Scielo RSS <![CDATA[Revista médica de Chile]]> vol. 136 num. 12 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Impacto de la inmunodepresión basal y su grado de recuperación al año de terapia antirretroviral en sobrevida, complicaciones oportunistas y reacción de recuperación inmune</b>]]> Background: Baseline (BL) CD4 cell count is a major factor in outcome of highly active antiretroviral therapy (HAART); treatment induced immune recovery and viral response can modulate this outcome. Aim: To evaluate the association between baseline CD4 cell count and outcome during the first HAART régimen. Material and methods: Prospective study in 2,050 patients on first HAART with a follow up (f/u) ofat least 1 year. All had BL CD4 and viral load (VL) counts which were repeated at least twice a year. Patients were grouped according to BL CD4 (cells/mm³) in &lt;100 (Gl), 100-199 (G2) and ≥ (G3). Groups were further divided according to immune and vírologícal response at 1 year in CD4 > or &lt; 200 and VL detectable or undetectable (&lt;80 copies/mL). Outcome measures were death, ALUS defining events (ADE) and, as a surrogate marker of immune recovery reaction, herpes zoster (HZ). Resulte: During the first year of follow up, 113 patients (10.8%) diedin Gl (n =1,044), 17 (2.5%) in G2 (n =675) (Gl-2 p <0.05) and 9 (2.7%) in G3 (n =331) (G2-3 p NS). One hundred twenty five of919 (13.6%) patients alive at 1 year had ADE in Gl, 55/643 (8.5%) in G2 (p <0.05) and 20/320 (5.2%) in G3 (G2-3 p NS). ADEs with follow up CD4 >vs&lt; 200 were: 25/274 (9.1%) vs 100/643 (15 7%) in Gl (p <0.005); 28/404 (6.9%) vs 27/235 (11.2%) in G2 (p NS) and 18/281 (6.4%) vs 2/41 (4.8%) in G3 respectively (p NS). Detectable VL was an additional risk for ADE only in Gl without CD4 recovery. HZ was seen in 6.6% of Gl vs 4% in G2 (p <0.05) and 4.3% in G3. HZ rate was higher in all groups reaching a follow up CD4 >200 than those who did not, with a statistically significant difference at p <0.05 only in Gl (9.5% vs 5.3%). Conclusions: The occurrence of death and ADE during the first year of HAART was significantly higher in patients with aBL CD4 <100, but no statistically significant difference was observed from BL CD4 >100 upwards. Immune recovery during f/u in the more immunosuppressed group greatly improved the outcome. The group with lowest BL CD4 and greater immune recovery showed the highest rate of immune recovery reaction. <![CDATA[<b>Evaluación de la calidad de vida en mujeres de 40 a 59 años mediante la escala MRS <i>(Menopause Rating Scale)</i></b>]]> Background: Climacteric symptoms have a direct relationship with biological and sociocultural factors and significantly impair the quality of life of women. Aim: To assess quality of life and factors affecting it in women aged 40 to 59 years. Material and methods: The Menopause Rating Scale (MRS) was applied to 370 healthy women aged 49 ± 6 years, that accompanied patients to public hospitals in Santiago. Results: Forty four percent of women were postmenopausal and 6% used hormone replacement therapy. Half of the group had less than 12 years of formal education and 67% had a couple. The mean number of children was 2.8 ± 1.5. Total MRS score was 16.2 ± 8.5. The higher score was given by the psychological domain (7.7 + 4.4), followed by the somatic domain (5.8 ± 3.5). The urogenital domain had the lowest score (2.7 ± 2.9). Eighty percent of women had moderate to severe climacteric symptoms. A logistic regression analysis showed that the postmenopausal condition was the factor that caused the greatest derangement in quality of life, followed by her parity. Formal education had the lowest impact. Conclusions: In this sample of women, menopause significantly deteriorated quality of life and sociocultural factors such as the parity also had an impact. <![CDATA[<b>Púrpura trombótico trombocitopénico</b>: <b>Revisión de la literatura a partir de 18 casos</b>]]> Background: Thrombotic thrombocytopenic purpura (TTP) is characterized by anemia, thrombocytopenia, neurological and renal involvement of variable severity and it has a dismal prognosis. Platelet-derived von Willebrand Factor-cleaving metalloprotease ADAMTS-13 activity may orient the diagnosis, but normal levels do not discard it. The most effective therapy thus known is plasmapheresis. Aim: To report the experience in 18 patients with TTP. Material and methods: Retrospective assessment of 11 patients and prospective assessment of seven subjects with TTP, aged 15 to 81 years. Results: All presented with anemia, thrombocytopenia and LDH elevation. Sixteen had neurological symptoms, five had fever, four had macroscopic urinary excretion of pigments, four had petechiae, and two had nosebleeds. Haptoglobin was low in 10 of 11 patients in whom it was measured. ADAMTS-13 had low activity in 15 of 17 patients (in 11, the inhibitor was found). Seventeen patients were treated with plasmapheresis and nine received steroids also. Seven patients died due to shock with respiratory involvement or múltiple organic failure. Conclusions: TTP has heterogeneous modes of presentation. If the diagnosis is strongly suspected, plasmapheresis can be started without laboratory confirmation. An ADAMTS-13 activity below 6% is almost exclusive of TTP . <![CDATA[<b>Frecuencia de tromboembolismo venoso en pacientes hospitalizados con cáncer. Factores de riesgo y eficacia de la tromboprofilaxis farmacológica</b>]]> Background: Hospitalized patients with cancer have a high risk of venous thromboembolism (VTE). Aim: To study the frequency of VTE and its risk factors in hospitalized patients with cancer. Material and methods: Retrospective analysis of clinical records of patients with cancer, hospitalized at a university hospital between 2002 and 2004. Patients with the diagnosis of VTE at admission or using anticoagulants, were excluded from the analysis. Results: The medical records of 366 patients were reviewed. Fifty three percent had a digestive cáncer, 19% lung cáncer, 10% breast cancer and 18% had a tumor of other origin. In 77%, the tumor was in an advanced stage. The most common admission diagnoses were pneumonía, vomiting and dehydration, gastrointestinal bleeding and urinary infection. In 125 patients (34%) pharmacological thrombo-prophylaxis was not used and 242 (66%) received regular or low molecular weight heparin. VTE was detected in 11 patients (3%) and was significantly more common among patients not receiving thrombo prophylaxis compared to those receiving heparin (6.4% and 1.2%, respectively p =0.014). Factors associated to VTE were a history ofprevious VTE with an odds ratio (OR) of 12.9 (p <0.01), obesity with an OR of 13.3 (p <0.01), recent chemotherapy with an OR of 6.9 (p =0.01). The use of pharmacological thromboprophylaxis had an OR of 0.24 (p =0.05). Conclusions: Three percent of patients in this series had VTE during the hospitalization. Pharmacological thrombo-prophylaxis significantly reduced the risk of VTE. <![CDATA[<b>Filtros de vena cava inferior en posición suprarrenal</b>]]> Background: Inferior vena cava (IVC) filters are used to prevent massive pulmonary embolism in cases where anticoagulation is contraindicated or has failed. It is usually implanted below the renal veins. In a few cases it is necessary to deploy the filter above them, with theoretical rísk of secondary renal failure. Aim: To report the experience with filters located above the renal veins. Patients and Methods: Medical records of all patients with percutaneous suprarenal filters are reviewed. Results: Between May 1993 and May 2007, 361 percutaneous IVC filter procedures were performed. In thirty patients aged 19 to 77 years (average 48years, 50% males), they were placed in suprarenalposition (8,3%). Suprarenal IVC filters were implanted in patients with extensive caval thrombosis, renal vein thrombosis extending to cava, displacement of previous IVC filters and double IVC system. Jugular vein approach was the access of choice. Technical success was 100%, no death or pulmonary embolism occurred. Patients were followed from 1 to 165 months (average 57 months). Eight deaths were recorded, five in patients with cáncer No patient had renal failure on follow up (average creatinine 0.90+0,26 mg/dL). Three patients developed a new deep vein thrombosis (10%), without pulmonary embolism. Conclusions: In this retrospective analysis of patients, suprarenal placement of IVC filters was not associated to secondary renal failure, and showed good short and long term results. <![CDATA[<b>Búsqueda de afecciones genéticas como etiología de déficit intelectual en individuos que asisten a escuelas de educación especial</b>]]> Background: Mental retardation or intellectual disability affects 2% ofthe general population, but in 60% to 70% of cases the real cause ofthis retardation is not known. An early etiologic diagnosis of intellectual disability can lead to opportunities for improved educational interventions, reinforcing weak aáreas and providing a genetic counseling to the family Aim: To search genetic diseases underíying intellectual disabilities of children attending a special education school. Material and methods: A clinical geneticist performed the history and physical examination in one hundred and three students aged between 5 and 24 years (51 males). A blood sample was obtained in 92 of them for a genetic screening that included a standard karyotype, fragile X molecular genetic testing and search for inborn errors of metabolism by tándem mass spectrometry. Results: This approach yielded an etiological diagnosis in as much as 29 patients. Three percent of them had a fragile X syndrome. Inborn errors of metabolism were not detected. Conclusions: This type of screening should be done always in children with intellectual disability to establish an etiological diagnosis. <![CDATA[<b>Efectos mnemónicos maternos prenatales sobre el sexo psíquico humano. Insuficiencia del mecanismo inmunitario</b>: <b>Nueva propuesta desde la tolerancia-rechazo materno-fetal</b>]]> In approximately 15% of homosexual men, their phenotype is associated to the fraternal birth order. Older biological brothers induce in their mothers anti-male factors (antibodies) that interfere the brain maleness development ofyounger fetuses. This effect is seldom seen in non-right-handed men and is not seen in women. The influence of older siblings is seen in their sex ratio (SR). In contradiction with previous hypothesis, significant heterogeneities of SR have been found among older siblings of males or females, right or non-right-handed and homo or heterosexual individuáis. This can only be understood as if the ñndings found among homosexuals were part of a general mechanism of fetus-maternal tolerance-rejection processes of placental mammals. We found, in relation to ABO and Rh systems and sex, that embryos with genes different from those of their mothers, induced better pregnancies and maternal tolerance than embryos similar to their mothers. Assuming that homo or heterosexuality and right or non-right-handedness behave similar to ABO or Rh alíeles, the author provides a speculative interpretation ofthese results. Homosexual women (¡esbians) and especially if they are non-right-handed, are preceded by siblings with a high SR (maternal environment with anti-female or pro-male factors); then lesbianism or non-right-handedness may induce tolerance to be a woman in such anti-female environment. Non-right-handedness could induce tolerance for anti-male factors of mothers, thus preventing the production ofgays in a pro-male maternal environment, but leading to the production of non-right-handed gays in anti-male maternal environments. Several new hypotheses and interpretations merge from this newproposition. Also, complete sexual orientation could be acquired after birth. <![CDATA[<b>Apendicitis aguda sin dolor o "El paraíso de los tontos"</b>: <b>Caso clínico</b>]]> The diagnosis of acute appendicitis has been based on the presence of ríght lower quadrant pain and guarding. Occasionally, the pain disappears, even in the presence of a continuing appendicular process. This phenomenon is called "the fools' paradise". We report two male patients aged 19 and 17 years with an acute appendicitis confirmed by an abdominal ultrasound in one and an abdominal CAT sean in the other, in whom the abdominal pain disappeared during the evolution. Despite of the absence of pain, both were operated, based on imaging and laboratory studies, confirming the presence of an inflamed appendix. <![CDATA[<b>Neumonía grave por <i>Streptococcus pyogenes</i></b>: <b>Reporte de un caso</b>]]> During the past two decades there has been a resurgence ofinvasive group A streptococcal (GAS) infection, specially pneumonia and bacteremia. We report a 35 year-old female previously subjected to a thyroidectomy for a thyroid cáncer, that five days after operation, presented with a severe community-acquired pneumonia caused by Streptococcus pyogenes (Lancefield Group A Streptococcus) that was complicated by acute respiratory failure and septic shock. She was treated with a combination of 3 g/day of cefotaxime and 1.8 g/day of clindamycin with a good clinical response and discharged from the hospital in good conditions. Although this microorganism is an uncommon cause of community-acquired pneumonia, previously healthy individuals may be infected and the clinical course may be fulminant. Patients with invasive GAS infection admitted to ICU have a high mortality rate. Treatment of choice of Group A streptococcal infection is penicillin. However, clindamycin should be added in severe infections . <![CDATA[<b>Enfermedad injerto contra huésped (EICH)</b>: <b>Caso clínico con expresión en mucosa bucal</b>]]> Gran versus Host Disease (GVHD) is a common complication in allogenic bone marrow transplants and in some cases, it involves the oral mucosa. Therefore, the appropriate diagnosis and timely treatment is essential to prevent ¡ocal complications which interfere with normal oral functions and facilitate infection spread. We report a 17 years old woman with GVHD associated to ¡ichenoid and ulcerative ¡essions in the oral mucosa, which responded to the topical administration of a 0.1% tacrolimus ointment. <![CDATA[<b>Accesibilidad geográfica para detección temprana de enfermedades crónico-degenerativas</b>]]> Background: The accessibility to health centers is a limitation to the use of preventive and curative health centers. Aim: To assess geographic accessibility using a parameter that integrates information about the use ofpreventive services and travelling time froin home to the health center. Material and methods: We analyzed target geographical áreas of10 community centers located at the Northeast of México. A survey was conducted to collect information about the utilization of preventive services for detection of diabetes and hypertension within last year and in women, detection of cervical and breast cáncer. The time required to travel between the health center and the farthest location point at every neighborhood of each geographic área, using public or private transportation, was calculated. Health service use and transportation time were condensed in a single parameter, called geographic accessibility index. Data was normalized using z scores. Resulte: Three geographical areas denominated 7, 8 and 10 had the lowest detection rates of chronic diseases, with valúes rangingfrom 45% to 48%. By car, área number 3 had the longest travelling time, corresponding to 14 minutes. The longest travelling times by public transportation were detected in áreas 1 and 3, corresponding to 27 and 29 minutes, respectively The geographic accessibility index showed that the least favorable z scores travelling by car corresponded to areas 6 and 10 and, when travelling on public transportation, to áreas 8 and 10. Conclusions: The geographic accessibility index identified areas that required improvements in accessibility. <![CDATA[<b>Envejecimiento cardiovascular</b>]]> Aging produces its own cardiovascular changes, mainly remodelling of arteries, heart and the microcirculation. These progressive changes, detected since adolescence, represent a major rísk factor for the development of cardiovascular diseases. Remodelling of arteries produces a thickening of the intima-media with fracture of elastic fibers and their replacement by collagen. These alterations induce an increase of the pulse wave and aortic impedance, with greater resistance to ventrícular ejection, that in turns induces the remodelling of the left ventricle. Ventricular remodelling leads to systolic, diastolic and chronotropic dysfunctions that explain the reduced capacity of old people to increase cardiac output during exercise. These alterations together with oxidative endothelial dysfunction and somatic mitochondrial mutations in the skeletal muscle decrease aerobic capacity, especially in adults aged >70 years. On the other hand, the transmission of an increased pulse wave to microvessels, mainly of the brain and kidneys, damage these organs. There is a search for candidate genes associated to this phenotype, especially those associated with arterial structure. Atpresent no specific treatment is available for cardiovascular aging. Exercise preserves a better aerobic capacity but does not prevent its decline with age. Vasodilator drugs may decrease aortic impedance and perhaps delay remodelling. However there is no clinical evidence available to recommend these drugs in young healthy people. Finally new drugs that modify aortic molecular structure are been investigated. <![CDATA[<b>Trastornos de la conducta alimentaria no especificados, síndromes parciales y cuadros subclínicos</b>: <b>Una alerta para la atención primaria</b>]]> Eating disorders not otherwise specified are the most common category of eating disorders encountered in routine clinical practice. Their prevalence íluctuates from 2.4% to 12.6% among female adolescents and up to 60% of cases in treatment centres. Binge eating disorder is the most differentiated subtype. Peripuberal period, diabetes mellitus type I, intense and increased physical activity, demographic and psychosociocultural aspects, physical and psychopathological diseases are risk factors. Clinical features, course, outcome and therapeutic approaches are similar to those of full syndromes. From an etiological point ofview, some authors believe that there is a continuum from altered eating behaviors and concerns about body shape and weight to typical anorectic and/or bulimic disorders. Others classify them as subcategories of full or mixed disorders. In conclusión, these conditions are heterogeneous syndromes that need to be reconsidered from both nosological and conceptual perspectives. They also demand an early recognition and treatment and further research about these disorders is required. <![CDATA[<b>Una mirada crítica en torno al plan AUGE. Algunos aspectos generales y valóricos</b>]]> The health reform in Chile established a health plan callee! AUGE that guarantees an access to diagnosis and treatment of certain specifie diseases within a time frame that must be respected. This article reviews and analyzes the general provisions of this plan and its management of values. Aspects that were implemented by the reform are discussed, especially those that refer to direct care of the population. The positive and negative aspects of the reform are balancea and are contrasted with eventual changes that should be made from an ethicalpointofview. <![CDATA[<b>Oportunidades y desafíos en el sistema de salud</b>]]> The health reform in Chile established a health plan callee! AUGE that guarantees an access to diagnosis and treatment of certain specifie diseases within a time frame that must be respected. This article reviews and analyzes the general provisions of this plan and its management of values. Aspects that were implemented by the reform are discussed, especially those that refer to direct care of the population. The positive and negative aspects of the reform are balancea and are contrasted with eventual changes that should be made from an ethicalpointofview.