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ED performance evaluation for QMS - quality management systems - is a widely discussed topic, aimed at measuring the degree to which planned results are achieved. However, there is very limited information on mechanisms or methodologies to evaluate the degree of compliance with ISO 9001:2015 requirements. Because the audit process is in charge of evaluating compliance with quality requirements dichotomously (compliant and non-compliant), this does not allow the gaps between the current state of the requirement and the expected result to be evidenced. In this sense, with this quantitative research, developed from a descriptive design study, a tool was designed for the DE of a QMS, based on normative criteria of different ISO documents, to provide a basis for companies that want to accurately and quantitatively measure the degree of to which the requirements of the ISO 9001:2015, PHVA cycle framework are being met and where the strengths and weaknesses of the system can be clearly and simply identified. La evaluación de desempeño ED para los sistemas de gestión de la calidad SGC, es un tema ampliamente tratado, y está orientado a medir el grado en el que se logran los resultados planificados, sin embargo, es muy limitada la información sobre mecanismos o metodologías que permitan evaluar el grado en el que se cumple los requisitos de la norma ISO 9001:2015. Debido a que es el proceso de auditoría el encargado de evaluar el cumplimiento de los requisitos de calidad de manera dicotómica (conforme y no conforme), aspecto que no permite evidenciar las brechas entre en estado actual del requisito y el resultado esperado. En este sentido, con la presente investigación de carácter cuantitativa y desarrollada a partir de un estudio de diseño descriptivo, se diseñó una herramienta para la ED de un SGC, considerando criterios normativos de diferentes documentos ISO, de manera que proporcione una base para aquellas empresas que quieran medir de manera precisa y cuantitativa el grado en el que se cumple los requisitos de la norma ISO 9001:2015 marco del ciclo PHVA y en donde se logre identificar de manera clara y sencilla de las fortalezas y debilidades del sistema. A avaliação de desempenho ED para sistemas de gestão de qualidade, SGQ, é um tema amplamente debatido, que visa medir o grau de realização dos resultados planejados, entretanto, as informações sobre mecanismos ou metodologias muito limitadas para avaliar o grau de atendimento dos requisitos da ISO 9001:2015. Sendo o processo de auditoria o encarregado de avaliar a conformidade com os requisitos de qualidade de forma dicotômica (conforme e não conforme), não é possível evidenciar as lacunas entre o estado atual do requisito e o resultado esperado. Neste sentido, com a presente pesquisa quantitativa, desenvolvida a partir de um estudo de projeto descritivo, foi projetada uma ferramenta para o DE de um SGQ, considerando critérios normativos de diferentes documentos ISO, para fornecer uma base para as empresas que precisam medir precisa e quantitativamente o grau de atendimento dos requisitos da ISO 9001:2015 estrutura do ciclo PHVA e na que os pontos fortes e fracos do sistema possam ser clara e facilmente identificados.

To estimate the association between childhood obesity and the risk of SARS-CoV-2 infection in a cohort followed from 4 to 12 years of age.The data were obtained from two independent sources: the Longitudinal Childhood Obesity Study (ELOIN) and the epidemiological surveillance system data from the Community of Madrid (Spain), which served to identify the population within the cohort with confirmed SARS-CoV-2 infection. The SARS-CoV-2 registry was cross-checked with the cohort population at 11-12 years of age. A total of 2018 eligible participants were identified in the cohort, who underwent physical examinations at 4, 6, and 9 years of age during which weight, height, and waist circumference were recorded. General obesity (GO) was determined according to the WHO-2007 criteria whereas abdominal obesity (AO) was defined based on the International Diabetes Federation (IDF) criteria. The relative risks (RRs) of infection were estimated using a Poisson regression model and adjusted by sociodemographic variables, physical activity, and perceived health reported by the parents.The accumulated incidence of SARS-CoV-2 infection was 8.6% (95% CI: 7.3-9.8). The estimated RR of SARS-CoV-2 infection was 2.53 (95% CI: 1.56-4.10) and 2.56 (95% CI: 1.55-4.21) for children 4-9 years old with stable GO and AO, respectively, compared with those who did not present GO.Childhood obesity is an independent risk factor for SARS-CoV-2 infection. This study provides new evidence that indicates that obesity increases the vulnerability of the paediatric population to infectious diseases.

Retoma-se o exame do relacionamento do poeta galego Manuel Maria com Portugal, reorientado aos focos da Poética e da Política, confirmando a exemplaridade do seu caso no que tem a ver com o aproveitamento e influência dessa relação, em termos de publicação, presenças temáticas e pensamento de língua própria e até pensamento de país. A abordagem segue três etapas sucessivas, acompanhando o percurso vital e literário do Poeta: contato retórico/literário com Portugal, reconhecimento apropriativo, retorno auto-afirmativo continuado. Concluímos que Manuel Maria efectivou um contato que no galeguismo sobrevivente do golpe militar tinha ficado desativado, circulou literariamente e editou com naturalidade em Portugal, e daí decorreu um reconhecimento e assimilação de afinidades linguístico-culturais, uma identificação apropriativa e um retorno auto-afirmativo, com marcas temáticas e posicionamento político/poético, por exemplo, sobre a Norma para o galego. Uma trajectória que reitera a importância do reencontro com Portugal na tomada de consciência Galeguista, e se liga à tradição do filolusismo das Irmandades da Fala.

IMPORTANCE: Abnormal peripheral perfusion after septic shock resuscitation has been associated with organ dysfunction and mortality. The potential role of the clinical assessment of peripheral perfusion as a target during resuscitation in early septic shock has not been established. OBJECTIVE: To determine if a peripheral perfusion–targeted resuscitation during early septic shock in adults is more effective than a lactate level–targeted resuscitation for reducing mortality. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized trial conducted at 28 intensive care units in 5 countries. Four-hundred twenty-four patients with septic shock were included between March 2017 and March 2018. The last date of follow-up was June 12, 2018. INTERVENTIONS: Patients were randomized to a step-by-step resuscitation protocol aimed at either normalizing capillary refill time (n = 212) or normalizing or decreasing lactate levels at rates greater than 20% per 2 hours (n = 212), during an 8-hour intervention period. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality at 28 days. Secondary outcomes were organ dysfunction at 72 hours after randomization, as assessed by Sequential Organ Failure Assessment (SOFA) score (range, 0 [best] to 24 [worst]); death within 90 days; mechanical ventilation–, renal replacement therapy–, and vasopressor-free days within 28 days; intensive care unit and hospital length of stay. RESULTS: Among 424 patients randomized (mean age, 63 years; 226 [53%] women), 416 (98%) completed the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and 92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 [95% CI, 0.55 to 1.02]; P = .06; risk difference, −8.5% [95% CI, −18.2% to 1.2%]). Peripheral perfusion–targeted resuscitation was associated with less organ dysfunction at 72 hours (mean SOFA score, 5.6 [SD, 4.3] vs 6.6 [SD, 4.7]; mean difference, −1.00 [95% CI, −1.97 to −0.02]; P = .045). There were no significant differences in the other 6 secondary outcomes. No protocol-related serious adverse reactions were confirmed. CONCLUSIONS AND RELEVANCE: Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality., Facultad de Ciencias Médicas

Resumen Objetivos Describir el manejo anestesico durante cesarea en una paciente con miocardiopatia dilatada. Materiales y metodos Se describe una paciente de 35 anos cursando su 33 a semana de gestacion con el antecedente de miocardiopatia dilatada del periparto que requirio la finalizacion del embarazo por descompensacion de su enfermedad. Se realizo una anestesia combinada espinal/epidural. Resultados En el intraoperatorio, la paciente presento un evento hipotensivo a causa de la perdida hematica al momento del alumbramiento. Dicho evento fue manejado exitosamente, sin el desarrollo de complicaciones posteriores. Posteriormente ingreso a la unidad coronaria estable hemodinamicamente y fue dada de alta a las 72 h. Discusion Mientras sea posible la realizacion de un bloqueo neuroaxial, este deberia ser empleado. En caso de realizar anestesia general, se deben tomar ciertos recaudos para evitar posibles complicaciones. El abordaje multidisciplinario debe ser tenido en cuenta en estas pacientes. Conclusion La tecnica anestesica combinada espinal/epidural fue segura y eficaz para el caso presentado.

Background Atrioventricular nodal reentrant tachycardia (AVNRT) and atrioventricular reentrant tachycardia (AVRT) often terminate spontaneously, presumably due to changes in the electrophysiological properties of the reentrant circuit. However, the mechanism of spontaneous termination of these arrhythmias is incompletely understood. Methods We included 70 consecutive patients with reentrant supraventricular tachycardias (35 AVNRT, 35 AVRT) in whom the arrhythmia ended spontaneously during the electrophysiologic study. We determined in each patient the duration of the induced arrhythmia, site of block, beat-to-beat oscillations in tachycardia cycle-length (CL), A-H, H-V, H-A and V-A intervals. Results In 21/34 (62%) patients with AVNRT and 19/30 (63%) with orthodromic AVRT, tachycardia termination was preceded by progressive increase in tachycardia CL due to prolongation of the A–H interval (Mobitz type-I pattern). In 13/34 patients with AVNRT (38%) and 11/30 with orthodromic AVRT (37%), termination occurred suddenly without a preceding change in CL, with block ensuing retrogradely either in the fast AV nodal pathway or the accessory pathway (Mobitz type-II pattern). In 4/5 patients with antidromic AVRT the tachycardia ended at the retrograde limb with previous prolongation of the VA interval. Conclusion Spontaneous termination of AVNRT and AVRT is a time-related phenomenon. Despite different pathways being involved in these two reentrant tachycardias, termination can follow antegrade or retrograde block in similar ratio (60% antegradely and 40% retrogradely). Antegrade block is preceded by prolongation of the AH interval (Mobitz type-I), whereas retrograde block occurs unexpectedly in the retrograde limb (Mobitz type-II). Fatigue of conduction appears to be involved in this phenomenon.

We report the first case of isolated biotin resistant 3-methylcrotonyl-CoA carboxylase (MCC) deficiency in Argentina. The diagnosis was established at 14 months of age by urinary organic-acid analysis and confirmed by enzyme assay in fibroblasts. The patient suffered from severe psychomotor retardation, hypotonia, areflexia, and failure to thrive, and died unexpectedly at 3 years 4 months of life. Brain MRI at 14 months showed signals of the white matter on cerebral T2-weighted, which were indicative of confluent and multiple foci of leukodystrophy, a pattern not previously described in this entity. In addition, high levels of oxypurines were detected in cerebrospinal fluid. This might be related to energetic consequences of the enzyme deficiency in the brain. This case extends the phenotype of isolated MCC deficiency in infancy and suggests this entity should be considered to be one of the possible causes of “metabolic leukodystrophies.”

To the Editor: St. Louis encephalitis is a mosquito-borne viral disease that affects humans. The causative agent, SLEV (formal name: Saint Louis encephalitis virus), is a member of the Flaviviridae family. Severity of the clinical syndromes increases with age, and persons >60 years old have the highest frequency of encephalitis. The primary transmission cycle involves wild passeiform, columbiform birds, and Culex sp. mosquitoes (1). In Argentina, an urban cycle may involve Cx. quinquefasciatus, which is a source of a viral isolate, and abundant birds (house sparrows, doves, or chickens) (2). The distribution of SLEV in Argentina is wide; seroprevalence ranges from 3% to 50% of the country’s population (3). Spinsanti et al. reported results of a serologic screening in persons ages 0–87 years who live in the city of Cordoba; antibodies were most frequently found in persons >60 years of age (4). However, cases of St. Louis encephalitis reported in Argentina are very rare. Two cases with serologic diagnosis were reported in 1964 and 1968, respectively (2). In 1971, two more cases were diagnosed on the basis of viral isolation (5). Finally, the last case reported was a patient with meningoencephalitis diagnosed in the province of Buenos Aires by hemagglutination inhibition assay (6). Herein, we report a case of Saint Louis encephalitis that occurred in the province of Cordoba, Argentina. A 61-year-old man was admitted to the hospital in February 2002, complaining of headache, fever, and diplopia. He had been well until 3 months before admission, when ophthalmic herpes zoster was diagnosed. He underwent therapy with oral acyclovir and had a good clinical outcome. Ten days before admission, he developed unstable gait with misbalance and hand tremors, mainly at his left side. On admission, he had occipital headache, diplopia, and nausea and vomiting associated with high fever and chills. Somnolence appeared a few hours before the consultation. The patient was a right-handed businessman, a native of Cordoba. He was married and had no risk factors for sexually transmitted diseases. He had not traveled inside or outside the country during the last year. He lived near a river with a high-density population of mosquitoes. Vital signs on admission showed axillary temperature of 39°C, pulse of 90 beats per minute, respiratory frequency of 20 per minute, and blood pressure of 110/70 mmHg. Physical examination demonstrated a somnolent patient who was easily aroused and oriented. His speech was slurred. Results of a fundoscopic examination appeared normal. Results of a cranial-nerve examination showed horizontal left diplopia with left sixth nerve paresia. A resting, postural, and intentional hand tremor was evident. Motor strength was 5/5 throughout with normal bulk and tone, tendon reflexes, and coordination. Examination of sensitivity showed no abnormalities. A slight neck rigidity was detected. Routine laboratory analysis was unremarkable, and results of serologic tests for coxsackie virus, echovirus, and HIV were negative. HIV-1 RNA by polymerase chain reaction (PCR) and p24 antigen were also negative. Cerebrospinal fluid study revealed a leukocyte count of 18/mm3 (80% lymphocytes), a glucose level of 48 mg/dL, and a protein level of 87 mg/dL. Cryptococcal antigen, antibodies for syphilis, Human herpesvirus 1 and 2, and PCR for varicella-zoster virus 1 and Human herpesvirus were also negative. Results of an electroencephalogram and a chest radiograph were normal. Therapy with intravenous acyclovir was initiated. A magnetic resonance imaging (MRI) scan of the brain showed a striking signal change on T2 in the substantia nigra of the midbrain, mainly at the right side. The patient continued febrile, diplopia disappeared, and meningeal signs progressed with frank cervical stiffness, positive Kerning sign, and photophobia. Diffuse tremulousness and axial rigidity appeared. Upper extremities showed rigidity with cogwheel phenomenon. Conversely, lower extremities showed spasticity with bilateral Babinski sign. Tendon reflexes became enhanced. His gait showed retropulsion with wide base sustentation. Dysdiadochokinesia appeared. On the third day, a new lumbar puncture showed worse results: a leukocyte count of 210/mm3 (82% lymphocytes), a glucose level of 51 mg/dL, and a protein level of 106 mg/dL. Another electroencephalographic examination showed unspecific centroparietal disorganization with right side predominance. Intravenous acyclovir was stopped. On the 5th day, the patient began to recover; he was discharged on the 10th day. After 3 months of follow-up, only left arm rigidity and a left hand tremor persisted. Acute- and convalescent-phase serum samples (taken 10 and 16 days after onset of illness, respectively) were sent to the Arbovirus and Arenavirus Disease Laboratory, Instituto de Virologia, Cordoba. SLEV immunoglobulin (Ig) M antibodies were positive by indirect immunofluorescence assay (IFA). Seroconversion for IgG antibodies was demonstrated by IFA (7) and hemagglutination inhibition assay, with titers of 640 and 80 in the first sample and 2,560 and 320 in the second sample. These results were confirmed by neutralization test using the reduction of plates technique in Vero cells culture, as described (8). Eastern equine encephalomyelitis virus and Western equine encephalomyelitis viruses with known circulation in Argentina were included in the assay with negative results (3). An increase in antibodies titers between acute- (320) and convalescent-phase (1,280) samples was found only for SLEV. Among other flaviviruses, dengue, yellow fever, and Ilheus circulate only in subtropical areas of Argentina (the province of Cordoba is not included in this area); only dengue virus was investigated (by neutralization test) because of a current epidemiologic surveillance program; results were negative. No evidence that West Nile virus is currently circulating or has entered Argentina was found, so we did not perform tests to detect it (2,9). Isolation of SLEV from the cerebrospinal fluid and blood was attempted in newborn mice and Vero cell cultures with negative results. While the typical clinical manifestations of viral encephalitis (fever, headache, and altered level of consciousness) are indistinguishable from each other, tremor and other extrapyramidal signs are described in St. Louis encephalitis and Japanese encephalitis (10). The typical MRI finding of patients with St. Louis encephalitis is localized in the substantia nigra (11). In summary, the occurrence of St. Louis encephalitis in a 61-year-old patient, after >10 years of no reports in Argentina, along with specific epidemiology, suggest that further studies are needed to assess the risk for human infection by SLEV in Argentina and the role of several mosquitoes species in its transmission.

We report the first case of isolated biotin resistant 3-methylcrotonyl-CoA carboxylase (MCC) deficiency in Argentina. The diagnosis was established at 14 months of age by urinary organic-acid analysis and confirmed by enzyme assay in fibroblasts. The patient suffered from severe psychomotor retardation, hypotonia, areflexia, and failure to thrive, and died unexpectedly at 3 years 4 months of life. Brain MRI at 14 months showed signals of the white matter on cerebral T2-weighted, which were indicative of confluent and multiple foci of leukodystrophy, a pattern not previously described in this entity. In addition, high levels of oxypurines were detected in cerebrospinal fluid. This might be related to energetic consequences of the enzyme deficiency in the brain. This case extends the phenotype of isolated MCC deficiency in infancy and suggests this entity should be considered to be one of the possible causes of "metabolic leukodystrophies."