Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 128 num. 5 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<I>The Autopsy in Crisis</I>]]> In the Western world the autopsy rate is declining at an alarming rate. In the United States of America the rate in some academic hospitals is less than 7% of all hospital deaths. This decline has been documented and deplored in many countries, articles and books. Suggestions on how to resuscitate the autopsy range from mandatory in all hospital deaths to economic bonuses to the doctors obtaining the highest autopsy rate. All in vain, the autopsy decline continues. Pathologists deploring this decline blamed clinical colleagues, new social attitudes, the litigious nature of modern society, but few have questioned a procedure little changed in more than a century. Perhaps the time has come to abandon the "classic" autopsy and rethink the procedure so as to make it useful, alluring and indispensable for the contemporary, concerned clinician. (Rev Med Chile 2000; 128: 457-59) <![CDATA[<I>Assessment of acute effect of GnRH administration on leptin secretion in normal and hyperandrogenic women</I>]]> Background: Several studies suggest that leptin modulates the reproductive axis function. Leptin may stimulate release of GnRH from hypothalamus and of gonadotrophins from the pituitary. A synchronicity of LH and leptin pulses has been described in healthy women and in patients with polycystic ovarian syndrome (PCOS), suggesting a relationship between the episodic secretion of LH and leptin. In vitro experimental studies have demonstrated that leptin administration promotes GnRH-LH release. However it is not established whether GnRH promotes the episodic secretion of leptin. Aim: To assess the response of LH and leptin to the administration of a GnRH bolus in hyperandrogenic and healthy women. Patients and methods: Eleven hyperandrogenic and eleven healthy women of similar age and body mass index (BMI) were studied. Under basal conditions three blood samples were collected every 30 min before and after the administration of a GnRH bolus (100 µg). LH and leptin concentrations were measured in all samples. Testosterone, SHBG and estradiol were determined in the first sample. For data analysis, the increment of LH and leptin between 0-30 and 0-60 min. was calculated. The LH and leptin areas under the curve (AUC) before and after GnRH administration were also calculated in both groups. Results: After GnRH administration. an increment in LH concentrations was observed in both groups; however, leptin concentrations were not modified. In both groups LH area under the curve increased after GnRH administration; however, the leptin area was not modified. Conclusions: These results suggest that circulating leptin concentration is not modulated by GnRH-LH. (Rev Méd Chile 2000; 128: 460-6) <![CDATA[<I>Improvement in inspiratory muscle function after percutaneous mitral valvuloplasty in mitral stenosis.</I>: <I>Preliminary report</I>]]> Background: It has been proved that there is an inspiratory muscle dysfunction in mitral stenosis; Although its causes still remain unknown. Aim: to evaluate the effect of percutaneous balloon mitral valvuloplasty (PMV) on inspiratory muscle performance (IMP) in patients with mitral stenosis (mitral area < 1.5 cm²). Patients and methods: We studied IMP in 8 patients (35 ± 10 years) before and 3 months after successful PMV. Inspiratory muscle strength was studied by measuring maximal statistical inspiratory mouth pressure (MIP). Endurance was evaluated using a two minute incremental threshold loading test in order to obtain the maximal sustainable inspiratory pressure (SIP), with the maximal sustainable load (MSL) the patients could sustain for 2 minutes. Results: Mitral valvuloplasty increased mean cardiac index from 3.1 ± 0.3 to 4.15 ± 0.3 l/min/m² (p<0.01), and significantly decreased mean pulmonary and capillary pressures. The MIP value(118 ± 6 cmH2O), similar to that of normal group, increased to 137 ± 7 cmH2O (p<0.01). SIP and maximal sustainable load were 52 ± 3 cmH2O and 294 ± 29 g respectively, lower than normal subjects (p<0.05) They increased after PMV to 80 ± 3 cmH2O and 463 ± 26 g respectively (p<0.001). Conclusions: PMV improved inspiratory muscle function in patients with severe mitral stenosis, probably secondary to a decrease work of breath and improvement of ventricular function. (Rev Méd Chile 2000; 128: 467-74) <![CDATA[<I>Antihypertensive effects of valsartan</I>: <I>Results of a national multicentric study</I>]]> Background: Valsartan is an angiotensin AT1 receptor antagonist. Clinical studies have shown that this is an effective and well tolerated drug. Aim: To compare valsartan with other commonly used antihypertensives in a National multicentric study. Material and methods: Between 1997 and 1998, a pharmacological surveillance of patients with mild or moderate hypertension, coming from different regions of the country, was carried out. Patients were followed during 8 weeks. In the group treated with valsartan, the initial dose was 80 mg/day. After four weeks of therapy, and according to patient's response the dose of valsartan or of the other antihypertensives was modified. Results: Five hundred ninety three patients, aged 59 years old as a mean, were included in the study. Of these 434 (265 female) received valsartan and 159 (101 female) other antihypertensive drugs. Fifteen percent of patients treated with valsartan and 25% of patients with other medications required a dose change at four weeks, due to lack of response (p < 0.01). At week eight, 1.5% of patients with valsartan and 17.4% of patients with other medications reported adverse effects such as cough, headache, edema or flushing (p < 0.01). Conclusions: In this Chilean observational multicentric study, valsartan proved to be more effective and to cause less adverse effects than commonly used medications in hypertensive patients. (Rev Méd Chile 2000; 128: 475-82) <![CDATA[<I>Chromatin condensation and seminal alpha glucosidase variability and their relationship to spermiogram</I>]]> Background: Sperm functional tests as an addition to semen analysis have been used to study the fertilization ability of spermatozoa. Besides the usual variability of the seminal analysis an individual variability in the results of functional tests has been recently found. Aim: to evaluate in a three months period, the individual variability of sperm parameters and sperm maturation using the chromatin condensation test and epidydime alpha-glucosidase (that allows to discriminate obstructive processes). Material and method: The evaluation was carried out in two donors (12 samples) apparently in good health. One of them presented evident semen analysis alterations (donor 1) and the other was considered normal under the WHO standards (donor 2). Results: The averages for donor 1 were: Sperm count 24x106 sperm/ml (range 10-58x106 sperm/ml), morphology 31.8% (range 30-35%), total motility 33% (range 20-42%), sperm maturation 38% (range 28-78%), a-glucosidase 8.65 (U/ml (range 5-10 (U/ml). The averages for donor 2 were: Sperm count 96x106 sperm/ml (range 50-140x106 sperm/ml), morphology 32.2% (range 30-35%), total motility 69% (range 58-78%), sperm maturation 17% (range 7-30%), a-glucosidase 36.9 (U/ml (range 20-82 (U/ml). Conclusions: These results show that significant variations can be found in the sperm parameters and in seminal plasma a-glucosidase; however these variations are generally maintained at the normal or abnormal ranges for each individual, except the sperm morphology that was constant and with low variation in both donors. The determination of the chromatin condensation in the semen analysis gives an additional information about the grade of sperm maturation and would be of great value for differentiating between sperm samples that show similar morphology values. (Rev Méd Chile 2000; 128: 483-9) <![CDATA[<I>Clinical and Molecular Characterization af autosomal recessive chronic granulomatous disease caused by p47-phox deficiency</I>]]> Background: The cytosolic protein p47-phox (phagocyte oxidase) is one of the essential components of the superoxide generating system in phagocytes and its defect causes approximately 30% of the chronic granulomatous disease (CGD) cases. Aim: Two patients were studied, belonging to the same family, without a consanguinous background, in which deficiency or absence of superoxide generation was found together with recurrent and severe infections in one case and benign infections in the second. Methods: The presence of gp91-, p67- and p47-phox in patients and controls was determined by Western Blot analysis of granulocytes. Sequencing of PCR amplified DNA was performed by an enzimatic method. Results: Western Blot analysis showed normal expression of gp91 and p67 and absence of p47-phox. The molecular genetic study demonstrated a homocygotic dinucleotide GT (GT) deletion at the beginning of exon 2 of the p47-phox gene. The same mutation has been found in European, American and Japanese patients. Conclusions: The molecular characterization of this pathology done for the first time in Chile is important for diagnostic classification, patient prognosis, and adequate genetic advice and a possible future therapy. (Rev Méd Chile 2000; 128: 490-8). <![CDATA[<I>Treatment of hyperthyroidism with radioiodine</I>: <I>effects of administered dose on complications and thyroid function</I>]]> Background: Radio-iodine is a definite therapy for Graves disease hyperthyroidism. However, the optimal dosage is still debatable. Aim: To assess the effects of different radioiodine doses on thyroid function and complications in patients with hyperthyroidism. Material and methods: A retrospective analysis of 139 patients with hyperthyroidism, treated with ratioiodine between 1988 and 1998. Radio iodine dose used was classified as low (<10 mCi), intermediate (10-14.9 mCi) or high ( > or = 15 mCi). Results: Thirty five patients were treated with low doses, 33 with intermediate doses and 71 with high doses. There were no differences between these patients in age, disease severity, frequency of post treatment euthyroidism or complications. Patients treated with low doses had a higher frequency of persistent hyperthyroidism than patients treated with high doses (25.7 and 4.2% respectively, p<0,001). Likewise, the frequency of subsequent hypothyroidism was 60% in patients treated with low doses and 84.5% of those with high doses, in whom it also appeared earlier. Associated complications were clinically irrelevant. In seven patients, Graves ophtalmopathy progressed after treatment, but this progression was not associated with the dose used. Conclusions: Radio iodine in high doses is useful, safe and effective for the treatment of Graves hyperthyroidism. (Rev Méd Chile 2000; 128: 499-507). <![CDATA[<I>Short-term therapy with azithromycin, amoxycilin and omeprazole for the eradication of Helicobacter pylori</I>]]> Background: the high cost and complexity of therapeutic schemes for the eradication of Helicobacter pylori has stimulated the search of simpler and cheaper treatment options. Aim: To evaluate the efficacy of 3 days of azithromycin 500 mg od, 7 days of amoxycilin 750 mg tid and omeprazole, 20 (Group A) or 40 mg (Group B) on randomization, as a treatment for Helicobacter pylori infection in patients with endoscopically diagnosed peptic ulcer. Methods: H. pylori status of peptic ulcer patients was pathologically confirmed by the examination of five gastric biopsies using the Giemsa stain and by rapid urease testing in two gastric biopsies. H. pylori status was reassessed not less than 28 days after completing treatment. Adverse events and compliance were evaluated. Results: Fifty four patients (29 men, 25 women, mean age 48 years) were enrolled, 28 in Group A and 27 in Group B. Per protocol the infection was cured in 58,8% of patients (30/51; 95% CI: 45-73%). On an intention to treat basis, H pylori infection was cured in 55%. Minor side effects including diarrhea and nausea were reported by 32% of patients. Ninety five per cent of patients consumed more than 95% of prescribed medications. H. pylori was successfully erradicated in 61% of group A and 57% of group B patients (p= NS). Conclusion: Short term therapy with azithromycin was poorly effective in curing H. pylori infection. The compliance was excellent. Increasing Omeprazole from 20 to 40 mg/day did not improve treatment effectiveness. (Rev Méd Chile 2000; 128: 509-12) <![CDATA[<I>BICAP tumor probe in the treatment of malignant esophageal stenosis</I>]]> Background: BICAP tumor probe is a device that consists in an energy source and olives that deliver bipolar electricity. It can be used for the fulguration of esophageal tumors after endoscopic dilatation. Aim: To report the experience in the treatment of malignant esophageal stenoses using the BICAP tumor probe. Patients and methods: Patients with advanced esophageal tumors in aphagia, that were not candidates for palliative surgery were included in this study. After endoscopic dilatation, the tumor was fulgurated with the BICAP tumor probe. Results: Twenty one patients (nine male, aged 43 to 91 years old) were treated with the device. A mean of 1.3 sessions with BICAP were necessary to obtain tumor permeabilization, which was obtained in all patients. One patient died of pneumonia 15 days after the procedure. All other patients were ingesting liquid or semisolid diets after two months of follow up. Mean survival after the procedure was 3.8 months. Conclusions: Electrical fulguration of esophageal tumors is a valid therapeutic alternative in aphagic patients. (Rev Méd Chile 2000; 128: 513-8) <![CDATA[<I>Anorectal congenital malformations and their associations in a Chilean university Hospital between 1979 and 1999</I>]]> Background: Anorectal atresia is a relatively frequent malformation in the newborn. According to the Latin American Collaborative Study for Congenital Malformations (ECLAMC), its frequency is 4.1 per 10,000 born alive. Aim: To determine the frequency of anorectal malformations at birth, and compare the figures with those of other maternity hospitals in Chile participating in ECLAMC, with the figures of the whole ECLAMC and with figures from other worldwide monitoring systems. Patients and methods: All births occurred in the University of Chile Clinical Hospital between January 1979 and August 1999, were reviewed. Results: During the study period, 70,242 children were born, 4,486 had a malformation and 54 had an anorectal malformation (7.7 per 10,000 born alive). Fifty nine percent had other associated malformations (of the urinary tract in 42.5%, skeletal in 26% and cardiovascular in 18.5%). Five stillborn babies had other severe malformations. Twenty one children had a fistula. Forty three % were male, 39% female and 18% had ambiguous sex. When compared with normal controls, malformed newborns had a lower birth weight, lower gestational age and a higher mean maternal age, a higher frequency of metrorrhagia during the first trimester of pregnancy, a higher number of siblings with malformations and a higher degree of consanguinity among parents. Conclusions: The participation of recessive genes in the etiology of anorectal malformations is suggested. (Rev Méd Chile 2000; 128: 519-25) <![CDATA[<I>Nocardia asteroides infection in a patient with Systemic Lupus Erythematosus</I>]]> Nocardia asteroides infection are unusually observed in sistemic Lupus erithematous (SLE) patients. They are generally associated to steroidal and immunosuppressive therapy. We report a 24 years old female with SLE diagnosed in 1994 who developed a severe preeclampsia in her first pregnancy requiring emergency caesarean section. Post partum acute renal failure and type IV lupus nephropathy were treated with hemodialysis, metilprednisolone, cyclophosphamide and prednisone. Three months later, while she was receving the fourth cyclophosphamide dose, she presented with a pleuro pneumonia and occipital abscess, both caused by Nocardia asteroides. She was treated with cotrimoxazole + cefixime and pleural decortication was required. Five months later, she developed Meningitis caused by Nocardia asteroides and hydrocephalus. She was treated with ceftriaxone, vancomycin, cotrimoxazole and ventricular shunting procedure. Two months later, a retroperitoneal abscess was diagosed and surgically drained but the patient died, due to a methicillin-resistant Staphylococcus aureus septicemia. (Rev Méd Chile 2000; 128: 526-8) <![CDATA[<I>Traumatic rupture of thoracic aorta and non operative treatment of concomitant splenic lesion</I>: <I>Report of one case</I>]]> We report a 26 years old male that suffered a motorcycle accident resulting in a traumatic aortic rupture and splenic laceration. He was subjected to a surgical repair of the aortic lesion under complete heparinization. The splenic rupture was non operatively managed successfully. (Rev Méd Chile 2000; 128: 529-32) <![CDATA[<I>Reflections on the current state of Anatomic Pathology in Chile</I>]]> The present article reviews the most relevant aspects of the practice of Anatomic Pathology in Chile. The importance of biopsy and autopsy are analysed, in particular the consequences of the fall in the number of autopsies performed in our hospitals, in the recent decades. The modern pathologist is confronted with two situations: the renovation of the value of the autopsy and the acquisition of new diagnostic technologies, both not usually considered in the classical morphologic approach of Pathology. The ways to solve these problems in a discipline that is still a fundamental specialty in modern medicine are analyzed. (Rev Méd Chile "000; 1"8: 533-8) <![CDATA[<I>Tumorogenesis and mdm2 protein</I>]]> Tumorogenesis is associated with several events by which a normal cell transforms itself into a tumour cell with an increased proliferation rate. One of the most important research initiatives in this area is the characterization of the molecular mechanisms involved in tumorogenesis and cancer. Oncogenes and tumour suppressor genes are directly involved in the cell cycle, differentiation, and apoptosis. The cellular oncogene MDM2 seems to be abnormally elevated in several human tumours, specially in sarcomas. The MDM2 gene product, mdm2 protein, pS3 and retinoblastoma (Rb) proteins, play crucial roles in the control of the cell cycle. The molecular interactions between mdm2, pS3 and Rb in cancer, are associated with a loss of control in the G1 phase of the cell cycle leading to uncontrolled cell proliferation. Studies by gene amplification appear to show an incomplete picture of mdm2 protein levels in tumour cells. The simultaneous determination of mdm2 protein and mRNA levels seems to give a more accurate interpretation of the abnormal function of the mdm2 protein. Thus, in addition to gene amplification, different mechanisms by which mdm2 is overexpressed in cancer cells also play an important role in tumorogenesis. (Rev Méd Chile 2000; 128: 539-46) <![CDATA[<I>The terminally ill patient</I>]]> The classification of a patient as terminally ill is based on an expert diagnosis of a severe and irreversible disease and the absence of an effective available treatment, according to present medical knowledge. Terminal diseases must not be confused with severe ones, since the latter may be reversible with an adequate and timely treatment. The physician assumes a great responsibility at the moment of diagnosing a patient as terminally ill. The professional must assume his care until the moment of death. This care must be oriented to the alleviation of symptoms and to provide the best possible quality of life. Also, help must be provided to deal with personal, legal and religious issues that may concern the patient. (Rev Méd Chile 2000; 128: 547-52). <![CDATA[<I>Evidence based medicine</I>]]> The classification of a patient as terminally ill is based on an expert diagnosis of a severe and irreversible disease and the absence of an effective available treatment, according to present medical knowledge. Terminal diseases must not be confused with severe ones, since the latter may be reversible with an adequate and timely treatment. The physician assumes a great responsibility at the moment of diagnosing a patient as terminally ill. The professional must assume his care until the moment of death. This care must be oriented to the alleviation of symptoms and to provide the best possible quality of life. Also, help must be provided to deal with personal, legal and religious issues that may concern the patient. (Rev Méd Chile 2000; 128: 547-52).