimized for o-dianisidine oxidation, obtaining a maximum at pH 7.0, in the absence of buffer, and a catechol/Fe(III) ratio of 1:2 to DHBA and 1:1 to DHPAA was found. Under these conditions, the catechols were able to reduce Fe(III) to Fe(II) acting like siderophore models. The Fe(III) complex of DHBA and of DHPAA degraded dioxane-lignin in 60% after 2 h and 85% after 24 h, respectively. DHBA/Fe(III) oxidized the bleaching effluent (E1) in 80% in 5 min under the studied conditions.

Health promotion. Beating the bands?

A survey of health authorities in England to establish GPs' health promotion activities found that anti-smoking and heart disease prevention were the most common initiatives. Many HAs were dissatisfied with the current arrangements, feeling that they had little control of GPs' health promotion activities. Two-thirds of HAs reported problems with monitoring GPs' health promotion activities. Few health promotion initiatives addressed mental health, cancer or accident prevention.

Serum lipids and apolipoproteins in Spanish children and adolescents: a 5 year follow-up

This study was designed to assess "tracking" of serum lipids and apolipoproteins in three age groups of Spanish children over a 5 year period. A total of 84 6-year-old, 89 10-year-old and 64 14-year-old children were evaluated in 1989 (with measurement of serum total cholesterol, triglycerides, lipoproteins and apolipoproteins A1 and B), and re-evaluated in 1994. Correlation coefficients between initial and final lipid and apolipoprotein values were as follows: total cholesterol, 0.66; low-density lipoprotein (LDL) cholesterol, 0.65; high-density lipoprotein (HDL) cholesterol, 0.61; triglycerides, 0.61; apolipoprotein A1, 0.60; apolipoprotein B, 0.66. When age groups were analysed separately, children who were 14 years old at the beginning of the study showed higher correlation coefficients, particularly for total cholesterol and LDL cholesterol ( > 0.7 in both cases). More than 70% of children who were in the top quintile of total, LDL or HDL cholesterol as well as apolipoprotein A1 or B in 1989 remained in the top quintile 5 years later.

Relations between nutrient intake and serum lipid and apolipoprotein levels

OBJECTIVE

To study the relation between diet and serum lipid and apolipoprotein levels in a large, homogeneous group of Spanish children.

DESIGN

Survey.

SETTING

Eleven schools chosen at random in Madrid City and the surrounding area.

SUBJECTS AND METHODS

Subjects comprised 1682 children, 2 to 12 years of age. Dietary data were obtained with a 24-hour record performed by the child's main caregiver. For statistical analysis the sample was divided into tertiles on the basis of calorie-adjusted consumption of dietary components.

RESULTS

Children in the highest tertile of total fat consumption, compared with children in the lowest tertile, had significantly higher mean serum levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), apolipoprotein A-I (Apo A) and apolipoprotein B-100 (Apo B). When compared with children in the lowest tertile, children in the highest tertile of saturated fat consumption had significantly higher mean levels of TC, LDL-C, and Apo B, and lower mean levels of HDL-C and Apo A. Children in the highest tertile of monounsaturated fat consumption, compared with children in the lowest tertile, had significantly higher mean levels of HDL-C and Apo A, and lower mean levels of TC, LDL-C, and Apo B.

CONCLUSIONS

Our findings suggest that diet composition strongly influences lipid profile in children and point out the importance of monounsaturated fatty acids as modulators of serum lipid and apolipoprotein levels.

Diet therapy for hypercholesterolemia in children and adolescents. A follow-up

OBJECTIVE

To determine the effectiveness and compliance of dietary restriction in a group of children and adolescents with hypercholesterolemia.

RESEARCH DESIGN

Prospective clinical trial.

SETTING

Pediatric hospital in Madrid, Spain.

PARTICIPANTS

Four hundred fifty-one children and adolescents of both sexes aged 2 to 18 years diagnosed as having hypercholesterolemia and treated with dietary restriction (American Heart Association Step-One and Step-Two Diets). The follow-up period ranged from 6 months to 2 years and was performed by one pediatrician.

RESULTS

Total cholesterol, low-density lipoprotein cholesterol, and apolipoprotein B-100 levels as well as the low-density lipoprotein cholesterol/high-density lipoprotein cholesterol ratio decreased significantly (P < .01) from the first month of dietary restriction, whereas the high-density lipoprotein cholesterol level increased (P < .01). The apolipoprotein A-I level increased significantly (P < .01) only after 6 months of diet therapy. After 12 months of follow-up, 30.7% (58/189) of patients did not follow the diet strictly. In this group, significantly higher levels of total cholesterol, low-density lipoprotein cholesterol, and apolipoprotein B-100 were found.

CONCLUSIONS

Diet therapy is effective in the treatment of hypercholesterolemia in children and adolescents. Dietary restriction has a beneficial effect not only on total cholesterol and low-density lipoprotein cholesterol levels but also on apolipoprotein A-I and B-100 levels.

Fibrinogen as a cardiovascular risk factor in Spanish children and adolescents. The Niño Jesus Group

Studies done on adults reveal a significant role of fibrinogen (FG) in cardiovascular disease. The main purpose of our study was to determine the level of plasma FG in children, its distribution according to age and sex, and its relationship to other cardiovascular risk factors such as cigarette smoking, plasma lipid disturbances, and a positive family history for other cardiovascular risk factors. We studied a population of 2224 children, aged 2 to 18 years, from five different schools located in Madrid. We found a significantly higher level of FG in the groups of females aged 6 to 8 and 16 to 18 years than in males of the same ages (p < 0.001). The study population was distributed into two groups according to the plasma fibrinogen level: > 394 mg/dl and < 394 mg/dl. In both groups we determined plasma levels of total cholesterol, triglycerides, and very low-density lipoprotein (VLDL) cholesterol and found these parameters significantly higher in the group with an FG level > 394 mg/dl (p < 0.05).

Smoking and apolipoproteins in adolescents. The Niño Jesus Group

The relation between smoking and blood lipids and apolipoproteins (A1,B100) were studied in a group of 1024 12- to 18-year-old school children in the Comunidad de Madrid. The percentage of smokers was 19% (17% for girls and 21% for boys). The average consumption of cigarettes per day was 7.83 +/- 5.06 in boys and 6.04 +/- 3.49 in girls (p less than 0.05). As compared with male nonsmokers, male smokers showed a higher mean level of low-density lipoprotein (LDL) cholesterol (112 versus 100 mg/dL, p less than 0.05), a higher LDL cholesterol to HDL-cholesterol ratio (2.27 versus 1.94, p less than 0.001), a higher mean level of apolipoprotein B100 (59 versus 53 mg/dL, p less than 0.05), and a higher apolipoprotein B100 to apolipoprotein A1 ratio (0.45 versus 0.40, p less than 0.01). Female smokers tended to show the same results, although significant differences were only found for LDL cholesterol to HDL cholesterol ratio and apolipoprotein B100 to apolipoprotein A1 ratio (1.8 versus 1.59 and 0.41 versus 0.38 respectively, both p less than 0.05). This work provides new data about the effects of smoking on apolipoproteins in adolescents and emphasizes on the need for preventive programs.

[Hemolytic-uremic syndrome. Experience with 154 cases]

One hundred and fifty four patients with hemolytic uremic syndrome (HUS) were admitted from year 1968 throughout 1989 to a public children's hospital (n = 139) and to a private general clinic (n = 15) at Metropolitan Santiago, Chile. Their mean age at admission was 16 months, 64% of them were 6 to 18 month old. One third of patients were admitted at spring season. The prodromal phase lasted between 1 and 19 days. In 92% of cases there was antecedent diarrhea and 31% showed neurological involvement. Anuria was present in 44 patients (21%) lasting an average of 7 days; sixty one affected children (40%) became hypertensive. Sixty patients (39%) underwent peritoneal dialysis, remaining cases were given maintenance treatment for acute renal failure (ARF). No specific treatment was used except heparin in 5 children along the first years of these series. Ten patients (6%) died during the acute phase of their disease, but death occurred in only 2 of the 76 most recent cases, probably because of more accurate diagnosis and greater experience of the professional team in the management of ARF, even though very heterogeneous clinical presentations were observed along the whole observation period. Three patients developed chronic renal failure.

[Fulminant hepatic failure in children]

We report the clinical characteristics and course of 38 children with fulminant liver failure. A viral etiology was demonstrated in 19 patients out of 25 with serologic screening (virus A in 17 patients, B in 2 patients). One patient had toxic liver damage from ingestion of a caustic substance. Mean age was 4 years and 6 months. Jaundice was present in all but 2 patients at admission. Encephalopathy developed at a mean of 13 days and 17 children were admitted with stage 3 or 4 coma. Evidence of severe liver failure was present in every patient. A lower prothrombin time and higher bilirrubin concentration were shown by non survivors. Hypoglycemia developed in 37% of patients, seizures in 37%, gastrointestinal bleeding in 45%, respiratory failure in 32% and severe infection in 32%. Overall mortality rate was 42% raising to 83% in patients with stage 3 coma at admission. Thus, although the etiology of fulminant liver failure differs in children as compared to adults, mortality rate and complications are similar.

[The Fuenlabrada study: relationship between anthropometric variables and cardiovascular risk factors]

Anthropometric variables were studied in 2,153 healthy children, 1,115 males and 1,038 females, aged 0 to 18 years, of the Fuenlabrada population, Madrid. Height was measured by an anthropometer and weight by a weighting scale. Tricipital and subscapular skinfold thickness were measured by Holtain caliper. Body mass index (kg/m2) and ponderal index (kg/m3) were calculated from weight and height. In the total population skinfold thickness had the highest correlation with total body fat. But, when only obese children (greater than 95 p) were analyzed, other variables like body mass index and ponderal index had also high correlation. Different fatness trends were observed between sexes, although females always were the fattest. In our population the correlation of skinfold thickness, body mass index and ponderal index with lipids, blood pressure, glycemia and uric acid were significant. Obese children and adolescents had nearly a twofold increase in relative risk of arterial hypertension, hypertriglyceridemia, hyperuricemia and low C-HDL.

[Fuenlabrada study: lipid and lipoprotein levels in children and adolescents associated with ischemic cardiopathy prevalence among their relatives]

The prevalence of coronary heart disease (CHD) was studied in parents and grandparents of 2,419 children surveyed for lipid levels. Children and their families were divided into 3 groups depending on the level of each lipid and lipoprotein studied in children: high greater than or equal to 95 percentile (p), medium 5-95 p, and low less than 5 p. Total cholesterol (Chol) and triglycerides (TG) were determined by enzymatic techniques in autoanalyzer. C-HDL was determined by precipitation method. C-LDL and C-VLDL were obtained by Friedewald-Fredrickson's equation. The prevalence of CHD in parents and grandparents was ascertained from clinical history. Fathers of children in the high groups of Chol, TG, C-LDL/C-HDL, and low group of C-HDL had increased prevalence of CHD compared with those of the low groups of Chol, TG, C-LDL, C-LDL/C-HDL and high group of C-HDL. The strongest association was with C-HDL. Maternal and paternal grandfathers of children in the high groups of Chol had also increased prevalence of CHD compared with those of low group of Chol. There was no association with any other variable. The association was not significant neither in mothers nor in maternal and paternal grandmothers. Childhood lipid and lipoprotein levels could identify families at elevated risk for CHD.

[Mortality in pediatric intensive care units. The role of acute failure of organs and systems]

Previous health state and acute failure of six organ system (cardiovascular, respiratory, neurologic, hematologic, renal and digestive systems) at admission to a pediatric intensive care unit (ICU) were evaluated in 71 patients that died along one year in an ICU of a pediatric hospital at Santiago, Chile. Acute organic system failure (AOF) and chronic organic failure (COF) were defined on clinical, laboratory and therapeutic standards at hand in this country. COF was present in 56% of the cases, and was mainly due to congenital heart malformations. At admission 44% of patients showed evidence of AOF most frequently of the respiratory (54%) and neurologic (44%) systems. Multisystemic failure occurred in 55% of the cases being present in 90.9% of patients with chronic heart diseases and in 77.7% of children admitted by different causes of sepsis. Multiple organ failure was the most frequent cause of death (33%) affecting preferentially patients with COF secondary to lung infections (40%) and central nervous system diseases (20%). AOF of the central nervous system was the second global cause of death and the first among previously healthy children. Irreversible respiratory malfunction caused 21% of deaths.

[The Fuenlabrada study: arterial pressure in children and adolescents]

Blood pressure was studied in 2,153 healthy children of both sexes, from 0 to 18 years of age; 1,115 were males and 1,038 females. Systolic and diastolic blood pressures were measured in the sitting position by the auscultatory method on the right arm with a mercury sphygmomanometer using an appropriate cuff size. Systolic blood pressure was measured on the first sound and diastolic blood pressure in the fourth phase of Korotkoff. In children younger than 3 years blood pressure was measured in the decubitus supine position using the Doppler technique. There were no significant differences in mean systolic and diastolic blood pressure in both sexes. But the percentage of systolic blood pressure greater than or equal to 130 mmHg was higher in males than females (p less than or equal to 0.01). 8.4% of the total population had systolic blood pressure greater than or equal to 130 mmHg, and 1.3% had diastolic blood pressure greater than or equal to 90 mmHg. The annual increase rates of systolic and diastolic blood pressure were 2.31/0.94 mmHg in males and 2/0.97 mmHg in females. Children with blood pressure greater than or equal to the 95th percentile had a higher prevalence of hypertriglyceridemia and obesity. 54% of the variation in systolic blood pressure was explained by the association of weight, subscapular skinfold, body mass index and C-HDL. 30% of the variation in diastolic blood pressure was explained by the association of weight, obesity index, subscapular skinfold and C-HDL.

[The Fuenlabrada study: a familial aggregation of ischemic cardiopathy and cardiovascular risk factors]

Familial aggregation of coronary heart disease (CHD) and coronary risk factors (CRF) were evaluated by clinical history in adult relatives of children surveyed for CRF. Population was divided into two groups: Group I included 2,153 children without parental history of CHD. Group II included 266 children of 112 families with parental history of early CHD (before 56 years). In 105 cases the patients were the fathers and in 7 cases the mothers. All the patients were admitted to a coronary care unit. Familial aggregation of CHD was 9.7 times more frequent in paternal families of group II (p less than or equal to 0.0001) than in group I; there was no differences in maternal families. Higher prevalence of hyperlipidaemia, blood pressure hypertension, smoking habits, diabetes and obesity in fathers of group II was observed. Children in group II showed increased levels of C-LDL and decreased levels of C-HDL compared with those of group I. The prevalence of CRF was also significantly higher in children of group II, although in the 33% of the children of group II no CRF was detected.

CONCLUSION

a substantial proportion, but not all cases, of familial aggregation of CHD could be explained by known CRF.

[Cardiorespiratory failure: results of resuscitation in a pediatric ICU]

Along one year, cardiorespiratory resuscitation was done to 71 patients, aged 3 days to 10 years (median 3.5 month), in a pediatric intensive care unit. Although 39 patients (55%) recovered through first-stage treatment, in 17 the arrest was recurrent and they died in the following 24 hours. Only 12 (16.9%) children definitely survived. No patients requiring reanimation for more than 10 min, survived. Asystole was the most frequent arrhythmia (92%). There were only 4 cases of ventricular fibrillation, all occurred in patients with congenital heart disease, and no one recovered. Survivors have not evidence of neurological deficiencies, and only one died along one year follow up, because of congenital heart disease.

[The Fuenlabrada study: lipids and lipoproteins in children and adolescents]

Lipids and lipoproteins were studied in 2,153 healthy children, of both sexes, aged 0 to 18 years old, of Fuenlabrada, Madrid, population. We determined: Total Cholesterol (TC) and Triglycerides (TG) by automatized enzymatic techniques. C-HDL by precipitation method. C-LDL and C-VLDL were calculated by Friedewald-Fredrickson equation. Our laboratory have previously standardized the techniques of obtention of TC, TG and C-HDL using serums of reference. Mean values were: TC = 166 +/- 36 mg/dl, TG = 63 +/- 39 mg/dl, C-HDL = 53 +/- 13 mg/dl, C-LDL = 102 +/- 34 mg/dl, C-VLDL = 13 +/- 6 mg/dl. In our population 14% had TC greater than or equal to 200 mg/dl, 2.6% TG greater than or equal to 140 mg/dl and 15% C-HDL less than or equal to 40 mg/dl. During adolescence a significant change in the lipid and lipoprotein pattern in both sexes was observed. At the end of the adolescence, males had C-HDL lower and TG, C-LDL and C-VLDL higher than females. Correlations and associations of lipids and lipoproteins were similar in our population than in adult population. The mean finding of this study is the actual high level of TC in our children population.

[Cardiovascular risk factors in children and adolescents in Fuenlabrada: objectives, features of the population, design, participation, equipment, laboratory technics, and quality control]

Fuenlabrada is at the present time the most industrialized town placed at the south are of Madrid. This population has some peculiar attractive characteristics from the epidemiologic point of view. Perhaps the most important is that the majority of its inhabitants are immigrant from other depressed rural areas of the country, with a low socio-economic and cultural level. The new conditions of life could have changed the life expectation and the causes of morbidity and mortality of this population. Between 1981 and 1984 we have studied the prevalence of cardiovascular risk factors in children and adolescents of its population, the relationships with cardiovascular risk factors and cardiovascular disease of the family and type of lactancy of the newborn. The variables studied were: height, weight, skin fold, blood pressure, lipids, lipoproteins, glycemia, uric acid and tobacco habit. The laboratory technics were standardized with serums of reference. The index of participation in the study of the required population was approximately of 80%.