Scielo RSS <![CDATA[Revista médica de Chile]]> http://www.scielo.cl/rss.php?pid=0034-988719990008&lang=es vol. 127 num. 8 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.cl/img/en/fbpelogp.gif http://www.scielo.cl <![CDATA[<I> Helicobacter pylori</I>: La revolución bacteriológica]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800001&lng=es&nrm=iso&tlng=es The finding of H pylori in the gastric mucosa has changed the understanding of the pathogenesis of common diseases of the stomach and duodenum. The bacteria causes acute and chronic gastritis and is the precursor of peptic ulcers, gastric lymphoma and gastric cancer. The most common test used to diagnose the infection is the urease test on a gastric biopsy but an endoscopy must be performed to obtain the biopsy. Determination of serum levels of IgG appears the most suitable test to perform in large population studies. Patients with peptic ulcers, gastric lymphoma and early gastric cancer should be treated. Combinations of antibiotics such as amoxicillin, chlaritromycin and a proton pump inhibitor have yielded the best results in erradicating H pylori. Unfortunately this therapy is expensive and new combinations should be explored. Vaccination should be the treatment of choice for prevention and erradication in countries like Chile with high infection rate. Preliminary results are encouraging. <![CDATA[Recanalización percutánea de oclusiones crónicas de arterias ilíacas con instalación primaria de Stent]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800002&lng=es&nrm=iso&tlng=es Background: Percutaneous transluminal angioplasty is a well established treatment method for aorto iliac stenoses. However its success is limited in arterial occlusions and vascular stent placement can improve the results. Aim: To assess the effectiveness of percutaneous revascularization with stent placement in patients with chronic iliac artery occlusions. Patients and methods: twenty six patients (18 male) aged 47 to 82 years, with iliac artery occlusions lasting six or more weeks were treated. Fourteen had involvement of common iliac artery, five had involvement of external iliac artery and seven of both. The occluded segment length ranged from 3.5 to 12 cm. According to the Society of Cardiovascular Surgery/International Society for Cardiovascular Surgery classification, 22 patients had category 1 claudication, 10 were in category 2, 12 in category 3 and two in category 4. Results: A technical success was obtained in 23 patients and clinical success in 21. After the intervention, the anklearm index improved from 0.49 ± 0.12 to 0.88 ± 0.18 (p < 0.001). Permeability after 12 months of follow up was 81% and after 36 months, 65%. Four patients had complications; one had a vascular perforation, two had an acute occlusion and one had an asymptomatic distal embolization. All these were solved using endovascular techniques. Conclusions: Percutaneous revascularization with stent placement is a valid alternative to surgery in selected patients with chronic iliac artery occlusion. <![CDATA[Comparación del estado nutricional entre escolares indígenas y no indígenas]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800003&lng=es&nrm=iso&tlng=es Background: The few studies in Chile assessing the nutritional status of indigenous children show a high prevalence of stunting, excess weight and feeding problems. Aim: to compare anthropometric indices in children from indigenous and non indigenous ancestry. Subjects and methods: school children aged 6 to 8 years old, living in locations with three clear cut levels of social vulnerability were studied. Children were considered indigenous if their last names, as well as those of their parents were of Mapuche origin. Non indigenous were those whose last names were of Spanish origin. Results: four hundred and fifty indigenous and 684 non indigenous children were studied. Indigenous children from high vulnerability communities were approximately 0.5 z score shorter than those of non indigenous origin. Heights of indigenous and non indigenous children were similar in communities with intermediate and low social vulnerability. The proportion of the lower segment followed the same trend. Weight/height ratios were higher among indigenous children in the three vulnerability levels. Among indigenous children coming from areas of low vulnerability arm circumference was 1 cm broader than that of their non indigenous counterparts. Conclusions: stunting is prevalent among school children from areas of high socioeconomic vulnerability, mainly rural, and independent from ethnicity. Among indigenous school children overweight and a broader arm circumference are frequent. These results urgently call for located and specific nutrition interventions <![CDATA[Comparación de la eficacia antihipertensiva de monoterapia en dosis crecientes versus terapia asociada en bajas dosis]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800004&lng=es&nrm=iso&tlng=es Background: When hypertension treatment does not achieve the expected reduction in blood pressure levels, experts recommend increasing the dose of the initially used drug or the addition of a new medication. Aim: To compare the efficacy of increasing doses of losartan or the addition of hydrochlorothiazide to achieve adequate blood pressure levels in patients with hypertension. Patients and methods: Seventy three patients aged 64.4 ± 5.3 years, with stage 1 or 2 essential hypertension were studied. If after four weeks of treatment with losartan 50 mg od, blood pressure levels were still high, the dose was increased to 100 mg od. After four weeks with this new schedule, the treatment was switched to losartan 50 mg and hydrochlorothiazide 12.5 mg for another four weeks. Results: Thirty seven patients normalized blood pressure with losartan 50 mg od. Of the 36 patients that did not respond, 69% achieved a normal blood pressure with losartan 100 mg od and 81% did so with the combination of losartan and hydrochlorothiazide. Combination therapy resulted in a better blood pressure lowering than monotherapy (33.2 ± 3.2 and 29.5 ± 3.4 mm Hg for systolic blood pressure respectively, 16.4 ± 3.2 and 13.2 ± 3.4 mm Hg for diastolic blood pressure, p <0.05). No changes in blood glucose, total and HDL cholesterol, triglycerides, urea nitrogen and uric acid were observed with the combination therapy. Conclusions: In this group of patients, combination therapy achieved better blood pressure levels than monotherapy in high doses. <![CDATA[Vigilancia de susceptibilidad de cocáceas grampositivas a betalactámicos, glicopéptidos y otros antimicrobianos]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800005&lng=es&nrm=iso&tlng=es Background: During the last decade, there has been a progressive increase in the resistance of gram (+) cocci to betalactamics and other antimicrobials. Therefore, vancomycin and teicoplanin have incorporated as alternative antimicrobial drugs. Aim: To assess the susceptibility of gram (+) cocci to different antimicrobials including vancomycin and teicoplanin. Material and methods: We studied 447 strains of gram (+) cocci coming from ambulatory and hospitalized patients. These included 308 Enterococcus sp strains, 99 Staphycoccus aureus strains and 40 coagulase negative Staphylococci strains. Enterococci susceptibility was measured using minimal inhibitory concentrations in agar and that of Staphylococci, through diffusion. Susceptibility to vancomycin and teicoplanin was measured using minimal inhibitory concentrations in all strains. Results: Enterococcus faecalis was 100% susceptible to ampicillin, penicillin, vancomycin and teicoplanin, 23% susceptible to tetracyclin and 47% to chloramphenicol. Susceptibility of E faecium was 61% to penicillin, 49% to chloramphenicol, 41% to tetracyclin, 100% to vancomycin and teicoplanin. Of 19 Enterococcus spp strains, 90% were susceptible to ampicillin, 80% to penicillin, 55% to chloramphenicol and 45% to tetracyclin. Only one E casseiflavus strain had a low level resistance to vancomycin and was susceptible to teicoplanin. No Staphylococcus aureus strain was resistant to vancomycin or teicoplanin. Conclusions: A permanent surveillance of gram (+) cocci antimicrobial susceptibility is required to update therapeutic schemes. <![CDATA[Resistencia a antimicrobianos en diferentes biotipos de <I>Acinetobacter baumannii</I> aislados en el norte de Chile]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800006&lng=es&nrm=iso&tlng=es Background: Acinetobacter baumannii nosocomial outbreaks are common and the microorganism is frequently resistant to multiple antimicrobials. There is little information about Acinetobacter baumannii antimicrobial susceptibility in the northern region of Chile. Aim: To identify different Acinetobacter baumannii biotypes isolated from clinical samples and to determine their antimicrobial susceptibility. Material and methods: One hundred twenty three Acinetobacter baumannii isolates were studied. The identification and typing of Acinetobacter baumannii was based on phenotypic characteristics. Antimicrobial susceptibility was investigated using agar dilution techniques. Results: Most Acinetohacter baumannii strains were isolated from wounds, urinary and respiratory infections. Seven biotypes were isolated, being biotype 9 the most frequent. lmipenem was the antimicrobial with the higher activity against the microorganism. Amikacin, cefoperazonesulbactam, ampicillinsulbactam and ceftazidime had a moderate activity. There were high resistance levels to ampicillin and older cephalosporins. Conclusions: Acinetobacter baumannii is emerging as a significant nosocomial pathogen in Chile and shows high resistance rates to multiple antibiotics. <![CDATA[Leucemia linfoma T del adulto en Chile.: Estudio clínico-patológico y molecular de 26 pacientes]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800007&lng=es&nrm=iso&tlng=es Background: Adult T cell leukemia lymphoma is a lymphoproliferative syndrome etiologically associated to human T cell lymphotropic virus type I. Aim: To describe the clinical and laboratory features of 26 Caucasian Chilean patients, with HTLV-I positive adult T-cell leukemia lymphoma (ATLL). Material and methods: Diagnostic criteria included clinical features, cell morphology, immunophenotype, HTLV-I serology and/or DNA analysis by Southern blot or PCR. Results: According to the clinical presentation, 12 cases had the acute ATLL form, 6 had a lymphoma, 4 the chronic form and 4 had smoldering ATLL. The median presentation age was 50 years, younger than the Japanese patients, but significantly older than patients from other South American countries (eg Brasil, Jamaica, Colombia). The main clinical features: lymphadenopathy, skin lesions and hepatosplenomegaly, were similar in frequency to those of patients from other countries, except for the high incidence of associated neurological disease. Tropical Spastic Paraparesis (TSP) in our series of ATLL, was seen in one third of the patients (8/26). A T-cell immunophenotype was shown in all 26 cases and HTLV-I serology was positive in 25/26 patients. Molecular analysis on the seronegative patient showed clonal integration of proviral HTLV-I DNA into the lymphocytes DNA, and thus he may have been a poor responder to the retroviral infection. Proviral DNA integration was also demonstrated in 15/16 patients being clonal in 10, polyclonal in 3 (all smoldering cases) and oligoclonal in one. Conclusions: ATLL in Chile has similar clinical and laboratory features than the disease in other parts of the world, except for a younger age than Japanese patients but older than those from other Latin American countries and a high incidence of patients with associated TSP. Detailed morphological and immunophenotypic analysis of the abnormal circulating lymphocytes, together with the documentation of HTLV-I by serology and/or DNA analysis are key tests for the identification of this disease. <![CDATA[El gen tax del virus linfotrópico humano tipo I en la identificación etiológica de la paraparesia espástica tropical: Estudio clínico, serológico y de polimerasa en cadena en 72 pacientes]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800008&lng=es&nrm=iso&tlng=es Background: Tropical spastic paraparesis (TSP) is an endemic disease in Chile. In most countries, only 50% of patients are seropositive to HTLV-I. However, new studies suggest that seronegative TSP is also associated with HTLV-I. Aim: To describe cLinical and virological features of seronegative patients with TSP. Patients and methods: Seventy two Chilean patients with TSP, studied by cLinical, radiological and laboratory methods during 1998, are reported. The determination of antibodies to HTLV-I was accompLished by ELiSA, immunofluorescence and Western-blot analysis. Polymerase chain reaction for tax and 5'Ltr genes was made using primers SK 43-44, LTR1 and LTR6. Results: Thirty one patients were HTLV-I positive and 41 were negative. No cLinical, radiological or laboratory differences were observed between both groups. In seropositive patients, tax and 5'ltr viral gene sequences of the HTLV-I provirus were detected in DNA of peripheral blood mononuclear cells. In seronegative cases, sequences of tax gene were detected, exclusively, in 18 of 41 patients. Conclusions: These results confirm an association with HTLV-I infection in 43,9% of the TSP seronegative patients. These findings support the hypothesis that a defective provirus infects peripheral blood mononuclear cells in seronegative cases of TSP. The importance tax gene in the diagnosis of the TSP is also emphasized. <![CDATA[Resultados premilinares de la gastroplastia horizontal con anastomosis en Y de Roux como cirugía bariática en pacientes con obesidad severa y mórbida]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800009&lng=es&nrm=iso&tlng=es Background: Morbidly obese subjects have a high incidence of complications. The poor results of dietary treatments, has prompted the search of new therapies for obesity and among these, surgical procedures. Aim: To report the long term results of horizontal gastroplasty with Roux en Y anastomosis in morbidly obese subjects. Patients and methods: Fifty patients with an initial body mass index of 41.3 ± 6 kg/m2 have been subjected to a horizontal gastroplasty with Roux en Y anastomosis. During the study period, surgical techniques were modified, reducing the gastric pouch size, adding a truncal vagotomy, cholecystectomy, and increasing the length of the Roux en Y loop from 70 to 100 cm. Twenty five patients have been followed for two years. Results: There was no operative mortality and one patient had an anastomotic leak that required 35 days of hospitalization. During follow up, in one patient, the stapled suture line loosened. After two years of follow up, weight decreased from 112 ± 19 to 77.2 ± 14 kg. Conclusions: Horizontal gastroplasty with Roux en Y anastomosis achieved an adequate weight loss with a low rate of complications in this group of morbidly obese subjects. <![CDATA[Disquinesia ciliar primaria.: Experiencia en 6 pacientes]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800010&lng=es&nrm=iso&tlng=es Background: Primary ciliary dyskinesia is characterized by a congenital alteration of the ciliary ultrastructure and function. As a consequence, their respiratory tract sweeping action is lost and recurrent respiratory infections ensue. Aim: To analyze a clinical series of patients with primary ciliary dyskinesia, their clinical and laboratory features. Patients and methods: A retrospective review of patients with primary ciliary dyskinesia seen a University Hospital, between 1994 and 1998. Bronchial biopsies were obtained with 3.6 mm diameter Olympus fibrobronchoscope, using a cayman type forceps. Ultrastructural alterations of respiratory tract ciliated cells were recorded. Results: Six patients (four male) aged 9 months to 13 years old were reviewed. Three patients had situs inversus. All had repeated bouts of obstructive bronchitis and pneumonia, five had sinusitis, four atelectasis, three recurrent otitis and three had bronchiectasis. Cystic fibrosis and immunological alterations were ruled out in five children. Ultrastructural analysis revealed absence of dynein arms in three cases, absence of the internal dynein arm in one, additional peripheral microtubules and absence of dynein arms in one case. Conclusions: Primary ciliary dyskinesia must be considered in the differential diagnosis of recurrent respiratory infections. Ultrastructural analysis of ciliary structure can be done in bronchial biopsies obtained through bronchoscopy. <![CDATA[Síndrome de Down e hipertiroidismo.: Comunicación de 3 casos]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800011&lng=es&nrm=iso&tlng=es We report three patients with Down syndrome that developed a hyperthyroidism. A 25 years old female and a 18 years old male had Basedow Graves disease and were treated with radioiodine. A 19 years old male had a Hashitoxicosis and is presently being treated with propylthiouracyl. Clinical and subclinical thyroid dysfunction is frequent in patients with Down syndrome and the risk increases with age. Therefore a surveillance with yearly TSH measurements should be done in these patients, since signs and symptoms of thyroid disease are barely detected in them. Hypothyroidism is the most frequent dysfunction but hyperthyroidism is also associated to Down syndrome. <![CDATA[Glomerulonefritis crescéntica con anticuerpos anticitoplasma de neutrofilos (+) en niños.: Casos clínicos]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800012&lng=es&nrm=iso&tlng=es Anti neutrophil cytoplasmic antibodies are associated to vasculitis and crescentic glomerulonephritis in adults. However, this association has been seldom reported in children. We report two girls aged 12 and 15 years old with ANCA + glomerulonephritis. Both were subjected to a percutaneous kidney biopsy. One girl had to enter a chronic hemodialysis program. The other patient recovered her renal function and after 12 months of treatment with steroids and cyclophosphamide microscopic hematuria and proteinuria persist but with normal kidney function. ANCA should be measured in children with vasculitis and glomerulonephritis <![CDATA[Quiste broncogénico cervical anterior, simulando lesión tiroidea.: Caso clínico]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800013&lng=es&nrm=iso&tlng=es Bronchogenic cysts are congenital malformations of the tracheo-bronchial tree usually located intrathoraxically. We report a 44 years old male with a bronchogenic cyst located exceptionally in the pre tracheal anterior cervical region, simulating a thyroid lesion <![CDATA[Medicina molecular: Presente y futuro]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800014&lng=es&nrm=iso&tlng=es The genetic background of individuals is recognized as an important clue in the analysis of classical hereditary and multifactorial acquired diseases. This new concept derives from the development and increasing use of molecular genetics in clinical medicine. The application of molecular biology techniques in biomedical investigation has encompassed the identification of the pathogenesis and etiology of diseases, prenatal diagnosis the production of new therapeutic agents, gene therapy and the development of pharmacogenetics. The impact on the fundamentals and practice of clinical medicine that will have the use of molecular biology is analyzed in this review. <![CDATA[Alcances de la responsabilidad moral por la acción terapéutica]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800015&lng=es&nrm=iso&tlng=es Besides utilitarianism, there are different ways to understand Medicine and its role. The opinion of the author is that the pursuit of mankind welfare is not the role of physicians and that their responsibility is not referred to the world. On the contrary, their humble mission is to cure or mitigate pain through therapeutic actions. Any other way of proceeding means that the medical action is becoming orchestrated, destroying the fundamental value of patient physician relationship. This article intends to demonstrate the insufficiency of the Aristotelian idea of technique applied to medicine and that, on the other hand, the modern ideal of a principle free science does not account for the complexity of medical practice, mainly in the field of Psychiatry. Finally the author wonders if the moral convictions of physicians may play a role in the treatment of specific diseases caused by morally inadequate behaviors. <![CDATA[Nuevas piezas en el puzzle de la aterogénesis]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800016&lng=es&nrm=iso&tlng=es The contribution of high serum levels of cholesterol to atherogenesis has been widely recognized, but the mechanisms are not completely clear. Numerous publications have emphasized that oxidized, but not native low-density lipoproteins, are the particles incorporated into the arterial wall. A group of receptors generically called "scavenger" (SR), actively bind these modified lipoproteins and incorporate them into monocytes-macrophages, in the arterial intima. SR are not down regulated by intracellular concentrations of cholesterol, thus accumulating huge amounts of lipids, transforming monocyte-macrophages into foam cells, predominant cell type of the fatty streak. The simultaneous cytokine production and migration of other cellular types progressively transform this initial lesion into the organized atherosclerotic plaque. In this setting SR, which are up-regulated by oxidized LDL, play a central promoting role. Its presence has been demonstrated in arterial plaques both in human and animal models, and its blockade protects animals from development or progression of atherosclerosis. In humans, elevated antibody titers to oxidized LDL in patients with coronary stenosis, and increased SR activity, in pro-atherogenic conditions such as haemodyalisis, indicate that this model may operate as well, but the evidences are still not solid enough to definitively conclude that the oxidized-LDL-SR hypothesis is a finished puzzle. <![CDATA[Factores de riesgo para las enfermedades no transmisibles: Metodología y resultados globales de la encuesta de base del programa CARMEN (Conjunto de Acciones para la Reducción Multifactorial de las Enfermedades no Transmisibles)]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800017&lng=es&nrm=iso&tlng=es Background: In the last decades, chronic non communicable diseases are becoming the main cause of disability and mortality among adults. The risk factor surveillance and management is the most efficient mean of reducing the impact of these diseases. Aim: To report the results of a non communicable disease risk factor surveillance program in Valparaiso, Chile. Material and methods: A random samples of people aged 25 to 64 years old living in Valparaiso, Chile was studied. Subjects were questioned about smoking and physical activity habits. Blood pressure, height and weight were measured using standardized techniques at their homes and blood samples were obtained to measure serum lipid levels and oral glucose tolerance test at the nearest outpatient clinic. Results: Of the initial 3852 homes selected, 752 individuals did no agree to answer the inquiry, therefore 3120 subjects were finally interviewed. Of these, 40.6% were smokers, 15% drank alcohol in two or more occasions per month, 84.6% were physically inactive, 19.7% had a body mass index over 30 kg/m2, 11.1% had high blood pressure, 3.9% were diabetic and 46.9% had high serum cholesterol levels. Conclusions: The basal survey for the CARMEN program shows a high prevalence of cardiovascular risk factors among Chileans. <![CDATA[Recuerdos de un viejo infectólogo]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800018&lng=es&nrm=iso&tlng=es Background: In the last decades, chronic non communicable diseases are becoming the main cause of disability and mortality among adults. The risk factor surveillance and management is the most efficient mean of reducing the impact of these diseases. Aim: To report the results of a non communicable disease risk factor surveillance program in Valparaiso, Chile. Material and methods: A random samples of people aged 25 to 64 years old living in Valparaiso, Chile was studied. Subjects were questioned about smoking and physical activity habits. Blood pressure, height and weight were measured using standardized techniques at their homes and blood samples were obtained to measure serum lipid levels and oral glucose tolerance test at the nearest outpatient clinic. Results: Of the initial 3852 homes selected, 752 individuals did no agree to answer the inquiry, therefore 3120 subjects were finally interviewed. Of these, 40.6% were smokers, 15% drank alcohol in two or more occasions per month, 84.6% were physically inactive, 19.7% had a body mass index over 30 kg/m2, 11.1% had high blood pressure, 3.9% were diabetic and 46.9% had high serum cholesterol levels. Conclusions: The basal survey for the CARMEN program shows a high prevalence of cardiovascular risk factors among Chileans. http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800019&lng=es&nrm=iso&tlng=es http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800020&lng=es&nrm=iso&tlng=es http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98871999000800021&lng=es&nrm=iso&tlng=es