Scielo RSS <![CDATA[Revista médica de Chile]]> http://www.scielo.cl/rss.php?pid=0034-988720030001&lang=es vol. 131 num. 1 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.cl/img/en/fbpelogp.gif http://www.scielo.cl <![CDATA[La importancia de declarar un conflicto de intereses en las revistas médicas]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100001&lng=es&nrm=iso&tlng=es Medical journals are often at risk of difussing research articles, reviews, position articles, editorials or letters whose message has been influenced by a conflict of interest. The readers may then be induced to accept conclusions and recommendations based on biassed protocols or an unwarranted interpretation of the results. Financial support or professional links with pharmaceutical companies or other supporting agencies are the most common sources of conflict of interests, often difficult to detect. Similarly, reviews of manuscripts can be biassed by personal relationships (good or bad) between reviewers and authors, by academic competition or intellectual passion, becoming other sources of conflict of interest. Even when a potential conflict of interest exists, it may not necessarily have influenced the manuscript or its review but in order to defend the transparency of the editorial process, from submission to publication, authors, reviewers and editors should declare any conflict of interest they may have and allow others to decide whether the action has been biassed or not. In the present issue of Revista Médica de Chile, an updated text of the Instructions to Authors establishes that all authors should sign a statement of having or not a conflict of interest, clarifying which aspects of the work might have been affected by it (Rev Med Chile 2003; 131: 7-9) <![CDATA[Estudio del polimorfismo de receptores Fc<FONT FACE=Symbol>g</FONT>IIa en pacientes chilenos con lupus eritematoso sistémico]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100002&lng=es&nrm=iso&tlng=es Background: Polymorphisms of Fc receptors for IgG (FcgR) have been proposed as a genetic factor that influences susceptibility for systemic lupus erythematosus (SLE). Human FcgRIIa has 2 codominantly expressed alleles, H131 and R131, which differ at amino acid position 131 in the second extracelular domain (histidine or arginine respectively) and differ substantially in their ability to bind human IgG2. The H131 allele binds IgG2 efficiently, whereas R131 binds it poorly. Because IgG2 is a poor activator of the classical complement pathway, the H131 is essential for the disposal of IgG2 immune complexes. Aim: To determine the distribution of FcgRIIA genes in a cohort of Chilean SLE patients, with or without a history of lupus nephritis. Patients and methods: We studied 52 Chilean SLE patients fulfilling the 1982 American College of Rheumatology (ACR) criteria, 20 of whom had a history of nephritis, and 44 ethnically matched disease-free controls. FcgRIIa allotypes were genotyped by PCR. Results: No significant association was observed between the low affinity FcgRII receptor (FcgRIIa-R131) and the presence of SLE or lupus nephritis. However, genotype frequencies in SLE patients but not in controls, departed from the proportions predicted by the Hardy-Weinberg equilibrium, suggesting this locus might be related to the disease. Conclusions: Our results suggest that in Chilean patients with SLE, as well as in many other populations, the R131 allotype is not a major factor predisposing to the development of SLE or lupus nephritis (Rev Méd Chile 2003; 131: 11-18) <![CDATA[Patología digestiva en niños infectados con el virus de inmunodeficiencia humana (VIH), en Santiago de Chile]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100003&lng=es&nrm=iso&tlng=es Background: Human immunodeficiency virus (HIV) epidemiology has changed, affecting an increasing number of children. As in adults, the disease predominantly affects the digestive and respiratory systems. Aim: To report the gastrointestinal problems in HIV infected pediatric patients. Patients and methods: Twenty four HIV infected children (nine male, aged 1 to 12 years old, followed for 1 to 170 months), are reported. This group has been under care by a multiprofessional team. Results: Oral candidiasis was present in 21 (88%), esophagic candidiasis in 3 (13%), oral ulcers in 4 (17%). Diarrhea was observed in 18 children (75%) and in eight, it had a chronic evolution. Cryptosporidium parvum was the most frequent agent found in six cases (1 with acute and 5 with chronic diarrhea). Schlerosing cholangiopathy was observed in one case, with a fatal outcome, in association to microsporidiosis. Upper endoscopy was done in 11 patients, demonstrating microscopic inflammatory changes in esophagic, gastric and duodenal epithelia in all. Conclusions: Digestive problems are common in HIV infected pediatric patients. They must be always sought actively. Endoscopy is a valuable tool for the early diagnosis of these problems (Rev Méd Chile 2003; 131: 19-24) <![CDATA[Anticuerpos anti-transglutaminasa tisular: ¿una mejor prueba para detectar transgresiones menores de la dieta en pacientes celíacos?]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100004&lng=es&nrm=iso&tlng=es Background: Endomysium antibodies (EMA) do not detect minor dietary transgressions in patients with celiac disease. Aim: To compare the sensitivity and specificity of tissue transglutaminase antibodies (tTGA) and endomysium antibodies (EMA) in biopsy proven celiac patients at the time of diagnosis and during gluten free diet (GFD). Patients and methods: One hundred fifty three subjects were studied: a) 30 healthy controls; b) 9 cases with cow's milk allergy; c) 24 celiac patients at time of diagnosis; d) 25 celiac patients adhering to the GFD; e) 65 celiac patients with poor/no adhesion to GFD. EMA and tTGA IgA were measured by immunofluorescence and ELISA, respectively. Results: Sensitivity and specificity were 100% and 97.4% for tTGA, respectively. All patients with cow's milk allergy were EMA (-) and 8 of 9 (88.9%) were tTGA (-). In celiac patients not adhering to the GFD, EMA and tTGA positivity were similar (80% and 81,5%, respectively); 95,4% of the subjects tested positive for at least one of them. All patients adhering to GFD were EMA (-) but tTGA were (+) in 28% of them. Conclusions: EMA and tTGA have similar sensitivity and specificity at the time of diagnosis of celiac disease. Positive tTGA in 28% of patients that adhered strictly to the GFD and whose EMA were negative suggest that tTGA may be helpful in detecting minor dietary transgressions and should be further evaluated (Rev Méd Chile 2003; 131: 25-29) <![CDATA[Determinación de anticuerpos anti-transglutaminasa en el diagnóstico de enfermedad celíaca]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100005&lng=es&nrm=iso&tlng=es Background: The diagnosis of celiac disease is based in clinical features, serology and intestinal biopsy. There are recent reports that antiglutaminase antibodies have a good correlation with anti endomisial antibodies. Aim: To assess the sensitivity and specificity of antitransglutaminase antibodies in the diagnosis of celiac disease and their correlation with antiendomisial antibodies. Material and methods: Forty nine patients with celiac disease (mean age 30 years, 12 male) were studied. Thirty were symptomatic and 19, asymptomatic. As controls, 34 subjects (mean age 27 years, seven male), with normal duodenal biopsies, were studied. Sera was processed for the determination of antigliadin IgA by ELISA, antiendomisium IgA by indirect immunofluorescence, and antitransglutaminase IgA by ELISA. Results: Antigliadin antibodies had a sensitivity of 73%, a specificity of 96%, a positive predictive value of 93% and a negative predictive value of 82% for the diagnosis of celiac disease. Antiendomisium and antitransglutaminase antibodies had a specificity and positive predictive value of 100%, sensitivities of 89 and 92% respectively and negative predictive values of 92 and 94% respectively. No significant differences in the diagnostic yield of antiendomisium and antitransglutaminase antibodies, were observed. Conclusions: In this group of patients, antitransglutaminase antibodies had a high concordance with antiendomisium antibodies, for the diagnosis of celiac disease. Considering that the determination of antitransglutaminase antibodies is of lower cost and less complicated than antiendomisium antibodies, it is a useful tool for the diagnosis and follow up of patients with celiac disease (Rev Méd Chile 2003; 131: 31-6) <![CDATA[Litiasis biliar en niños: un estudio clínico-morfológico]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100006&lng=es&nrm=iso&tlng=es Background: The use of ultrasonography increased the frequency of diagnosis of cholelithiasis in childhood. Aim: To determine the clinical and laboratory features and follow up of children with biliary stones. Patients and methods: Twenty six children (13 male, aged 1 month to 14 years) were prospectively enrolled. Results: Nine children had a past medical history of factors potentially predisposing to stones. A clinical presentation with vomiting (50%), abdominal pain (46%) and jaundice (23%) was the most common indication for surgery. The diagnosis was based on abdominal ultrasound in all children. Cholecystectomy was performed in 15 children (laparoscopy in 13 and open surgery in 2). Children who underwent surgery were older than those who did not undergo surgery (p <0.001), but they did not have differences in liver function tests. Eight children had pigmented stones and seven had cholesterol stones. Conclusions: In our patients, neither family history nor laboratory tests were useful in the diagnosis as well as in the clinical decision of surgery, which was based on symptoms. The presence of cholesterol stones in a high proportion of these children may be a unique situation in Chile, considering the high prevalence of this disease in the adult population (Rev Méd Chile 2003; 131: 37-45) <![CDATA[Anomalías de la esteroidogénesis suprarrenal en niños chilenos con micropene]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100007&lng=es&nrm=iso&tlng=es Background: Mutations in type II 3ß hydroxysteroid Dehydrogenase (3ßHSD) are found in male children with severe undervirilized genitalia. Mild undervirilization (isolated micropenis or with distal hypospadia) can be associated with a partial deficit in 3ßHSD activity. Aim: To assess the frequency of abnormal adrenal response to ACTH, suggesting a deficit in adrenal enzymatic activity, in children with mild undervirilization. Patients and methods: We studied 26 male children with micropenis, aged one to eight years. Children with evidences of puberal development or in treatment with drugs that affect steroidal metabolism were excluded from the study. Serum levels of androstenedione (A), dehydroepiandrosterone (DHEA), progesterone (P), 17 hydroxyprogesterone (17 P) and the ratios DHEA/A, P/17 P, 17 P/DHEA were measured after an adrenal stimulation with 0.25 mg/m2 intramuscular ACTH. Results: Two children had DHEA y DHEA/A values suggesting a defective 3ßHSD activity. Other two children had high levels of 17 P, suggesting a deficiency of cytochrome p450c21. A CYP 21 gene mutation was found in one of the later children. Conclusions: A low proportion of children with micropenis have a deficient 3ßHSD activity (Rev Méd Chile 2003; 131: 46-54) <![CDATA[Edad materna avanzada y riesgo reproductivo]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100008&lng=es&nrm=iso&tlng=es Background: Pregnancy at extreme ages is a risk factor for maternal, perinatal and infantile death. Aim: To assess the obstetric risk of women over 40 years old. Material and methods: The risk of maternal, late fetal, neonatal and infantile deaths and the risk of low birth weight was assessed in women over 40 years old and compared to the risk of women aged 20-34 years. Data was obtained from the 1999 Annual Report of the National Statistics Institute and the odds ratios (OR) with a 95% confidence interval were calculated. Results: Women over 40 years had a higher risk of maternal death (OR 7.13, 3.31-14.97), late fetal death (OR 2.19, 1.69-2.85), neonatal death (OR 1.8, 1.4-2.32), infantile death (OR 1.8, 1.49-2.18) and low birth weight (OR 1.72, 1.58-1.88). Conclusions: The higher reproductive risk of women over 40 years is confirmed. Better birth control programs at this age will reduce this risk (Rev Méd Chile 2003; 131: 55-59) <![CDATA[Estudio retrospectivo de 232 casos de cáncer y precáncer de labio en pacientes chilenos: Correlación clínico-histológica]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100009&lng=es&nrm=iso&tlng=es Background: The most common type of oral cancer is squamous cell carcinoma, which accounts for approximately 90% of all oral malignancies. Therefore the oral cancer problem primarily concerns the diagnosis, biology and management of squamous cell carcinoma (SCC). However, there are red and white lesions, that are considered premalignant, since they may unpredictably transform into cancer. According to WHO, leukoplakia, eritroplakia and actinic cheilitis are considered precancerous lesions which pathologically may correspond to intraepithelial dysplasia, hyperkeratosis, carcinoma in situ or SCC. Aim: To study the clinical and pathological features of lip cancer and premalignant lip lesions. Patients and methods: A retrospective analysis of 232 cases with lip lesions. The frequency, location, gender, age and pathological diagnosis of the lesions were recorded. Results: One hundred fifty four lesions were observed in men and 78 in women, 92% of lesions were located in the lower lip. Seventy two of the 232 lesions were SCC and 72% of these carcinomas were well differentiated. The age of patients with cancer was higher than that of patients with precancerous lesions. Conclusions: The difference in age between patients with cancer and precancerous lesions, reinforces the existing knowledge that precancerous lesions may transform into cancer if they are not properly diagnosed and treated (Rev Méd Chile 2003; 131: 60-6) <![CDATA[Ehrlichiosis humana en Chile: evidencia serológica]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100010&lng=es&nrm=iso&tlng=es Background: Ehrlichiosis is a non contagious infectious disease, mainly transmitted by thick bites. In 1998, this infection was detected in dogs, for the first time, in Chile. Aim: To establish if there is human exposure to Ehrlichia sp in Chile. Material and methods: Blood samples from 17 dogs with ehrlichiosis and 19 humans who had contact with them were studied to determine human exposure to Ehrlichia equi and Ehrlichia chaffeensis in Chile. Samples were analyzed by indirect inmunofluorecence and by polymerase chain reaction (PCR). Results: Six dogs had positive titers against both species of ehrlichia; 2 with titers of 1/256; 3 with titers over 1/512 to Ehrlichia equi and titers of 1/256, 1/128 and 1/64 to Ehrlichia chaffeensis respectively, and 1 with titers of 1/256 to Ehrlichia equi and titers of 1/128 to Ehrlichia chaffeensis. Two of the 19 humans, had positive titers against both antigens (1/128). PCR reactions were negative in both human and canine sera. Conclusions: These results confirm that human exposure to Ehrlichia sp. Epidemiological surveillance for human ehrlichiosis should be implemented in the country (Rev Méd Chile 2003; 131: 67-70) <![CDATA[Pubertad precoz periférica por tumor ovárico de las células de la granulosa juvenil, con manifestaciones iso y heterosexuales en una niña de 6 años: <I>Report of one case</I>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100011&lng=es&nrm=iso&tlng=es A six years old girl consulted due to mammary development. On physical examination, clitoris enlargement and a tumor localized in the abdominal-pelvic region were observed. Hormonal study disclosed elevated testosterone and estradiol levels. On exploratory laparotomy, a right ovarian tumor was observed and a right salpingo-oophorectomy was performed. The contemporary biopsy informed a disgerminoma, leading to a surgical staging of the tumor. The definitive pathological diagnosis was a juvenile granular cell tumor, limited to the ovary. In the postoperative period, estradiol and testosterone levels returned to normal values and the pseudopuberty reverted. The patient did not receive adjuvant treatment and after three years of follow up, there is no evidence of tumor recidivism (Rev Méd Chile 2003; 131: 71-6) <![CDATA[Infección sistémica por <I>Paecilomyces lilacinus </I> en un paciente inmunodeprimido pediátrico: <I>Report of one case</I>]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100012&lng=es&nrm=iso&tlng=es The incidence of systemic fungal infections increased during the last two decades. Rare fungi, such as Mucor, Fusarium and Paecilomyces, are emerging as causes of systemic fungal infections in immunocompromised hosts. There are reports of cutaneous infections, endophthalmitis, keratitis, sinusitis, neumopathy and fungemia in immunocompromised and immunocompetent adult patients. We report a 5 years old neutropenic patient with acute myeloid leukemia treated with multiple courses of chemotherapy, with a fungemia caused by Paecilomyces lilacinus (PL). His initial clinical course was characterized by fever, skin lesions, respiratory distress and shock. Blood and bone marrow cultures were positive. The patient was treated with amphotericin B and itraconazole with a good clinical response (Rev Méd Chile 2003; 131: 77-80). <![CDATA[Neumonía eosinofílica inducida por mesalazina: Caso clínico]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100013&lng=es&nrm=iso&tlng=es A 50 years old male with a diagnosis of ulcerative colitis treated with mesalazine, developed after 2 months of treatment, cough, fever and progressive dyspnea. Chest X ray examination and CT scan showed pulmonary infiltrates in the right upper lobe that subsequently involved both lower lobes. A biopsy, made through videothoracoscopy, showed an eosinophilic pneumonia. After the discontinuation of mesalazine and the use of glucocorticoids, the respiratory involvement resolved, and pulmonary infiltrates regressed. Mesalazine is widely used in the treatment of inflammatory bowel diseases. Pulmonary toxicity is an uncommon complication of mesalazine treatment. Nevertheless, this complication should be considered in patients that use it and develop respiratory symptoms (Rev Méd Chile 2003; 131: 81-84) <![CDATA[Hipersensibilidad visceral: Un concepto a nuestro alcance]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100014&lng=es&nrm=iso&tlng=es Despite significant advances in the recognition of etiological factors and pathological mechanisms, the pathophysiology of functional gastrointestinal disorders (FGD) is still not fully understood. Visceral hypersensitivity has been recognized as a characteristic of patients with FGD, especially in patients with irritable bowel syndrome (IBS). Visceral afferent input is modulated by a variety of mechanisms, operating between the gastrointestinal tract and the brain. Dysfunction of these regulatory mechanisms could distort gastrointestinal perceptions. Recent findings suggest that in the majority of cases of IBS the primary abnormality may be at the periphery with alterations of the motor and secretory sensory activity. Although imaging techniques indicate that there are also differences in cortical activation. Furthermore, selective serotonin reuptake inhibitors may benefit FGD. Recent pharmacological studies suggest that 5-HT3 antagonist such as alosetron and cilansetron, and 5-HT4 agonist such as tegaserod and prucalopride may also have a potential use in FGD (Rev Méd Chile 2003; 131: 85-92) <![CDATA[El conflicto de intereses en las revistas biomédicas]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100015&lng=es&nrm=iso&tlng=es Despite significant advances in the recognition of etiological factors and pathological mechanisms, the pathophysiology of functional gastrointestinal disorders (FGD) is still not fully understood. Visceral hypersensitivity has been recognized as a characteristic of patients with FGD, especially in patients with irritable bowel syndrome (IBS). Visceral afferent input is modulated by a variety of mechanisms, operating between the gastrointestinal tract and the brain. Dysfunction of these regulatory mechanisms could distort gastrointestinal perceptions. Recent findings suggest that in the majority of cases of IBS the primary abnormality may be at the periphery with alterations of the motor and secretory sensory activity. Although imaging techniques indicate that there are also differences in cortical activation. Furthermore, selective serotonin reuptake inhibitors may benefit FGD. Recent pharmacological studies suggest that 5-HT3 antagonist such as alosetron and cilansetron, and 5-HT4 agonist such as tegaserod and prucalopride may also have a potential use in FGD (Rev Méd Chile 2003; 131: 85-92) <![CDATA[Consenso sobre el diagnóstico y tratamiento de la pubertad precoz central]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100016&lng=es&nrm=iso&tlng=es The beginning of puberty is marked by breast growth in girls and testicular enlargement in boys. These occur at the age of 10.5 ± 2.0 years in females and 11.5 ± 2.0 years in males. Recent but controversial publications suggest that these events are being observed at younger ages, at least in the USA. There are no studies demonstrating that this is true in Chile. For this reason we still consider that puberty is precocious when it occurs before 8.0 years in girls and before 9.0 years in boys. True or central precocious puberty (CPP) must be distinguished from peripheral or pseudoprecocious puberty (PPP), from premature telarche and from premature adrenarche. We suggest that the workup of a patient with premature development should include an LHRH test to demonstrate if the hypothalamic-pituitary axis is activated, plasma levels of sex steroids, bone age and pelvic ultrasound in girls. All children with CPP should have a CAT scan or MNR of the brain, since a lesion of the central nervous system is observed in 15% of the girls and 50% of the boys whith CPP. Additional studies are needed in cases of PPP. The aim of treating CPP is to avoid adult short stature that results from premature fusion of the epiphysis and to avoid eventual emotional and psychological stress. Treatment consists of monthly intramuscular injections of a depot preparation of LHRH analogs. Suppression of pituitary and gonadal activity produces regression of secondary sex characteristics and slowing down of growth velocity and bone maturation. The opportunity, duration of treatment and their effect on final stature are discussed (Rev Méd Chile 2003; 131: 95-110) <![CDATA[¿A quien pertenece la Ficha Clínica?]]> http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100017&lng=es&nrm=iso&tlng=es It is not clear if medical records belong to the physician, the institution or the patient. There is a bill being discussed in the Chilean Congress that establishes that "the patient, personally or through a representative, has the right to access and review his medical record. In case of death, this right may be exerted by his inheritors". In this article we postulate that this bill infringes a number of legal norms in force and universally accepted ethical principles. We distinguish between patient's advocacy to be informed and their free access to medical records. The main ethical principles violated are those of beneficence and non maleficence (Rev Méd Chile 2003; 131: 111-4) http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100018&lng=es&nrm=iso&tlng=es http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0034-98872003000100019&lng=es&nrm=iso&tlng=es