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English to Spanish: Newsweek- Smugness is our Greatest Enemy General field: Social Sciences Detailed field: Journalism
Source text - English Smugness Is Our Greatest Enemy
Today, many Democrats are playing Charlie Brown to Bush’s Lucy. Just as they were talking about a quagmire, the war was won.
By Jonathan Alter
Newsweek
April, 2003 issue — I know it’s a common complaint, but why can’t people ever admit that their side might be wrong? The doves can’t admit they were wrong about the rightness of freeing 24 million Iraqis, however chaotic the aftermath. And the hawks can’t admit that they are wrong about the go-it-alone occupation, including a boneheaded Pentagon decision I came across that helped open the door for the looting of some of civilization’s treasures. Both sides are more dug in than the Third Infantry Division at Baghdad International Airport.
Let’s be clear about the doves. They never said the United States wouldn’t win militarily; their objection was based on other factors (rejection of “preventive” war, botched diplomacy, etc.). And they may be proved right: history’s jury will be out a long time. Even so, I can’t get over how churlish the left has become. When did the liberals take the “lib” out of liberation? This was a totalitarian regime we’re talking about, with a boot on the face of the Iraqi people. The same folks who led the charge against fascism in Europe; who rightly spoke up against the U.S. government about “disappearances” in El Salvador and Guatemala; who carried high the banner of human rights—now they yawn at revelations of mass graves in Iraq and argue that the Iraqis will be no better off than before. Freedom’s just another word that liberals have figured out how to lose.
The explanation is partly partisan politics. Many Democrats are so blinded by their loathing of George W. Bush that they can’t think straight. In their hearts, they don’t see Bush as the legitimately elected president, just as Tom DeLay and the right-wing attack machine tried to deny President Clinton’s legitimacy from the outset, without even a Florida rationale. In both cases, this thinking can take you right over the cliff.
Today too many Democrats are playing Charlie Brown to Bush’s Lucy. Just as they started talking about a quagmire, the war was won. Next football to be snatched away: WMD. At the precise moment this week or next that the liberals proclaim that Iraq has no chemical weapons after all, they’ll finally turn up in Syria or some bunker. Promise. Republicans, meanwhile, remind me of Chris Rock’s foe in “Head of State.” His slogan is “God Bless America—and no place else.” Ari Fleischer says the White House can’t keep the Rev. Franklin Graham, who has called Islam “a very evil and wicked religion,” from performing Good Friday services in Baghdad and trying to Christianize the country. How about a phone call from his good friend the president (at whose Inaugural he spoke)?
Then there are those images all over the Arab world of Gen. Tommy Franks & Co. smoking cigars and getting comfortable in Saddam’s presidential palace, as if they were the pigs in George Orwell’s “Animal Farm” celebrating their revolution by moving into the farmer’s house. Doesn’t look too good to the other animals—or the Iraqi people. Gens. Douglas MacArthur and Lucien Clay took great pains to understand Japanese and German society before administering their occupations. This crowd is more Kiplingesque.
Smugness can kill. It may be satisfying to say “Screw you” to the United Nations, and the United States got away with it during the war. But in an occupation, it’s not smart. Isn’t it about time the DOD started playing some defense? Which is the more likely target of suicide bombers: a barracks full of American soldiers or a barracks full of peacekeepers—including Muslim troops—from around the world? You’d think we could figure out how to run the occupation without presenting such a fat target.
In short, the fighting was brilliant; the immediate “follow-on” a failure. Donald Rumsfeld was right to have a light, speedy war plan. Another division wasn’t necessary. But the “retired officers embedded in TV studios” (to quote our draft-deferment vice president about former generals Barry McCaffrey and Wesley Clark, who have four Silver Stars between them) were not entirely wrong. I learned last week that many Army officers wanted to airlift in 3,000 MPs (military police) from Europe to protect supply lines and police Baghdad. That would have aided the drive to the capital and helped to protect institutions like hospitals and museums once forces arrived there. As it was, the main hospital wasn’t even secured until an officer was alerted to the looting by New Yorker reporter Jon Lee Anderson. But Rumsfeld apparently decided: no MPs. The European MPs would have had to be replaced by reservists. And if more reservists had been called up in the middle of the war, it would have reinforced the criticism that Rumsfeld hadn’t sent enough troops.
When the real history is written, we may find out that some of the world’s oldest treasures were lost to looters in part because someone at the Pentagon suffers from the oldest of human sins—pride.
Translation - Spanish Presunción Es Nuestro Mayor Enemigo
Hoy en día, muchos demócratas juegan el rol de Charlie Brown a Lucy de Bush. Justo cuando se estaba hablando de un pantano, la guerra ha sido ganada.
Por Jonathan Alter
Newsweek
Abril, 2003- Yo sé que es una queja común, pero ¿Por qué la gente no puede admitir que su partido podría estar equivocado? Las palomas no pueden admitir, que se equivocaron en cuanto a la rectitud de la liberación de 24 millones de iraquíes, por más caóticas que sean las repercusiones. Y los halcones no pueden admitir que están equivocados acerca de la solitaria ocupación, incluyendo la estúpida decisión del Pentágono, con la cual me encontré, y la cual ha ayudó abrir la puerta al saqueo de algunos tesoros de la civilización. Ambas partes están más clavadas que la Tercera División de Infantería en el aeropuerto de Bagdad.
Seamos claros acerca de las palomas. Nunca dijeron que Estados Unidos no iba a ganar militarmente, su objeción estaba basada en otros factores (el rechazo de la guerra 'preventiva', la diplomacia fallida, etc.) Y pueden tener razón: el jurado de la historia quedará afuera por mucho tiempo. Aún así, no puedo superar lo grosero en que se ha convertido la izquierda. ¿Cuándo los liberales han sacado el 'lib' de la liberación? Este fue un régimen totalitario del cual estamos hablando, con una bota en la cara al pueblo iraquí. La misma gente que llevó el cargo contra el fascismo en Europa, que habló justamente en contra del gobierno de EE.UU. sobre las 'desapariciones' en El Salvador y Guatemala, que llevó en lo alto la pancarta de los derechos humanos, ahora bosteza ante las revelaciones de fosas comunes en Irak y discute que los iraquíes no serán mejores que antes. La libertad es solo una palabra más que los liberales se han dado cuenta cómo perderla.
La explicación es la política partidista en parte. Muchos demócratas están tan cegados por su odio a George W. Bush, que no pueden pensar claro. En sus corazones, no ven a Bush como el presidente legítimamente elegido, al igual que Tom DeLay y la máquina de ataque de la derecha trataron de negar la legitimidad del presidente Clinton desde el principio, sin siquiera las razones de la Florida.
En ambos casos, este pensamiento te puede llevar al borde de la locura.
Hoy en día, demasiados demócratas juegan Charlie Brown a Lucy de Bush. Así como empezaron a hablar sobre un atolladero, la guerra ha sido ganada. Próximo fútbol para ser arrebatado: armas de destrucción masiva. En el momento preciso de esta o la siguiente semana de que los liberales proclaman que Irak, después de todo, no tiene armas químicas, aparecen finalmente en Siria o en algún búnker. Promesa. Los republicanos, mientras tanto, me recuerdan el enemigo de Chris Rock en 'Jefe de Estado'. Su eslogan es 'Dios bendiga América y ningún otro lugar'. Ari Fleischer dice, que Casa Blanca no puede mantener al Reverendo Franklin Graham, quien ha llamado Islam 'una religión muy malvada y perversa, por desempeñar los oficios del Viernes Santo en Bagdad y tratar de cristianizar al país. ¿Qué tal una llamada telefónica de su buen amigo, el presidente (en cuya toma de posesión habló)?
Luego están esas imágenes, en todo el mundo árabe, del general Tommy Franks & Co. fumando cigarros y poniéndose cómodo en el palacio presidencial de Saddam, como si fueran cerdos en 'Rebelión en la granja' de George Orwell, celebrando su revolución mudándose a la casa del granjero. No parece muy bueno para los otros animales- tampoco para el pueblo iraquí. Gens. Douglas MacArthur y Lucien Clay hicieron un gran esfuerzo para entender la sociedad japonesa y alemana antes de administrar sus ocupaciones. Esta muchedumbre es más al estilo Kipling.
Presunción puede ser mortal. Puede ser satisfactorio para decir 'Vete a la mierda' a las Naciones Unidas y los Estados Unidos salió con la suya durante la guerra. En una ocupación, no es inteligente. ¿No es la hora de que el Departamento de Defensa comenzara a jugar algún tipo de defensa? ¿Cuál es el objetivo más probable de los terroristas suicidas: un cuartel lleno de los soldados estadounidenses o un cuartel lleno de fuerzas de paz, incluyendo tropas de musulmanes de todo el mundo? Uno pensaría que pudiéramos encontrar la manera de llevar la ocupación sin presentar un objetivo tan grande.
En síntesis, la lucha fue brillante; la inmediata 'continuación' a un fracaso. Donald Rumsfeld tenía razón al tener un ligero y rápido plano de guerra. Otra división no era necesaria. Pero los 'oficiales retirados incrustados en los estudios de TV' (para citar a nuestro aplazamiento vicepresidente de ex generales Barry McCaffrey y Wesley Clark, quienes tienen cuatro estrellas de plata entre ellos) no estaban completamente equivocados. Me enteré la semana pasada, que muchos militares querían el transporte aéreo en 3,000 MP (Policía Militar) de Europa para proteger las líneas de suministro y patrullar Baghdad. Eso hubiese ayudado llegar a la capital y a proteger a las instituciones, como hospitales y museos, una vez las fuerzas llegarían allí. Así como fue, el hospital principal no estaba ni siquiera protegido hasta que un oficial fue avisado del saqueo por el reportero del New Yorker, Jon Lee Anderson. Sin embargo, Rumsfeld aparentemente decidió: ningunos parlamentarios. Los diputados europeos tendrían que haber sido reemplazados por reservistas. Y si más reservistas hubieran sido llamados a filas en el medio de la guerra, se habría reforzado la crítica de que Rumsfeld no había enviado suficientes tropas.
Cuando la verdadera historia se escribe, podemos descubrir que algunos de los más antiguos tesoros del mundo se perdieron a los saqueadores, en parte, porque alguien en el Pentágono sufre del mayor de los pecados humanos, el orgullo.
Polish to English: Drug-induced erythroderma complicated by multiorgan failure General field: Medical Detailed field: Medical (general)
Source text - Polish Wprowadzenie
Zmiany skorne o charakterze erytrodermii po raz pierwszy opisal von Hebra w 1868 roku. Erytrodermia nie jest jednolitym schorzeniem, lecz pojeciem klinicznym, za ktorym moga kryc sie schorzenia wywolujace zapalenie calej skory objawiajace sie klinicznie uogolnionym rumieniem, luszczeniem i przewaznie takze naciekami zapalnymi. Wspolna cecha wszystkich erytrodermii jest zwiazane z nimi ryzyko glebokiego uszkodzenia skory z utrata jej funkcji termoregulacyjnej i jako bariery ochronnej. W wiekszosci przypadkow zmiany skorne obejmuja ponad 90% powierzchni skory (9). W ciezkich postaciach erytrodermii moze dochodzic do uszkodzenia innych narzadow, jak: uklad sercowo-naczyniowy, watroba, nerki. Mozliwy jest takze zgon. Erytrodermie zwykle dzieli sie wedlug powodujacego je czynnika etiologicznego, na ostre i przewlekle oraz formy idiopatyczne. Moga rozwijac sie na podlozu wielu schorzen dermatologicznych i systemowych (alergicznych i niealergicznych zapalen skory, chorob pecherzowych, schorzen ukladowych, zakazen grzybiczych, procesow nowotworowych) (9, 10, 16, 17). W ostatnim czasie duzo uwagi zwraca sie na polekowa etiologie erytrodermii, ktora wedlug roznych zrodel stwierdza sie w 5-22% przypadkow wszystkich diagnozowanych erytrodermii, czesciej u plci zenskiej (1,2,9,13,16,17). Jako czynnik sprawczy, najczesciej wymieniane sa w pierwszej kolejnosci leki z grupy: antybiotykow (makrolidy, penicyliny) (7,17), niesterydowych lekow przeciwzapalnych (paracetamol) (13), blokery kanalu wapniowego (7,12), leki przeciwpadaczkowe (karbamazepina, hydantoina) (13), blokery pompy protonowej (5), H2- blokery (cymetydyna), sole litu i zlota, narkotyki (4,8,12). Erytrodermie polekowe cechuje co prawda gwaltowny poczatek i czestsze wspolistnienie uszkodzenia innych narzadow (watroba, sledziona, nerki), ale zarazem najlepsze rokowanie w porownaniu do innych przyczyn.
Prawdziwa czestosc pojawienia sie erytrodermii na swiecie nie jest znana, a publikowane sa calkowicie rozbiezne dane. Sehgal et al. (15) w badaniu prospektywnym w populacji indyjskiej okreslil zapadalnosc na erytrodermie na poziomie 35 przypadkow na 100 000/rok pacjentow zglaszajacych sie do poradni dermatologicznych, a Sigurdsson et al. (16) ocenil roczna zapadalnosc na erytrodermie w Holandii na poziomie 0,9/100 000 pacjentow.
Opis przypadku
Kobieta lat 23 skierowana do Kliniki Toksykologii w Krakowie z Oddzialu Intensywnej Terapii jednego z krakowskich szpitali celem leczenia niewydolnosci watroby. W wywiadzie, 4 miesiace przed hospitalizacja, z powodu krwawienia z dolnego odcinka przewodu pokarmowego podejrzenia wrzodziejacego zapalenia jelita grubego wdrozono leczenie mesalazyna. Oczekiwala na termin badania kolonoskopowego. Dwa tygodnie przed hospitalizacja pojawily sie objawy rzekomo-grypowe z bolesnym powiekszeniem obwodowych wezlow chlonnych i objawy niezytu zoladkowo-jelitowego. Od lekarza POZ pacjentka otrzymywala antybiotyk i leki przeciwzapalne (klarytromycyna, acetaminofen, ibuprofen). W trakcie leczenia nie obserwowano poprawy, dodatkowo na skorze calego ciala pojawila sie drobno-plamista wysypka o charakterze krwotocznym. Przyjeta do Oddzialu Chorob Zakaznych, gdzie rozpoczeto diagnostyke roznicowa, wykluczajac kolejno: mononukleoze, grype typu A i B, CMV, EBV, WZW B i C, HIV. Przeprowadzone badania bakteriologiczne i mikologiczne daly wynik ujemny. Z uwagi na zmiany skorne konsultowana dermatologicznie. Stwierdzono uogolniona drobno-plamista, zlewna osutke o charakterze krwotocznym. Zmiany krwotoczne opisano jak szpilkowate petechie, obejmujace skore konczyn i tulowia. Dodatkowo stwierdzono obfite zluszczanie drobnoplatowe skory glowy, zmiany na sluzowkach jamy ustnej i jezyka w postaci bialawych nalotow, zapalenie kacikow ust. Wyniki pozostalych przeprowadzonych badan przedstawiono w tabeli I.
W 8 dobie hospitalizacji u pacjentki nastapilo pogorszenie stanu ogolnego z rozwojem objawow ostrej niewydolnosci watroby (encefalopatia, skaza krwotoczna, obrzeki). Zmiany skorne przybraly obraz rozlanego zluszczania sie naskorka, praktycznie na calej powierzchni skory, z drobnymi wynaczynieniami podskornymi. Z uwagi na narastajace zaburzenia swiadomosci oraz niewydolnosc oddechowa pacjentka wymagala intubacji i respiratoroterapii. Obecnosc zmian krwotocznych na skorze, anemizacja, oraz nieoznaczalne wydluzenie wskaznika INR bylo powodem przetoczenia 7 jednostek swiezo mrozonego osocza oraz 2 jednostek koncentratu krwinek czerwonych. Po transfuzjach uzyskano pozytywna odpowiedz w postaci skrocenia INR. Z powodu narastania encefalopatii, zaburzen krzepniecia, pacjentke konsultowano z osrodkiem transplantacji watroby pod katem kwalifikacji do przeszczepu watroby (LTx). Pomimo, ze pacjentka spelniala kryteria King's Hospital Criteria (KCH) do przeszczepu watroby dla ostrej niewydolnosci watroby, to obecnosc niewydolnosci oddechowej z podejrzeniem zmian zapalnych w plucach spowodowala odroczenie decyzji o kwalifikacji do LTx do czasu poprawy wydolnosci oddechowej i ustapienia zmian zapalnych. Wobec tej decyzji pacjentke zakwalifikowano do leczenia wspomagajacego funkcje watroby (dializa albuminowa - MARS). Przyjeta do Kliniki Toksykologii UJ CM w 10 dobie od pierwszej hospitalizacji. Przy przyjeciu pacjentka byla w stanie ogolnym bardzo ciezkim, gleboko nieprzytomna (III/IV stopien encefalopatii wg kryterium West Haven), sztucznie wentylowana (oddech wlasny niewydolny). Osluchowo nad polami plucnymi stwierdzalo sie cechy obrzeku pluc, z hipoksemia (pO2???? 35,2 mmHg) bez retencji dwutlenku wegla. Wartosci cisnienia tetniczego byly niskie, ale stabilne. Nie wymagala wlewu amin presyjnych. Parametry nerkowe nieznacznie podwyzszone. Zwracaly uwage uogolnione obrzeki z obfitym zluszczaniem platowym naskorka, praktycznie na calej powierzchni ciala, najbardziej nasilone na powierzchni dloniowej rak i podeszwowej stop. Na skorze pod zluszczajacym sie naskorkiem obecne petechie. Poza tym obecne zazolcenie powlok skory i twardowek. W kontrolowanym badaniu radiologicznym wykonanym w chwili przyjecia widoczne bylo znacznego stopnia uposledzenie powietrznosci pluc, jak przy ARDS, z obwodowym poszerzeniem rysunku naczyniowego pluc i obecnoscia plynu w obu jamach oplucnych. Biorac pod uwage przetoczenia preparatow krwi w poprzednim miejscu hospitalizacji brano takze pod uwage mozliwosci nakladania sie na istniejace uszkodzenie pluc, ostrego potransfuzyjnego uszkodzenia pluc (TRALI). W ciagu kolejnych 3 dni przeprowadzono 3 szesciogodzinne zabiegi dializy albuminowej watroby z wykorzystaniem MARS monitora 1TC (Gambro Lundia AB) oraz Prismaflex (Gambro Lundia AB) w technice CVVHDF. Z uwagi na cechy obrzeku pluc, oraz uogolnione obrzeki, pacjentke podczas pierwszych 2 zabiegow odwadniano, nie obserwujac zaburzen hemodynamicznych. Juz po pierwszym zabiegu obserwowano poprawe parametrow wentylacji (wzrost PO2), a po trzecim, w kontrolnym obrazie radiologicznym odnotowano poprawe upowietrznienia pluc. W trzeciej dobie pobytu nastapilo splycenie glebokosci spiaczki, pojawila sie reakcja na bodzce zewnetrzne w postaci otwierania oczu. Obrzeki obwodowe ulegly istotnej redukcji. W 4 dobie pobytu zaobserwowano stopniowy powrot swiadomosci, jednak przy probach zmniejszania wspomagania oddechu nastepowalo pogorszenie parametrow wentylacji. W 5 dobie pobytu - pacjentka bez zaburzen swiadomosci, nietolerujaca rurki intubacyjnej, odlaczona od respiratora i ekstubowana. W kotrolnych badaniach laboratoryjnych widoczna byla stopniowa normalizacja wynikow badan, w tym prob watrobowych. Zmiany skorne wykazywaly tendencje do zanikania. W ciagu nastepnego tygodnia pacjentka zostala uruchomiona, z pelna samoobsluga. Wypisana do domu w 14 dobie pobytu. Po pobycie w Klinice Toksykologii u pacjentki przeprowadzono diagnostyke roznicowa, ktora nie dala podstaw do rozpoznania choroby ukladowej lub procesu nowotworowego.
Dyskusja
W rozpoznaniu erytrodermii polekowej nalezy zebrac dokladny wywiad co do czasu i rodzajow stosowanych lekow, naduzywania narkotykow, obecnosci objawow infekcji, ekspozycji na swiatlo sloneczne. Wazne jest wykluczenie nakladajacych sie schorzen skory, oraz schorzen ukladowych i nowotworowych. W prezentowanym przypadku w wywiadzie mamy potwierdzenie jednoczasowego leczenia antybiotykiem (makrolid) i niesterydowymi lekami przeciwzapalnymi (acetaminofen, ibuprofen), w okresie 2 tygodni poprzedzajacych wystapienie objawow chorobowych. Obie wymienione grupy lekow sa wg najnowszego pismiennictwa najczesciej wymieniane jako odpowiedzialne za wystapienie polekowej erytrodermii (17). Poza uszkodzeniem skory u pacjentki wystapily inne objawy ogolne i narzadowe (goraczka, niewielka anemizacja, limfadenopatia, hepato-splenomegalia). Najwieksze zagrozenie stanowila narastajaca niewydolnosc watroby w postaci encefalopatii, zoltaczki, skazy krwotocznej, a w ostatnich dwoch dniach poprzedzajacych hospitalizacje w Klinice Toksykologii narastajaca niewydolnosc oddechowa, w przebiegu zmian zapalnych pluc. Pacjentka spelniala kryteria transplantologiczne do przeprowadzenia przeszczepu watroby i tylko obecnosc ciezkiej niewydolnosci oddechowej i stanu zapalnego w plucach spowodowaly odroczenie skierowania pacjentki do osrodka transplantologicznego. Przebieg choroby pokazal zbyt niska swoistosc stosowanych obecnie w kwalifikacji do LTx kryteriow transplantologicznych, gdyz nie doszlo do terminalnego uszkodzenia watroby i obserwowano pelna regeneracje uszkodzonej watroby.
W omawianym przypadku zwraca uwage przetoczenie w ciagu 48 godzin 7 jednostek swiezo mrozonego osocza oraz 2 jednostek koncentratu krwinek czerwonych u pacjentki, z juz obecnymi objawami niewydolnosci oddechowej. Istnialy co prawda bezwzgledne wskazania do takiego dzialania, jednak przetoczenie takiej objetosci skladnikow krwi w krotkim przedziale czasowym moglo przyczynic sie do wystapienia ostrego potransfuzyjnego uszkodzenia pluc (TRALI) (3,18). TRALI jest forma zespolu ostrej niewydolnosci oddechowej (acute respiratory distress syndrome - ARDS) wywolanym przetoczeniem preparatow krwi. W obrazie klinicznym charakteryzuje sie ostra hipoksemia oraz obustronnym, niekardiogennym obrzekiem pluc. Dokladny patomechanizm TRALI nie jest znany, ale wymienia sie dwie teorie jego powstawania: 1. mechanizm immunologiczny, 2. mechanizm nieimmunologiczny (3,6,14,18,19).
W mechanizmie immunologicznym do uszkodzenia tkanki plucnej dochodzi poprzez reakcje przeciwcial dawcy z antygenami neutrofilowymi lub antygenami zgodnosci tkankowej - HLA biorcy. Reakcja to doprowadza do aktywacji granulocytow z wytworzeniem czasteczek adhezyjnych i przemieszczenia granulocytow do przestrzeni srodmiazszowej pluc, gdzie uwalniaja mediatory zaplane prowadzace do uszkodzenia sciany naczyn, wzrostu ich przepuszczalnosci i rozwiniecia niekardiogennego obrzeku pluc (14).
W nieimmunologicznym TRALI wspolistnieja dwa niezalezne czynniki: pierwszy to ogolny ciezki stan pacjenta ze zmieniona reaktywnoscia granulocytow i srodblonka naczyniowego, drugi czynnik, to masywne przetoczenie preparatow krwi (zwlaszcza dlugo przechowywanych), ktore moga zawierac rozpadle komorki krwi uwalniajace aktywne lipidy. Lipidy te aktywuja neutrofile, ktore uwalniajac mediatory zapalne, w identyczny sposob jak w immunologicznym mechanizmie, uszkadzaja srodblonek naczyn wlosowatych pluc, powodujac przesiek plynu do wnetrza pecherzykow plucnych i rozwoj obrzeku pluc. Zarowno stwierdzane w badaniu fizykalnym odchylenia, jak i badanie radiologiczne w dniu przyjecia do Kliniki Toksykologii przemawialy z obecnoscia zmian obrzekowych w plucach. Rozpoczete leczenia pozaustrojowe (dializa albuminowa watroby - MARS), mialo nie tylko korzystny efekt wspomagajacy funkcje uszkodzonej watroby, ale przede wszystkim umozliwilo redukcje przewodnienia i najprawdopodobniej usuwalo mediatory zapalne z krwioobiegu, minimalizujac tym samym uszkodzenie srodmiazszowe pluc. Juz po pierwszym zabiegu uzyskano poprawe parametrow wentylacji i zmniejszenie ciezkiej hipoksji. Mimo bardzo burzliwego przebiegu erytrodermii, pacjentka w stosunkowo krotkim czasie powrocila do zdrowia. Przeprowadzona po wypisie pacjentki z oddzialu diagnostyka nie potwierdzila innych procesow chorobowych mogacych ujawniac sie pod postacia erytrodermii.
Podsumowanie
W zwiazku z powszechnym, jednoczasowym stosowaniem antybiotykow i niesterydowych lekow przeciwzapalnych nalezy sie liczyc z wystapieniem ciezkich zespolow chorobowych o ostrym przebiegu, ktore w pierwszej kolejnosci manifestuja sie nasilonymi zmianami skornymi w postaci erytrodermii, nierzadko prowadzacym do niewydolnosci innych narzadow, zwlaszcza watroby, nerek i pluc. Dynamika objawow, stan pacjenta pozostawiaja zbyt malo czasu, aby przeprowadzic pelna diagnostyke roznicowa i wdrozyc odpowiednie leczenie przyczynowe. Z tego powodu leczenie skupia sie na podtrzymywaniu czynnosci zyciowych, wyrownywaniu stwierdzonych zaburzen metabolicznych, czy tez jak w przedstawionym przypadku, pozaustrojowym wspomaganiu funkcji uszkodzonych narzadow.
Translation - English Introduction
Erythrodermic skin lesions were first described by von Hebra in 1868. Erythroderma is not a single disease, but a clinical notion, which can hide diseases that cause inflammation of the entire skin clinically manifested by generalized erythema, scaling, and usually also the inflammatory infiltrates. A common feature of all erythroderma is the risk of deep skin damage with a loss of its thermoregulatory functions and being a protective barrier. In most cases, skin changes include more than 90% of the skin surface [9]. In severe forms of erythroderma may occur damage to other organs, such as the cardiovascular system, liver, kidneys. Death is also possible. Erythroderma is usually divided by its etiological agent into acute and chronic as well as idiopathic forms. They can develop on the ground of many dermatological and systemic diseases (allergic and non-allergic dermatitis, vesicular diseases, systemic disorders, fungal infections, neoplastic processes) [9, 10, 16, 17]. In recent years a lot of attention is given to drug-induced etiology of erythroderma, which according to various sources is found in 5-22% of all diagnosed cases of erythroderma, more often in female [1,2,9,13,16,17]. As the causative agent, most often mentioned in the first place are the class of drugs: antibiotics (macrolides, penicillins) [7.17], non-steroidal anti-inflammatory drugs (paracetamol) [13], calcium channel blockers [7.12], anticonvulsants (carbamazepine, hydantoin) [13], proton pump blockers [5], H2-blockers (cimetidine), salts of gold and lithium, drugs [4,8,12]. Drug-induced erythroderma is characterized by sudden onset and more frequent coexistence of damage to other organs (liver, spleen, kidney), but also the best prognosis when compared to other causes.
The actual frequency of erythroderma in the world is not known, and the published data is totally divergent. Sehgal et al. [15] in a prospective study in an Indian population described the incidence of erythroderma at the level of 35 cases to 100 000/year of patients of dermatological clinics and Sigurdsson et al. [16] assessed the annual incidence of erythroderma in the Netherlands at 0.9/100 000 patients.
Case report
A 23-year-old woman, referred to the Clinic of Toxicology in Cracow from the Intensive Care Ward of one of Cracow's hospitals to treat liver failure. In the patient's medical history, four months before hospitalization due to bleeding from the lower gastrointestinal tract came up the suspicions of ulcerative colitis, and because of that mesalazine treatment was implemented. She was waiting for her colonoscopy day. Two weeks before hospitalization appeared kind of flu symptoms with a painful enlargement of peripheral lymph nodes and gastroenteritis symptoms. The patient received antibiotic and anti-inflammatory drugs (clarithromycin, acetaminophen, ibuprofen) from the GP doctor. During the treatment there was no improvement, in addition, the skin of the whole body was covered with finely-papular rash of a hemorrhagic nature. Admitted to the Infectious Diseases Ward, where a differential diagnosis was initiated by excluding successively: mononucleosis, influenza type A and B, CMV, EBV, hepatitis B and C and HIV. The bacteriological and mycological studies gave a negative result. Due to skin changes dermatologically consulted. It was said to be a generalized finely-papular, confluent rash of a hemorrhagic nature. Haemorrhages were described as needle-like petechia, including the skin of limbs and trunk. In addition, it was found profuse small flaked scalp skin exfoliation, changes in the oral mucosa and tongue in the form of whitish deposits, inflammation of the corners of the mouth. The results of other studies are shown in table I.
In the 8th day of hospitalization, patient's general condition worsened developing symptoms of acute liver failure (encephalopathy, hemorrhagic diathesis, edema). Skin changes took the picture of diffuse epidermis shedding, virtually on the entire surface of the skin, with little subcutaneous extravasation. Due to the increasing consciousness disorders and respiratory failure, the patient required intubation and respiratory therapy. The presence of haemorrhages on the skin, ischemia, as well as undetectable prolongation of the INR indicator were the reasons for transfusion of 7 fresh frozen plasma units and 2 units of packed red blood cells. After transfusions, a positive response in the form of shortening INR was obtained. Due to the rise of encephalopathy, coagulation disorders, the patient was being consulted with the center for liver transplantation in terms of qualifications for liver transplantation (LTx). Even though the patient met the criteria of King's Hospital Criteria (KCH) for liver transplantation for acute liver failure, the presence of respiratory failure with suspected inflammation of the lungs caused a postponement of the decision on eligibility for LTX until the improvement of lung function and inflammation recovery. Towards this decision, the patient qualified for the adjunctive treatment of liver function (albumin dialysis - MARS). Admitted to the Clinic of Toxicology of the Jagiellonian University CM (Collegium Medicum) on 10th day after the first hospitalization. On admission, the patient's general condition was very hard, deep unconscious (III / IV encephalopathy degree according to West Haven criteria), artificially ventilated (own breath inefficient). Auscultating the lung fields, characteristics of pulmonary edema with hypoxemia (PO2 35.2 mmHg) without carbon dioxide retention were found. Blood pressure values were low, but stable. Did not require the infusion of pressor amines. Slightly elevated renal parameters. Generalized edema with abundant flaked epidermis exfoliation caught attention, virtually on the entire surface of the body, the most severe on the palms of hands and soles. Under the exfoliating epidermis on the skin, petechia is present. Moreover, the yellowing of skin and sclerotic coat are also present. In a controlled radiological examination made at the time of acceptance, a significant degree of lung aeration failure was seen, as in ARDS, with peripheral vascular lung expansion drawing and a presence of fluid in both pleural cavities. Regarding the transfusion of blood derivatives in the previous place of hospitalization, there was also taken into account a potential overlapping of the transfusion-related acute lung injury (TRALI) on already existing lung injury. Over the successive three days, three six-hour liver albumin dialysis treatments were conducted with the use of MARS Monitor 1TC (Gambro Lundia AB) and Prismaflex (Gambro Lundia AB) in CVVHDF technique. Due to the characteristics of pulmonary edema and generalized edema, the patient was being dehydrated during the first two treatments, no hemodynamic disturbances observed. Already after the first treatment, an improvement of ventilation parameters (increase of PO2) was observed, and after the third one, in the control radiographic image, an improvement of lung aeration was noted. During the third day of admission there was a shortness of coma depth and a reaction to external stimuli in the form of eye opening. Peripheral edema was significantly reduced. On the 4th day of stay it was observed a gradual return of consciousness, however, when trying to reduce breath support, deterioration of ventilation parameters occured. On the 5th day of stay - the patient without consciousness disturbances, not tolerant about the endotracheal tube, disconnected from the ventilator and extubated. In the control laboratory studies, gradual normalization of test results was seen, including liver function tests. Skin lesions showed a tendency to fade. Over the next week, the patient was started with full self-service. Discharged home on the 14th day of stay. After a stay in the Clinic of Toxicology, differential diagnosis was carried out on the patient, which did not give grounds to a diagnosis of systemic disease or neoplastic process.
Discussion
The diagnosis of drug-induced erythroderma should collect accurate medical history as to the time and the kinds of drugs used, drug abuse, presence of symptoms of infection, exposure to sunlight. It is important to exclude superimposed skin diseases, as well as systemic disorders and cancer. In the medical history of the presented case we have a confirmation of a concurrent treatment with an antibiotic (macrolide) and non-steroidal anti-inflammatory drugs (acetaminophen, ibuprofen), during the two weeks preceding the onset of disease symptoms. Both of the mentioned groups of drugs according to recent literature are most often deemed as responsible for the occurrence of drug-induced erythroderma [17]. In addition to skin damage in the patient, there were other general and organ symptoms (fever, low ischemia, lymphadenopathy, hepatosplenomegaly). The biggest threat was a increasing liver failure in the form of encephalopathy, jaundice, bleeding diathesis, and in the last two days prior to hospitalization in the Clinic of Toxicology, increasing respiratory distress, in the course of lung inflammation. The patient met criteria for the liver transplant, and only the presence of severe respiratory insufficiency and lung inflammation caused postponement of the patient to the transplantology center. The course of the disease showed very low specificity of current qualification criteria for LTx transplantation, since there was no terminal liver damage and a full regeneration of damaged liver was observed.
In the mentioned case draws attention a 48-hour transfusion of 7 units of fresh frozen plasma and 2 units of packed red blood cells in a patient with already existing respiratory distress symptoms. Although there were outright indications for such action, but transfusion of that blood components volume in such a short period of time may have contributed to the occurrence of transfusion-related acute lung injury (TRALI) [3.18]. TRALI is a form of acute respiratory distress syndrome (acute respiratory distress syndrome - ARDS) caused by transfusion of blood derivatives. It is characterized by acute hypoxemia and bilateral, noncardiogenic pulmonary edema. The exact pathogenesis of TRALI is not known, but there are mentioned two theories of its creation: 1. immune mechanism, 2. nonimmunologic mechanism [3,6,14,18,19].
In the immunological mechanism, the lung tissue damage occurs by the reaction of donor's antibodies to neutrophilic antigens or histocompatibility antigens – HLA of the recipient. This reaction leads to the activation of granulocytes together with the production of adhesion molecules and granulocytes displacement into the lung parenchyma, where they release inflammatory mediators, which lead to arterial walls damage, rise of their permeability and noncardiogenic pulmonary edema unfolding [14].
In nonimmunologic TRALI in two independent factors coexist: the first is a general, hard condition of the patient with changed reactivity of granulocytes and vascular endothelium, the second factor is the massive transfusion of blood derivatives (especially the long-stored ones), which may contain disintegrated blood cells releasing active lipids. These lipids activate neutrophils, which releasing inflammatory mediators in the same way as in the immune mechanism, damage the lungs capillaries endothelial, causing fluid transudation to the interior of the lung alveoli and the development of pulmonary edema. Both the observed variations in the physical examination and radiographic examination on the day of admission to the Clinic of Toxicology spoke with the presence of edema changes in the lungs. The initiated extracorporeal treatment (liver albumin dialysis - MARS) not only had a beneficial effect supporting the damaged liver function, but above all enabled the reduction of overhydration and probably removed the inflammatory mediators from the bloodstream, thereby minimizing damage to the lung parenchyma. Already after the first treatment, an improvement of ventilation parameters and reduction of hard hypoxia were achieved. Despite a turbulent course of erythroderma, the patient came back to health in a relatively short time. The diagnosis performed after discharging the patient did not confirm other disease processes that could reveal themselves as erythroderma.
Summary
In relation to common, concurrent use of antibiotics and non-steroidal anti-inflammatory drugs should be expected severe disease syndromes of acute course, which first manifest themselves with increased skin lesions in the form of erythroderma, often leading to other organs failure, especially the liver, kidneys and lungs. The dynamics of symptoms, the patient condition leave too little time to carry out a full differential diagnosis and implement an appropriate causal treatment. For this reason, the treatment focuses on maintaining vital functions, aligning identified metabolic disorders, and also as in the presented case, extracorporeal support of the damaged organs functions.
Spanish to English: ¿Por qué no soy feliz? General field: Art/Literary Detailed field: Poetry & Literature
Source text - Spanish ¿Por qué no soy feliz?: PID 401205
Introducción
La historia presentada en el prefacio de este libro es parte de las Sagradas Escrituras y se conoce como el relato de los discípulos de Emaús. Se encuentra en el Evangelio de Lucas, capítulo veinticuatro. Podemos relacionar este relato a nuestro caminar por la vida: vivimos momentos de desánimo, somos educados y decidimos cambiar nuestra forma de actuar para disfrutar del gozo. En nuestros tiempos, podemos asociar ese relato a un proceso denominado “coaching”.
Coaching es un término que describe la relación entre un profesional capacitado y objetivo, denominado “coach” y su cliente, con el propósito de facilitar al cliente definir y alcanzar sus metas personales y profesionales mediante un proceso estructurado de desarrollo de consciencia. El método de “coaching” desarrollado en este libro consiste de cuatro pasos básicos extraídos de la interpretación del relato de los discípulos de Emaús: 1. Identificar, 2. Educar, 3. Decidir, 4. Actuar. El libro presenta la teoría: “Mis 24 horas saludables" y los conceptos: 1.Balance en Rojo, 2. Costo Efectivo, 3. Expectativas, 4. Tolerancia al riesgo, 5. Las pruebas son buenas.
Este libro es el resultado de largas horas de estudio, numerosas secciones de práctica y sobretodo la guía del Espíritu Santo. Está basado en un principio fundamental: Jesús, es el Camino, la Verdad y la Vida. Cabe mencionar, que utilizamos referencia bíblica a lo largo del libro, no para validar nuestro método. Por el contrario, entendemos que todogozo proviene de nuestra relación con Dios y Él nos muestra el camino para el logro de nuestras metas.
En este libro se entrelazan de forma simple y efectiva, las enseñanzas del relato de los discípulos de Emaús, con varias historias, incluyendo mi historia profesional. Pero, más allá de este libro ser una historia de reflexión, es un manual de ejercicios que te facilitará el proceso de identificar, educar, decidir y actuar. Los ejercicios de práctica se presentan al final de cada capítulo y se requiere un compromiso de parte del lector para obtener los resultados deseados. Los ejercicios son parte de un método estratégico y secuencial de preguntas que te llevaran a meditar sobre tu propio camino de Emaús, con el propósito de asumir responsabilidad de tus emociones, definir claramente tus opciones y establecer un efectivo plan de acción para el pronto y exitoso logro de tus metas.
Entendemos que sería sencillo, si Jesús mismo nos interpretara los mensajes como lo hizo con los discípulos de Emaús, pero muchas veces utiliza delegados. En nuestras vidas, los delegados de Dios pueden ser personas o libros como este y es importante estar atentos para poder actuar.
La pregunta utilizada como título de este libro: “¿Porqué no soy feliz?, nos sirve de punto de partida para descubrir que las emociones o sentimientos negativos son una señal que indica que no contamos con las herramientas necesarias para manejar un evento particular en nuestras vidas. La buena nueva es que Dios camina con nosotros, ofreciendo vida y vida en abundancia; y esperando pacientemente a que asumamos la responsabilidad de ser feliz.
Finalmente, es importante mencionar que los pasos y conceptos presentados en este libro pueden ser utilizados para alcanzar metas o fortalecer diferentes dimensiones de tu vida: físico, mental, intelectual y espiritual.
¿El porqué de este libro?
Una mañana del mes de Marzo, mientras me preparaba para mis actividades del día, recibí una llamada telefónica.
Mi hijo angustiado me dijo “Mamá, iba de camino a la escuela y un oficial de la policía me dio un boleto”.
Le respondí: “¿Qué hiciste?”
Mi hijo contestó: “Mamá, no obedecí una ley de tránsito”
Le pregunté: “¿Porqué no obedeciste?”
Mi hijo me contestó: “Mamá, yo no sabía”
Le dije “Hijo, tendrás que asumir tu responsabilidad e ir a la escuelita de las leyes de tránsito.”
Mi corazón de madre solo pudo responderle: “No te preocupes, todo se va a solucionar”.
El propósito de este libro es facilitar tu caminar y sobretodo que no le respondas a Dios como mi hijo me respondió a mí: “Mamá, yo no sabía”.
Mi hijo me repitió: “Mamá, yo no sabía”
Translation - English Why am I not happy?: PID 401205
Introduction
The story presented in the preface of this book is a part of the Holy Scriptures and is known as the story of the disciples from Emmaus. It is found in the Gospel of Luke, chapter twenty-four. We can relate this story to our walk through life: we live discouragement moments, we are educated and we decide to change our behaviour in order to enjoy the pleasure. In our times, we may associate that story with a process called "coaching."
Coaching is a term that describes the relationship between a qualified and objective professional called "coach" and his client, in order to facilitate the client to define and achieve their personal and professional goals through a structured process of consciousness development. The method of "coaching" developed in this book consists of four basic steps taken from the interpretation of the story of the disciples from Emmaus: 1. Identify, 2. Educate, 3. Decide, 4. Act. The book presents the theory: "My 24 healthy hours" and concepts: 1. Balance in Red, 2. Effective Cost, 3. Expectations, 4. Risk tolerance, 5. Testing is good.
This book is a result of long study hours, numerous practice sessions and most of all the guidance of the Holy Spirit. It is based on a fundamental principle: Jesus is the Way, the Truth and the Life. It is worth mentioning that we use biblical references throughout the book, not to validate our method. On the contrary, we understand that all the pleasure comes from our relationship with God and He shows us the way to achieve our goals.
In this book are intertwined in a simple and effective way the teachings of the story of disciples from Emmaus, with several stories, including my professional history. But, regardless of this book being a story of reflection, it is a manual of exercises that will facilitate you the process of identifying, educating, deciding and acting. Practical exercises are presented at the end of each chapter and the reader's commitment is required to obtain desired results. The exercises are part of a strategic and sequential method of questions that will take you to reflect on your own 'way to Emmaus', in order to take responsibility for your emotions, clearly define your options and establish an effective plan of action for an early and successful achievement of your goals.
We understand that it would be easy, if Jesus himself interpreted the messages for us, as he did it with the disciples from Emmaus, but often uses delegates. In our lives, God's delegates can be people or books like this and it is important to be attentive to act.
The question used as the title of this book: "Why am I not happy?'' is a starting point to discover that negative emotions or feelings are a sign that we don't have at our disposal the necessary tools to handle a particular event in our lives. The good news is that God walks with us, offering life and life in abundance, and waiting patiently for us to assume the responsibility of being happy.
Finally, it is important to mention that the steps and concepts presented in this book can be used to achieve goals or strengthen different dimensions of your life: physical, mental, intellectual and spiritual.
The reason for this book?
One March morning while I was preparing for my daily activities, I received a phone call.
My son told me distressed: "Mom, I was on my way to school when a police officer gave me a ticket."
I said: "What did you do?"
My son answered: "Mom, I didn't obey one traffic law"
I asked: "Why did you not obey?"
My son said: "Mom, I did not know"
I told him: "Son, you have to assume your responsibility and go to school of traffic laws."
My mother's heart could only answer: "Do not worry, everything will be solved."
The purpose of this book is to facilitate your walk and especially do not tell God what my son told me: "Mom, I did not know."
My son repeated: "Mom, I did not know"
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