Scielo RSS <![CDATA[Revista médica de Chile]]> https://scielo.conicyt.cl/rss.php?pid=0034-988720180008&lang=es vol. 146 num. 8 lang. es <![CDATA[SciELO Logo]]> https://scielo.conicyt.cl/img/en/fbpelogp.gif https://scielo.conicyt.cl <![CDATA[Experiencia del trasplante de microbiota fecal a través de colonoscopía en el tratamiento de la infección por <em>Clostridium difficile</em> recurrente]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800823&lng=es&nrm=iso&tlng=es Background: Most cases of Clostridium difficile infection (CDI) respond to a standard course of antibiotics, however recurrent CDI is becoming common and alternative therapeutic strategies are needed. In this scenario, fecal microbiota transplantation (FMT) has been suggested. Aim: To describe the efficacy and safety of FMT for the treatment of recurrent CDI. Patients and Methods: Review of medical records of all patients with recurrent CDI treated with FMT between April 2013 and April 2017. Demographic and clinical data were abstracted including details of treatment prior to FMT, rate of FMT treatment success and clinical course during follow-up period. Telephone surveys were conducted to determine patient satisfaction. Results: Eight patients aged 19 to 82 years (six women) underwent FMT. They experienced a median of four previous episodes of CDI (range 3-8). The mean duration of CDI was 18 days (range 3-36) before FMT. All procedures were performed by colonoscopy. Effectiveness with one session of FMT was 100%. During the follow-up period (median 24 months, range 7-55), two patients developed CDI, one of them after using antibiotics. Adverse events were reported in three patients. Two had bloating and one patient with Crohn's disease and a history of bacteremia had an episode of Escherichia coli bacteremia. All patients would use FMT again if necessary. Conclusions: FMT through colonoscopy appears to be a safe, effective and long-lasting therapy in cases of recurrent CDI. <![CDATA[Estratificación de riesgo de muerte a mediano plazo de pacientes evaluados por enfermedad coronaria con SPECT de perfusión miocárdica bajo efecto de dipiridamol]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800831&lng=es&nrm=iso&tlng=es Background: Dipyridamole (DIP) is the most commonly employed pharmacological stressor for myocardial perfusion tomography (SPECT) in patients unable to reach an adequate work load. Aim: To assess the predictive capacity of DIP SPECT on survival. Material and Methods: We included 985 adults aged 66 ±11 years (45% women) with rest and DIP-SPECT. The main indications for the procedure were coronary artery disease (CAD) screening in 66% and known CAD in 33%. Participants were followed up for a median of 65 months (interquartile range 54 to 86 months). During the follow up, 261 deaths were recorded and 98% had a specified cause in their death certificate. Results: Myocardial SPECT was abnormal in 44% of participants. Transient ischemic defects were observed in 34%, fixed defects concordant with infarction in 27% and post-stress systolic dysfunction in 23%. Twenty five percent of deaths were attributable to cardiac or ischemic cause and 22% to cancer. In a bivariate analysis, the hazard ratio (HR) of death of any cause was lower in females and higher in the presence of CAD. The multivariate analysis showed that being older than 46 years increased the HR of death of any cause. In a bivariate analysis, the HR for cardiac death was higher when the myocardial SPECT showed ischemia, necrosis or left ventricular dilation. In the multivariate analysis, post-stress left ventricular systolic function was associated with a lower risk of cardiac death. Conclusions: An abnormal myocardial SPECT, perfusion abnormalities, left ventricular systolic function or dilation are independent predictors of cardiac death in these participants. <![CDATA[Factores de riesgo asociados a bajo nivel de actividad física y exceso de peso corporal en estudiantes universitarios]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800840&lng=es&nrm=iso&tlng=es Background: University students are considered a vulnerable group due to their adoption of unhealthy diets and lifestyles. Aim: To determine the main risk factors associated with low level of physical activity and excess body weight in university students. Material and Methods: This cross-sectional study included 358 university students from Talca, (53% female). Sociodemographic, academic, health, lifestyle, nutritional status, physical activity and sedentary behavior variables were analyzed by logistic regression. Results: Men were more likely to present excess body weight than women (Odds ratio (OR): 2.16 [95% CI: 1.17-4.01], p = 0.01). Similarly, those with low level of physical activity (OR: 2.13 [95% CI: 1.10-414], p = 0.03), musculoskeletal injuries (OR: 2.43 [95% CI: 1.09-6.34], p = 0.05) and smokers (OR: 2.09 [95% CI: 1.05-4.14], p = 0.04) were more likely to have excess body weight. Individuals with excess body weight (OR: 2.94 [95% CI: 1.31-6.61], p &lt; 0.01), high sedentary behaviors (OR: 2.01 [95% CI: 1.04-4.55], p = 0.04), those who spent more than 7 hours per week studying (OR: 2.11 [95% CI: 1.06-4.66], p = 0.04), and those with presence of musculoskeletal injuries (OR: 1.49 [95% CI: 1.06- 3.66], p = 0.04) were more likely to be physically inactive. In addition, men were 73% less likely to have low physical activity levels compared to women (OR: 0.27 [95% CI: 0.11-0.56], p &lt; 0.01). Conclusions: University students have several modifiable risk factors associated with low levels of physical activity and excess weight. Healthy lifestyles promotion should modify these risk behaviors. <![CDATA[Mortalidad por enfermedades isquémicas del corazón en Ecuador, 2001-2016: estudio de tendencias]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800850&lng=es&nrm=iso&tlng=es Background: Ischemic Heart Disease (IHD) is the leading cause of mortality worldwide. Aim: To analyze the evolution of mortality by IHD in Ecuador, from 2001 to 2016. Material and Methods: Analysis of Ecuador death registries elaborated by the National Statistics and Census Institute. Specific and age-adjusted mortality rates were calculated for the 2001-2016 period in Ecuador. The annual percent change (APC) and the average annual percent change (AAPC) were estimated. Changes in trends were located through joinpoint regression analysis. Results: From 2001 to 2016 there were 46,133 deaths due to IHD in Ecuador, of which 60% (n = 27,489) corresponded to men. In the joinpoint regression analysis, the crude mortality rates for IHD reported an increase in the AAPC of 4.0% (2001-2016, 95% CI: 1.5 – 6.6). Rates adjusted for age increased with an AAPC of 3.2% (2001-2016, 95% CI: 0.7 – 5.8). Conclusions: Mortality due to ischemic heart disease increased in Ecuador in the period 2001-2016. Two marked periods were observed, one with a decrease followed by a significant increase, in both sexes and all age groups. <![CDATA[Investigación clínica de la ptosis cerebral. Presentación de seis nuevos casos]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800857&lng=es&nrm=iso&tlng=es Background: Cerebral ptosis is understood as the bilateral paralysis of eyelid elevation linked to a stroke or hemorrhage of the middle cerebral artery (MCA). It is a transient condition, independent of the evolution of the lesion. Aim: To analyze six patients with the condition. Patients and Methods: Report of five women and one male aged 42 to 72 years. Results: All suffered an infarction or hemorrhage in the territory of the middle cerebral artery of the non-dominant hemisphere and developed a bilateral palpebral ptosis. The recovery started after the fourth day. At the tenth day, eye opening was effortless and did not require frontal help, despite the persistence of hemiplegia. Conclusions: Cerebral ptosis is a mimetic dysfunction of a specific non-injured area of the cerebral cortex, originated from a nearby parenchymal damage such as the middle cerebral artery of the same hemisphere. Cerebral ptosis expresses the inhibition of the voluntary eyelid elevation center, of prefrontal location in the non-dominant hemisphere. <![CDATA[Evaluación de la funcionalidad y fragilidad de las personas mayores asistentes a centros de día]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800864&lng=es&nrm=iso&tlng=es Background: Older people attending day care centers improve their social activities, perception of quality of life and reduce their institutionalization rate and risk of mortality in the medium term. Aim: To evaluate the changes in the integral geriatric assessment and frailty of a group of older people attending a day care center in Santiago. Material and Methods: Health self-perception, integral geriatric assessment, Barthel scale, frailty indicators, mini-mental state scale, Yesavage depression score and a scale about solitude perception were evaluated in 35 participants aged 73 ± 6 years on admission and at discharge from a day care center for older people. Results: At discharge, significant improvements were observed for depression, perception of social support and physical frailty. However, no changes in functional status, cognitive function and perception of solitude were observed. Conclusions: Older people attending improve their perception of social support and decrease their frailty and depression scores. <![CDATA[Asociación entre diabetes mellitus tipo 2, historia familiar de diabetes y deterioro cognitivo en adultos mayores chilenos]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800872&lng=es&nrm=iso&tlng=es Background: Although cardiovascular risk factors are associated with an impaired cognitive function, the impact of diabetes on cognitive function in Chilean adults is unknown. Aim: To investigate the association of diabetes or family history of the disease with cognitive impairment in older adults. Materials and Methods: Data from the 2009-2010 Chilean National Health Survey including 1,384 participants aged ≥ 60 years were included in this study. A score below 13 points for the Mini Mental State Examination (MMSE) was considered an indication of cognitive impairment. Logistic regression analyses were performed to assess the association between MMSE, diabetes and family history of the disease. Results: Cognitive impairment increased with age (Odds ratio (OR): 1.83 [95% confidence intervals (CI): 1.53; 2.19], p &lt; 0.01, per 5 years increment in age). This trend was greater in individuals with diabetes (OR: 2.37 [95% CI: 1.68; 3.35], p &lt; 0.01) compared to those without the disease. A similar trend was identified among individuals with a family history of diabetes compared to those without. Conclusions: Older adults with diabetes are more susceptible to develop cognitive impairment. <![CDATA[“Comemos así porque…”. Entendiendo las conductas alimentarias de mujeres chilenas de bajos recursos]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800882&lng=es&nrm=iso&tlng=es Background: The prevalence of obesity is higher in women than in men, especially in those of lower socioeconomic status. It is established that this group tends to have a less healthy diet. Aim: To explore the eating behaviors of low-income Chilean women. Material and Methods: Semi-structured interviews with photo-elicitation were conducted with 31 Chilean women aged 36 ± 6 years, who lived with a partner and had at least one sibling under 12 years of age. The interviews were transcribed and an inductive analysis of the participants’ discourses was made. Results: Seven themes were described in relation to their influence on three eating behaviors (food purchase, preparation and intake): Family, preferences, temporality, financial issues, special occasions, perceptions about food, and availability of food. The family exerted a strong influence on the behaviors and had an impact on the other themes encountered. Conclusions: Eating behaviors were influenced by several factors, both at the personal and environment levels. These factors interacted with each other to produce different forms of behavior modulation. It is therefore problematic to promote healthy eating behaviors while not considering all the influences on this behavior. <![CDATA[Experiencia de atención en red entre Hospital del Salvador y tres unidades de Atención Primaria Oftalmológica: Un modelo de salud pública para mejorar la atención oftalmológica]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800890&lng=es&nrm=iso&tlng=es Background: Primary care units of ophtalmology (UAPO) were incorporated in 2003 into the healthcare system of the Ministry of Health, in response to the high demand for hospital care. Three of these primary care units were incorporated to provide a network care with the ophthalmology service of a tertiary care hospital. Aim: To report the public health impact of networking. Material and Methods: A descriptive-prospective study was carried out analyzing all the healthcare attentions carried out between June and August 2016. An epidemiological characterization of the sample was made. We recorded: clinical diagnoses, decisions, resolution of the clinical problem at the primary care or referral to the hospital. Results: A total of 2,096 ophthalmologic attentions were carried out in the three UAPOs during the study period. The main diseases attended were disorders of refraction, cataracts, glaucoma and diabetic retinopathy. The resolution index was 84% of attentions. Only 16% of attentions required referral and consisted mainly of cataracts (covered by a special health care system), diabetic retinopathy, capsulotomies, iridotomies, uveitis, pterygium and lacrimal duct obstruction. Conclusions: This model of care allowed an efficient management of the high demand for hospital referral. This is expressed in the high-resolution index and low derivation, resulting in a decrease in waiting lists at the tertiary level. This system should be implemented by other tertiary centers of our country. <![CDATA[Análisis crítico del tratamiento de la enfermedad hepática grasa no alcohólica]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800894&lng=es&nrm=iso&tlng=es Non-alcoholic fatty liver disease (NAFDL) includes fatty liver or simple steatosis, characterized by lipid deposits in hepatocytes and more advanced stages such as steatohepatitis (NASH) and non-alcoholic cirrhosis. Physical inactivity, hypercaloric and unbalanced diet together with aging play a key role in the pathogenesis of NAFLD and are strongly associated with metabolic and physical activity continue to be major components in prevention and first-line treatment to attenuate or reverse NAFLD. Dietary patterns, their composition and weight reduction would be the most relevant nutritional aspects in NAFDL treatment. Physical exercise, moderate to intense, aerobic and resistance type contributes to weight loss, improves metabolic control and body composition. Pharmacological therapy can be useful in clinical circumstances that require it and needs a medical evaluation when there is no adherence and success in non-pharmacological interventions. <![CDATA[Muerte súbita en epilepsia]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800902&lng=es&nrm=iso&tlng=es The risk of sudden unexpected death in patients with epilepsy (SUDEP), is 20 to 25 times greater than in the general population. This increased risk is seen specially in refractory epilepsy, with an incidence of 9:1,000 patients-years. Risk factors have been established based on retrospective studies, finding that the frequency of seizures, specially generalized tonic clonic seizures, is the most important one. The physiopathological mechanism of SUDEP is not yet fully understood. Autonomic system abnormalities, as well as cardiac and respiratory changes have been found. The finding of new molecular biomarkers to identify patients with increased risk should be a priority. Treatment is based in the management of risk factors, although clear recommendations are hard to establish given the low level of evidence. <![CDATA[Actualidad del deber de informar en Chile]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800909&lng=es&nrm=iso&tlng=es The new Chilean regulation about patients’ rights and duties is generating a significant change in the information that health care professionals must provide to their patients. This issue will gravitate on medical liability. If this duty is accomplished incorrectly, professionals would fall into an illicit act and become liable to lawsuits and compensations to patients. This article provides a panoramic view about the grounds and content of the duty to inform and how judges are regulating the issue. <![CDATA[Historia, propósitos y características de las revistas médicas]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800913&lng=es&nrm=iso&tlng=es Medical journals are fundamental elements in medical education, in professional life, in research and in academic careers. They communicate new scientific and clinical findings, legitimate and give credibility to biomedical and clinical investigation, are guarantors of the authors’ intellectual property, are a useful forum for the discussion of relevant topics, distribute selected information to readers and are archives of their publications. Out of the numerous medical journals appeared before and during the XIXth Century, only 24 of them remain active until today and Revista Médica de Chile appears as number 20 in the list. Nowadays thousands of medical journals are published worldwide but only a small fraction are qualified as “mainstream journals”, because they strictly apply an independent editorial process with clear criteria in manuscript selection based in external peer review, format requisites according to ICMJE Recommendations, are included in major databases, publish a high proportion of research articles, and other reasons. English language predominates in mainstream journals and abstracts in English become available in some databases. Electronic publications and open access are important tools to disseminate new information but the appearance of “predatory journals” is a threatening menace to the integrity of medical publications. Authors should identify and reject them. Some reflections may help those who intend to create new medical journals. <![CDATA[Explicaciones no atendidas sobre las brechas de género en la enfermedad cardiovascular ¿Cómo entender diferencias de género en el infarto de miocardio?]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800921&lng=es&nrm=iso&tlng=es Advances in cardiovascular diseases research have shown that there are differences in social groups, which have been solely explained by biomedical dimensions. Although there have been advances in the biological understanding of these diseases, they do not account for the complexity of the phenomenon. To address this, the introduction of psychosocial variables have shown that they may be useful to understand the manifestations and evolution of these conditions. Thus, gender gaps should not be studied exclusively from a biomedical perspective. This article reviews the explanations about the gender gaps in the expression of acute myocardial infarction based on gender stereotypes, as an alternative to the biomedical approach. Stereotypes can predict different consequences when they are used by health professionals or patients. Finally, alternatives are proposed to reduce the negative results of the gender stereotype activation when an acute myocardial infarction is suffered. Also new development lines in theoretical, methodological and interdisciplinary work are proposed. <![CDATA[Docencia en violencia y abuso sexual en estudiantes de pregrado de medicina: percepción de los docentes sobre barreras y facilitadores]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800927&lng=es&nrm=iso&tlng=es Background: Considering the frequency of sexual abuse and domestic violence (SA-DV) in the population, the likelihood of a medical student meeting patients with this problem is substantial. However, most students do not consider SA-DV in their differential diagnoses. Since 2014, this team has been working in strengthening undergraduate curriculum in SA-DV. It has been a challenging and slow process. Purpose: To identify barriers and facilitators perceived by the undergraduate teaching team in order to suggest modifications in the curriculum in relation to the competencies required for screening and early intervention for victims of SA-DV. The conclusions obtained may be useful for other medical schools and universities facing this challenge. Methods: Qualitative study using grounded theory method for the analysis of interviews and focus groups. Results: SA-DV are perceived as a problem that is pertinent for physicians. However, there is a common belief that teaching about SA-DV should be limited to only certain specific specialties. The main barriers are the limited curricular time, the need to prioritize contents and the lack of specific training of the teachers. A key facilitator is the fact that gender violence is on the public agenda today. Conclusions: The identified barriers coincide with those reported in the literature; limited curricular time and prioritization of contents. Although this study does not show the perception of SA-DV as ‘not a medical issue’ nor as a subject that pertains to other health professionals, there is the perception that teaching clinical approach to SA-DV only pertains to specialists who are directly involved in this topic. <![CDATA[Pseudoquiste pancreático intramural gástrico en páncreas heterotópico, una causa infrecuente de retención gástrica. Caso clínico]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800933&lng=es&nrm=iso&tlng=es Heterotopic pancreas is a silent gastrointestinal malformation that may become clinically evident when complicated by inflammation and pseudocyst formation. We report a 26 year-old male presenting with vomiting, pain and abdominal distention. An abdominal CT scan showed an important gastric distention secondary to a 4-cm cystic lesion located in the antrum wall. An endosonography showed that the lesion obstructed the gastric outlet and was compatible with a pseudocyst. A cysto-gastrostomy was performed draining the cyst. Its high lipase and amylase content confirmed that it was a pancreatic pseudocyst. Six months later, the lesion appeared again and a subtotal gastrectomy was performed Histopathology confirmed ectopic pancreatic tissue. <![CDATA[Sospecha diagnóstica de síndrome de Ehlers Danlos tipo vascular: reporte de un caso y revisión de literatura]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800938&lng=es&nrm=iso&tlng=es Ehlers Danlos Syndrome comprises a heterogeneous group of genetic disorders of the connective tissue, due to defects in collagen or its modifying enzymes. We report a 21 years old male presenting with translucent skin revealing the subcutaneous venous pattern. He had a thin face, large-appearing eyes, thin lips, thin nose, joint hypermotility and history of hip dysplasia. A vascular Ehlers Danlos Syndrome was suspected. However, the genetic study to confirm the diagnosis was not done. <![CDATA[Porfiria cutánea tarda. Caso clínico]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800943&lng=es&nrm=iso&tlng=es Porphyria cutanea tarda (PCT) is the most common type of porphyria: it is characterized by blistering lesions, erosions and crusts on the back of the hands, associated with photosensitivity and facial hypertrichosis. It is produced by acquired or hereditary deficiency of the enzyme UROD, fifth enzyme in the chain of production of the Heme group. This causes accumulation of porphyrins in the liver, which are subsequently mobilized to the skin, where lesions are generated by photosensitivity. This deficiency can be exacerbated by multiple causes. We report a 51-year-old female presenting with the characteristic dermal lesions described above, which disappeared when she discontinued her hormone replacement therapy with estradiol and dydrogesterone. Urinary and blood uroporphyrin and hexacarboxyl porphyrins were elevated and plasma ferritin was 479 ng/ml. Hormone replacement therapy was discontinued and phlebotomies were attempted but not tolerated by the patient. The dermic lesions have not relapsed. <![CDATA[Pérdida rápida de peso: el caso de los deportes de combate]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800947&lng=es&nrm=iso&tlng=es Porphyria cutanea tarda (PCT) is the most common type of porphyria: it is characterized by blistering lesions, erosions and crusts on the back of the hands, associated with photosensitivity and facial hypertrichosis. It is produced by acquired or hereditary deficiency of the enzyme UROD, fifth enzyme in the chain of production of the Heme group. This causes accumulation of porphyrins in the liver, which are subsequently mobilized to the skin, where lesions are generated by photosensitivity. This deficiency can be exacerbated by multiple causes. We report a 51-year-old female presenting with the characteristic dermal lesions described above, which disappeared when she discontinued her hormone replacement therapy with estradiol and dydrogesterone. Urinary and blood uroporphyrin and hexacarboxyl porphyrins were elevated and plasma ferritin was 479 ng/ml. Hormone replacement therapy was discontinued and phlebotomies were attempted but not tolerated by the patient. The dermic lesions have not relapsed. <![CDATA[Beethoven y el síndrome de Cogan]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800949&lng=es&nrm=iso&tlng=es Porphyria cutanea tarda (PCT) is the most common type of porphyria: it is characterized by blistering lesions, erosions and crusts on the back of the hands, associated with photosensitivity and facial hypertrichosis. It is produced by acquired or hereditary deficiency of the enzyme UROD, fifth enzyme in the chain of production of the Heme group. This causes accumulation of porphyrins in the liver, which are subsequently mobilized to the skin, where lesions are generated by photosensitivity. This deficiency can be exacerbated by multiple causes. We report a 51-year-old female presenting with the characteristic dermal lesions described above, which disappeared when she discontinued her hormone replacement therapy with estradiol and dydrogesterone. Urinary and blood uroporphyrin and hexacarboxyl porphyrins were elevated and plasma ferritin was 479 ng/ml. Hormone replacement therapy was discontinued and phlebotomies were attempted but not tolerated by the patient. The dermic lesions have not relapsed. <![CDATA[Comentarios al artículo: Actividad física y perfil de estilos de vida promotores de la salud en adultos mayores chilenos]]> https://scielo.conicyt.cl/scielo.php?script=sci_arttext&pid=S0034-98872018000800950&lng=es&nrm=iso&tlng=es Porphyria cutanea tarda (PCT) is the most common type of porphyria: it is characterized by blistering lesions, erosions and crusts on the back of the hands, associated with photosensitivity and facial hypertrichosis. It is produced by acquired or hereditary deficiency of the enzyme UROD, fifth enzyme in the chain of production of the Heme group. This causes accumulation of porphyrins in the liver, which are subsequently mobilized to the skin, where lesions are generated by photosensitivity. This deficiency can be exacerbated by multiple causes. We report a 51-year-old female presenting with the characteristic dermal lesions described above, which disappeared when she discontinued her hormone replacement therapy with estradiol and dydrogesterone. Urinary and blood uroporphyrin and hexacarboxyl porphyrins were elevated and plasma ferritin was 479 ng/ml. Hormone replacement therapy was discontinued and phlebotomies were attempted but not tolerated by the patient. The dermic lesions have not relapsed.