Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 128 num. 12 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<I>Clinical status of patients subjected to cholecystectomy ten years ago</I>]]> Background: The "post cholecystectomy" syndrome comprises a series of vague symptoms referred by patients subjected to this surgical procedure. These symptoms are unspecific and their association with the operation is dubious. Aim: To assess the frequency of digestive symptoms among patients subjected to a cholecystectomy ten years ago. Patients and methods: One hundred patients subjected to a cholecystectomy between 1987 and 1990, were contacted by mail. They were invited to a clinical interview and to an abdominal ultrasound examination. Results: Two invited patients had died of an acute myocardial infarction. Therefore, 98 patients (78 women), aged 30 to 85 years old, were assessed. Seventy two percent had diverse dyspeptic symptoms, 90% had no food intolerance and 94% had gained weight after the operation. Ninety six percent was satisfied with the surgical results, 3% had severe symptoms due to gastroesophageal reflux or depression. One patient had a residual choledocholithiasis and refused any treatment. Conclusions: Cholecystectomy is well tolerated and has good long term results (Rev Méd Chile 2000; 128: 1309-12) <![CDATA[<I>Early erythropoietin use for the prevention of anemia in very low birth weight newborns</I>]]> Background: Anemia is common among very low birth weight newborns and requires frequent blood tranfusions. Erythropoietin was been reported to be useful in the prevention of this anemia. Aim: To asses the benefits of early (before the third week of life) Human recombinant Erythropoietin (r-EPO) administration to reduce the requirement of blood tranfusions in very low birth weight newborns. Patients and methods: sixty newborns under 1500g of birthweight were randomly assigned to recive r-EPO (n=29) or placebo (n=31) three times per week, during four weeks. Packed red cell volume and reticulocyte counts were measured weekly. Serum erythropoietin was measured prior to eigth dose. Transfusion requirements were recorded. Results: r-EPO reduced transfusions from 1.41 ± 1.1 to 0.69 ± 1 transfusions/newborns (p<0.001). At the fourth week of treatment, reticulocyte count was 14.8 ± 7 and 6.4 ± 4.9% in the active treatment group and placebo group respectively (p<0.001). Conclusions: r-EPO reduces the requrement of transfusions in low birth weight infants (Rev Méd Chile 2000; 128: 1313-17). <![CDATA[<I>In vitro activity of moxifloxacin and other antimicrobials against respiratory pathogens</I>]]> Background: Respiratory pathogens are becoming increasingly resistant to antimicrobials. A new group of drugs, called respiratory quinolones have been synthesized to overcome this problem. Aim: To study the in vitro susceptibility of respiratory pathogens to old and new antimicrobials. Material and methods: Forty five strains of S pneumoniae, 44 strains of H influenzae, 21 strains of M catarrhalis, 10 strains of methicillin susceptible S aureus and 20 strains of methicillin resistant S aureus were studied. All were isolated from community acquired respiratory infections during 1999. Minimal inhibitory concentrations of moxifloxacin, amoxicilin, amoxicilin/clavulanic acid, clarithromycin, azithromycin, ciprofloxacin and levofloxacin were determined using the Etest method. Betalactamase production by H influenzae and M catarrhalis was also studied. Results: S pneumoniae strains were 100% susceptible to quinolones and cotrimoxazole, 2% were resistant to macrolides, 11% were resistant to amoxicilin/clavulanic acid and 47% were resistant to cefuroxime. H influenzae was 100% susceptible to quinolones, azithromycin and amoxicilin/clavulanic acid. There was a 53% resistance to cotrimoxazole, 21% to amoxicilin, 9% to clarithromycin and 7% to cefuroxime. M catarrhalis was 100% susceptible to quinolones and 100% resistant to amoxicilin, 5% resistant to macrolides, 14% resistant to amoxicilin/clavulanic acid, 20% to cefuroxime and 30% to cotrimoxazole. Methicilline susceptible S aureus was susceptible to all antimicrobials and methicillin resistant S aureus was resistant to all. Conclusions: Moxifloxacin and the new respiratory quinolones can be useful in the treatment of respiratory infections (Rev Méd Chile 2000; 128: 1319-26). <![CDATA[<I>Thromboembolic risk factors in atrial flutter</I>: <I>a transesophageal echocardiographic study</I>]]> Background: The thromboembolic risk of atrial flutter (AFL) is not well defined. On the other hand, in atrial fibrillation (AF), the echocardiographic demonstration of thrombus or spontaneous echo contrast in the left atria or its appendage, a lower flow velocity in the left atrial appendage, and its reduced mobility, are well known risk factors of thromboembolism. Aim: To study the incidence of these echocardiographic risk factors in patients with AFL. Material and methods: We prospectively studied 50 consecutive patients with AFL comparing them with two groups of patients with a well known increased risk of thromboembolism: 54 patients with AF and 24 patients with sinus rhythm and severe mitral stenosis (RSEMS). The group of patients with AFL was also compared with a control group of 27 patients with sinus rhythm and no increased risk of thromboembolism. In each group, we studied the presence of thrombi and spontaneous echo contrast in the left atria and left atrial appendage, emptying velocity (Vel A), filling flow (Vel B) and motility of the left atrial appendage and left atrial dimensions. Results: When compared with control patients, AFL subjects had a higher incidence of spontaneous echo contrast in the left atria and left atrial appendage (11 and 42% respectively, p<0.05); slower flow velocity in the left atrial appendage (Vel A 69.25 ± 25 and 41 ± 19 cm/s respectively, Vel B 55 ± 16 and 46 ± 20 cm/s respectively, p<0.05); lower atrial appendage wall motility (4 and 84% respectively, p<0.001) and a larger left atrium (40 ± 10 and 45 ± 0.6 mm respectively, p<0.05). Patients with AFL had a lower incidence of echocardiographic abnormalities than subjects with AF or RSEMS. Thrombi were found in 2 patients with AFL, 12 patients with AF, 4 patients with RSEMS and in no control patient. Conclusions: In AFL, there are echocardiographic markers of increased thromboembolic risk in comparison with a control group. Nevertheless, the incidence of these factors is lower than in patients with AF or with RSEMS (Rev Méd Chile 2000; 128: 1327-34). <![CDATA[<I>Animal reservoir and genotipic characterization of Enterohemorrhagic Escherichia coli (EHEC) in Argentina</I>]]> Background: There is a high prevalence of infection by Enterohemorrhagic Escherichia coli (EHEC) and patients with hemolytic uremic syndrome (HUS) in Argentina. Aim: To study cattle and pigs as a possible reservoir of EHEC in Argentina. Material and methods: One hundred two healthy animals (68 cattles and 31 pigs) from a livestock in Argentina, were studied. Stool samples were obtained with a rectal swab. The strains were identified by DNA hybridization with specific gene probes detecting Shiga-like toxin 1 and 2 (Stx1, Stx2), and hly gen related to fimbrial adhesin-associated plasmid. EHEC strains were serogrouped using comercial antisera. Results: EHEC was isolated from 30 out of 68 bovines cultures (44.1%) and from 25 out of 31 pigs (58.1%). Isolates carrying genes codifying both Stx1 and Sxt2, were observed in 50% of cattle and 63.9% of pigs. The gene which codifies for hemolysin (associated to fimbrial adhesin) was observed in about 41% of EHEC isolates. Strains belonging to serogroups O26, O111, and O157 were isolated from cattle, and O111, and O157 from pigs. Conclusions: The high percentage of EHEC in both cattle and pigs and the presence of human infection-associated serogroups, suggests that these animals are a reservoir of EHEC associated with disease in humans (Rev Méd Chile 2000; 128: 1335-41). <![CDATA[<I>Toxic epidermal necrolysis. Report of one case treated with intravenous immunoglobulins</I>]]> We report a 27 years old homosexual male with AIDS that was admitted to the ICU dehydrated, with fever and severe malaise. He had irregular bullae, an extensive purpuric exanthema and a zone of epidermic detachment in the right arm. A toxic epidermal necrolysis was diagnosed and therapy with i.v. immunoglobulins was started. After four days of treatment, bullous lesions disappeared and the extension of exanthema decreased. Toxic epidermal necrolysis is a potentially fatal disease and the use of intravenous immunoglobulins for this condition has been reported as successful (Rev Méd Chile 2000; 128: 1343-48). <![CDATA[<I>Bleeding gastric ulcers and acute hepatitis</I>: <I>Two simultaneous adverse reactions due to nimesulide in one patient</I>]]> A 66 year-old obese woman with arthrosis, self-medicated with oral nimesulide, 200 mg daily. After 6 weeks she developed nausea, jaundice and dark urine. Two weeks later she had recurrent hematemesis and was hospitalized. Besides obesity and anemia her physical examination was unremarkable. An upper GI endoscopy revealed 3 acute gastric ulcers and a 4th one in the pyloric channel. Abdominal ultrasonogram showed a slightly enlarged liver with diffuse reduction in ecogenicity; the gallbladder and biliary tract were normal. Blood tests demonstrated a conjugated hyperbilirubinemia (maximal total value: 18,4 mg/dl), ALAT 960 U/l, ASAT 850 U/l, GGT 420 U/l, alkaline phosphatases mildly elevated, pro-time 49% and albumin 2.7 mg/dl. Serum markers for hepatitis A, B and C viruses were negative. ANA, AMA, anti-SmA, were negative. Ceruloplasmin was normal. A liver biopsy showed bridging necrosis and other signs of acute toxic liver damage. Gastric ulcers healed after conventional treatment and hepatitis subsided after 2 months leaving no signs of chronic liver damage. The diagnosis of toxic hepatitis due to nimesulide was supported by the time-course of drug usage, sex, age, absence of other causes of liver disease, a compatible liver biopsy and the improvement after drug withdrawal. Peptic ulcers or toxic hepatitis have been previously described as independent adverse reactions in patients taking nimesulide or other NSAIDs but their simultaneous occurrence in a single patient is a unique event that deserves to be reported (Rev Méd Chile 2000; 128: 1349-53). <![CDATA[<I>Obesity and fatty acids in the etiology of insulin resistance</I>]]> Fatty acids, obesity and insulin resistance relationship are discussed. In the last decades fatty acids (FA) have been implicated in the etiology of insulin resistance. Initially, this process was related to FA inhibitory effects on glucose uptake mediated by the FA oxidation metabolites. This mechanism known as the Randle cycle has been presently discarded based on recent evidence for FA effects on glucose metabolism. Now is known that cytosolic lipid content and FA molecular structure determines higher or lower storage and oxidation capacity. Another factor is given by Tumor Necrosis Factor-a, which is overexpressed in animal and human obesity, producing insulin signaling and glucose uptake inhibition. This paper discuss the role played by FA and obesity on insulin resistance, mainly in relation to FA effects on glucose metabolism in the liver, muscle and adipose tissues. In the obesity condition adipose tissue releases higher levels of free FA which in turn stimulates hepatic glucose production. Adipose tissue also, increase TNF-a secretion impairing glucose utilization and insulin signaling. In muscle, cytosolic lipid content activate a Protein Kinase that inhibits the insulin signaling and reduce GLUT-4 translocation. The study of cellular and metabolic changes associated to weight gain and its relationship with insulin resistance etiology are encouraged (Rev Méd Chile 2000; 128: 1354-60). <![CDATA[<I>Natural Killer cells and the innate immune system in infectious diseases</I>]]> Natural killer (NK) cells form a unique third group of lymphocytes that differs from T and B cells in surface phenotype, target cell recognition and function. NK cells have two relevant functions, related to the innate immune response against pathogens microorganisms. One is cytotoxicity, mediated by the recognition and lysis of target cells such as virus and bacteria infected-cells. The second NK cell function is to produce cytokines, mainly IFN-g, that can modulate innate and specific immune responses. Cytotoxicity and cytokine secretion contribute to host resistance against microorganisms and both functions are significantly altered in infectious diseases (Rev Méd Chile 2000; 128: 1361-70). <![CDATA[<I>It is time to think in patient’s rights</I>: <I>An introduction</I>]]> The underlying purpose of the Hippocratic oath and most medical ethics codes dictated during the twentieth century, is patient protection. Nowadays, however, clients of health services do not conform themselves with ethical declarations of the medical profession but demand that the rights that arise from those declarations, become legal instruments that force professionals, health authorities and governments to satisfy their health needs and respect their individual rights. Probably this is a consequence of the depersonalization of medical care, the weakening of ethical bases of physician- patient relationship and the emergence of new economical and social philosophies. Now, clients also have more expectations and a better knowledge about medicine than in yesteryears. Citizen organizations to defend health rights should not be seen as a threaten to medical profession and health institutions but as an opportunity to improve health care and respect towards people. They should not either harm the mutual confidence between the physician and his patient, nor the beneficial spirit of medical act, two fundamental components of medical acts (Rev Méd Chile 2000; 128: 1371-73). <![CDATA[<I>Human rights and their relationship with patient’s rights</I>]]> This historical article reviews the most important milestones in the evolution of human and patient’s rights. The latter have derived from human rights and have followed a similar historical evolution, but in markedly different times. This has lead to the persistence of monarchic type, paternalistic clinical relationship forms in republican societies. The acceptance of informed consent and patient’s rights has been a democratization of clinical relationships. On the other hand the right to body health management is a real cultural revolution. The democratization of clinical relationship is in agreement with our technical, pluralist and secularized times (Rev Méd Chile 2000; 128: 1374-79). <![CDATA[<I>About patient’s rights</I>]]> This article discusses the difficulties and requirements to accomplish medical obligations of veracity, confidentiality, fidelity and respect to intimacy. Veracity consists in not saying all what we think but nothing contrary to our thoughts. In the fields of terminal care and genetics, conflicts arise between the right to veracity and the principles of beneficence and avoiding harm. The so called "therapeutic privilege" or the right of physicians to withhold information, has been considered among the exceptions to informed consent and is rejected by some specialists in ethics. Confidentiality is, for many people, an ideal more than a reality, not fulfilled by many physicians in the full sense of the word and threatened by third parties. Patients should claim their right to confidentiality. The obligation of loyalty or fidelity, that is the obligation that physicians have to give priority to patient’s needs over own needs, has generated divided loyalties in many fields of medical practice due to changes in health organization and social context. The right to territorial, body and psychological or spiritual intimacy are three aspects of the right to intimacy that must be considered. Maybe, patient’s rights are just the other face of medical obligations towards them. If we physicians become defenders of patient’s rights, this could be another subtle facet of paternalism. (Rev Méd Chile 2000; 128: 1380-84). <![CDATA[<I>The right to a good quality</I>]]> Quality has a central role in medical care. The satisfaction of the rights of people to medical care, presupposes good quality medical acts. The meaning of quality goes further than a good attention based on scientific evidence and with competent skills. It comprises patient-physician relationship where professional behavior is evaluated, based on the fundamental principles of bioethics. These principles sustain the measures to control quality of medical actions, to comply with the rights of patients to have access to a good professional care (Rev Méd Chile 2000; 128: 1385-88). <![CDATA[<I>Health research in Chile</I>]]> An analysis of health research in Chile is made, considering factors like exaggerated professional training during undergraduate studies and clinical residencies, and displacement of professionals from academic activities to more remunerative positions. Additionally, the limited role of the Ministry of Health in research promotion, evidenced by the almost absent participation of public hospitals in clinical research is discussed. Research investment, among a 0.6 to 0.8% of the GNP, is far from developed countries and Chile has not defined relevant health problems where a search effort would have an impact in public health. The marked centralism of the country attempts against regional application to financed projects. The following suggestions are made: to increase the financing for investigation, to reassign resources allowing the access of regional institutions, to financing, to discuss in the Chilean Association of Medical Faculties (ASOFAMECH) the creation of an academic degree by means of a thesis during the professional studies and to give facilities to develop research during clinical residencies. Also, the Ministry of Health should be involved, creating a national agenda or research priorities and increasing its association with Universities. Also training programs for professionals with a special interest in investigation should be devised (Rev Méd Chile 2000; 128: 1389-95).