[A cooperative study on early and intermediate gastric cancer: clinical, diagnostic and therapeutic aspects]

A cooperative study involving 13 hospitals in Chile allowed the analysis of 353 patients with gastric cancer in early stages. 82 cancers were located at the mucosal level, 151 at the submucosa and 120 reached the muscular layer. There were no differences in age and sex among these groups. Compared to early stage, patients with intermediate stage had a greater incidence of bleeding, anemia and undernutrition and exhibited lower body weight. Endoscopy had a higher diagnostic yield compared to radiological study. The diagnosis was confirmed by biopsy in 95% of patients. Total or subtotal gastrectomy was performed according to the location of the lesion, with a low operative mortality rate. Early gastric cancer accounts for 8 to 10% of all patients with gastric cancer undergoing surgical treatment.

[Chilean hospitals: availability and productivity of the public and private sectors]

Hospital bed availability, trends in number of beds, productivity and administrative aspects in the public and private hospital sectors are analyzed. At present, there are 3.3 beds per 1000 population in Chile. This represents a decrease from previous figures, in spite of increasing demands derived from population aging and greater birth assistance needs. Overall productivity of the hospital system is reflected in 31 annual admissions per bed, an average hospital stay of 8 days and a 75% occupancy rate. The National Health Service System is responsible for 76% of admissions. However, it takes care of more than 90% of bed needs for tuberculosis patients and more than 80% for hospital birth assistance, complications of pregnancy, perinatal disease, communicable diseases, respiratory illnesses, miscarriages and skin diseases. The private sector takes care of more than 40% of rheumatic and musculo skeletal diseases and more than one third of mental health problems. The National Health Service, compared to the private sector, exhibits a greater occupancy rate with an average stay only one day longer. Complexities of hospital administration, new world trends and the relation to external economic resources are discussed.

[Clinical course characteristics of gastric cancer 1958-1990]

The clinical, surgical and histopathologic characteristics of patients with gastric cancer were compared among 3 consecutive periods from 1958 to 1990. A significant increase in the frequency of location at the upper third of the stomach, a greater proportion of resectable lesions, an increasing tendency towards extended total gastrectomy and a significant increase in the frequency of undifferentiated or diffuse carcinoma were observed. A change in pathogenetic factors along the years may be involved in the differences described.

[Intestinal tuberculosis in acquired immunodeficiency syndrome]

We present a case of disseminated tuberculosis with peritoneal and intestinal involvement in a homosexual patient who presented micronodular fibrosis and was infected by HIV, with an AIDS diagnosis since he had previously presented an esophagitis caused by candida. Diagnosis was made from a sample obtained from an ulcerated lesion from rectum-sigmoid region by colonoscopy, and when stained with Ziehl-Nielsen revealed acid-alcohol resistant bacilli (AARB) identified as M. tuberculosis. The torpid evolution of the process, which was complicated by the uncompensation of the cirrhosis determined the patient's death inspite of treatment. The characteristics of intestinal tuberculosis in HIV infected patients is reviewed.

[Incipient and intermediate gastric cancer II. Anatomo-pathological and surgical aspects. Cooperative study in 13 hospitals]

Anatomic and surgical characteristics of 233 pts with early, and 120 with intermediate gastric cancer, from 13 hospitals in Chile are analyzed. 63% had depressed or excavated lesions. Most of the tumors were located in the inferior or middle third, while only 17% of the early carcinomas were found in the superior third of the stomach, specially in the lesser curvature. 5% had residual tumor in the gastric remanent. Histologically, tubular adenocarcinoma was the most common finding. According to Lauren's classification intestinal carcinoma was more frequent than the diffuse type. Surgeons underestimated lymphatic node involvement (macroscopic appreciation) in up to 58% of the cases when compared to the pathologists observation (microscopic appreciation). This was specially true in muscular carcinomas. The incidence of lymphatic metastases was 6% in mucous, 12% in submucous and 57% in muscular carcinoma. The need of complete lymph node dissection of all the lymphatic barriers is emphasized.

[Breast cancer epidemiology]

204 pts with breast cancer were compared to 208 pts of similar age, with pathologies other than cancer, to assess the frequency of biological and social factors related to breast cancer, in Chilean females. The pts with breast cancer were in the 40 to 65 year old group, had a higher frequency of AB blood group, lower pregnancy and delivery rates and later pregnancies. Age of menarche and menopause, prolonged breast feeding, oral contraceptives and nutritional state were not related to a higher frequency of breast cancer. Further studies that include the analysis of previous breast pathology, diabetes, psychosomatic factors, alcohol and caffeine consumption, tobacco and others are suggested.

[Prevalence of gallbladder neoplasms in cholecystectomies]

The prevalence of gallbladder cancer in 10,468 cholecystectomy patients was studied: 3.4% of the female and only 1.32% of the male population had gallbladder cancer (p < 0.001). The female population had 2.7 times more cholelithiasis, and 7.9 times more cancer than the male population. Cancer incidence increases progressively with age, specially after the 5th decade.

[Epidemic of cholera in Chile; 1991]

In January 1991 a severe epidemic of cholera started in Peru, a country located north of Chile. The first case in Chile was confirmed in april and so far 41 cases and 2 deaths have been reported. The epidemic is caused by Vibrio cholerae 01, El Tor biotype, Inaba serotype. Most cases occurred in Santiago, 2/3 of them in men and all above 15 years of age. An unknown number of asymptomatic infected people arriving in Santiago are the likely agents for the epidemic. Contamination of sewage and use of infected water to irrigate vegetable fields is involved in the transmission of the disease. The situation is linked to the inexistence of sewage treatment plants. In comparison to Peru, with near 200,000 patients and over 1000 deaths, the epidemic in Chile has been small as a consequence of intensive health education efforts. Personal hygiene, abstinence from eating raw vegetables and fish, destruction of presumed infected crops, and prohibition of vegetable transportation to other areas have been the cornerstone of the preventive strategies. Early treatment of severely dehydrated patients has determined a low fatality rate. At present, the epidemic is virtually controlled with 1 or 2 cases a week. However, the sanitary problems related to sewage treatment and the existence of cholera in other South American countries poses a serious problem for the future.

[Smoking and health in Chile]

Findings from a literature review on the smoking problem in Chile are presented. According to prevalence studies, nearly 40% of the general adult population in Chile smokes. The proportion of smokers is smaller among women than among men. Between 1971 and 1984 the proportion of smokers rose from 36% to 41%, with an especially marked increase in women (from 26% to 39%). Calculation of the relative risk of mortality in smokers indicates that smoking accounts for 11% of all deaths in the country. Moreover, 11% of the infant mortality in Chile is attributable to the lower neonatal weight of children of women who smoke. The presence of smokers in homes is responsible for a 30% higher rate of acute respiratory infections. Women smokers have twice as many spontaneous abortions as nonsmokers and enter menopause an average of five years earlier. Hoarseness is 17 times more frequent and excess facial hair is seven times more frequent among women who smoke compared with those who do not. The habit tends to start during adolescence. The rising smoking rate among Chilean women is inversely related to level of schooling and directly related to economic capacity. Smoking during pregnancy is influenced by level of concern for the effects of tobacco and educational actions encountered during this period. The role of physicians and other members of the health team is crucial in this regard. Reference is made to organized antismoking measures, including bans on smoking, restrictions on advertising, warnings about its harmful effects, and various educational efforts. The main components of the Ministry of Health's smoking control program are reviewed.

[Medical specialties and specialists in Chile]

The majority of Chilean physicians work as specialists, mainly as internists, surgeons pediatricians or gynaecologists. The number is higher in Santiago than in other parts of the country, with a better supply in the predominantly urban areas of the country. Only a fraction of the Chilean specialists work at the National Health Service. During the 1980 decade a process of specialist certification was initiated as a joint effort of the Universities, the Chilean Medical Association, the scientific societies and the Chilean Academy of Medicine. The residency programs offered by the universities, the high level of specialization, the need for a better knowledge of the specialists needed in the country and the absence of a planning system for the production are discussed.

[Candida esophagitis treated with a single dose of fluconazole in patients with HIV: presentation of 11 cases]

We have reviewed the efficacy of the use of fluconazole in patients with definitely proven Candida esophagitis (CE) associated with human immunodeficiency virus (HIV) infection, using a single 400 mg oral dose of fluconazole and evaluating the patient three days afterwards. This drug showed to be effective for the clinical and endoscopic cure in all patients (100%), and with microbiological cure in ten cases. There was no clinical feature of toxicity. The only side effect was an increased alkaline phosphatase and transaminase activity without hyperbilirubinemia, but this finding was not statistically significant (p greater than 0.05). Fluconazole, given in a single 400 mg dose, was absolutely effective to cure esophagitis in AIDS, thus permitting to avoid parenteral amphotericin.

[Complicated hepatic hydatid cyst and acute pancreatitis. Value of ERCP and treatment with endoscopic sphincterotomy]

We present the case of a 29 year-old cholecystectomized woman with hepatic hydatid cysts who was admitted for acute pancreatitis. Echography and abdominal CAT revealed three thydatid cysts-the one in the right liver lobe being complicated-as well as pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed the suspected diagnosis of intrabiliary hydatid cyst rupture. An endoscopic sphincterotomy was performed, posterior evolution being asymptomatic, thus permitting the postponing of surgery.

[Health in Chile: reflections for the future]

The health situation in Chile is analyzed. The influence of geographic, ethnic, racial, demographic, socio-economic and cultural factors is considered. Strategies for prevention depend on the epidemiologic status of communities. The quality and availability of health care services is considered to be the main factor influencing health maintenance in Chile. The present health coverage situation which provides for health insurance to 15% of the population using 37% of the resources is clearly inappropriate. The separation of hospitals and outpatient facilities is recognized as an unfavourable situation. A worrying increment in the incidence of tuberculosis and a stagnation in the improvement of maternal child health indexes since 1983 have been observed. Priorities for health development and modifications in health care and prevention systems are discussed.

Segmental tuberculosis of the colon diagnosed by colonoscopy

We describe the case of a woman with rectorrhagia and rectal tenesmus. Colonoscopy revealed a 3-4 cm-long ulcerated lesion with a reduced colon lumen 35 cm from the anus, and multiple biopsies were obtained from the ulcerated region, but histopathology was non-specific. Biopsy culture was positive for M. tuberculosis. Anti-tuberculous chemotherapy was initiated on the diagnosis of segmental tuberculosis of the colon. Subsequent evolution was favorable, both clinically and endoscopically. Emphasis is placed on the importance of colonoscopy and biopsy in the diagnosis of tuberculosis of the colon.

[Physical exercise and gastric acid secretion]

The effects of physical exercise on the basal acid secretion of the stomach has been investigated in 10 healthy individuals and 16 hypersecretors with duodenal ulcer. The gastric basal secretion was collected during 3 hours; during the first hour the patient was at rest, during the second he realized a training exercise, according to Roskamm's formula, and in the third was at rest. While normal subjects showed a significative reduction of the acid secretion during the period of exercise, in the hypersecretory patients with ulcer the acid secretion increased significantly during exercise, from 4.25 +/- 1.52 mEq/h to 7.79 +/- 3.49 mEq/h; these figures reverted to normal values (5.45 +/- 2.21) during the recovery period. We comment the potential mechanisms of these differences in both groups of patients.

[Effects of cigarette smoking in women]

The relation between cigarette smoking and obstetrical history, characteristics of skin and voice, presence of hirsutism and newborn weight/height index was studied in 100 hospitalized women. 45 had never smoked, 36 were present and 19 former smokers. No differences were found in the average age of menarche, number of live births or stillborns. Abortions were twice as frequent in women smoking more than 10 cigarettes a day. Menopause occurred an average of 5 years earlier among smokers. A significant increase in hoarseness and face hirsutism was detected, the relative risk for heavy smokers (more than 10 cigarettes per day) being 14.2 for hoarseness, 5.6 for facial hirsutism and 2.8 for other locations of hirsutism. Obesity was twice as common among smokers. These findings, related to hormonal disturbance, should be used in education efforts in the anti-smoking campaign among Chilean women.

Low-back pain in pregnancy. Abdominal muscles, sit-up performance, and back pain

An attempt was made to determine the effect of pregnancy on the abdominal muscles and to correlate changes in abdominal muscles strength with low-back pain during pregnancy. The study included 328 women. Group A consisted of 164 pregnant women; group B consisted of 164 non-pregnant women. The race, age, height, weight, parity, profession, time devoted to physical fitness per week, abdominal length, and relation between the abdominal length to height were recorded. A detailed history relating to backache prior to and during pregnancy was obtained. Each woman was asked to perform a single sit-up. The results of the study indicate that about 10% of pregnant women develop severe low-back pain that interferes with daily life activities. About 49% of the non-pregnant women complained of LBP. The pain did not interfere with activities of daily living. During pregnancy, due to overstretching of the abdominal muscles, the ability to perform a sit-up is significantly decreased. Whereas all non-pregnant women could perform a sit-up, 16.6% of pregnant women could not perform a single sit-up. There was no statistically significant correlation between the sit-up performance and backache. It may be concluded that during pregnancy the abdominal muscles become insufficient.

Combined effect of click rate and stimulus polarity on BAEP latencies

Previous studies addressed themselves to the effect of different parameters on the brainstem auditory evoked potentials (BAEPs). Of special interest were the repetition rate and the click polarity, both able to influence significantly the results. While previous contributions studied these two parameters separately, the present investigation is concerned with their combined effect, non-parametric statistical analyses allowing simultaneous consideration. 37 patients, 21 females and 16 males, with an age range of 20 to 95, carrying different diagnoses, were studied using rarefaction as well as condensation polarities, 10/sec as well as 30/sec repetition rates. Abnormalities present with only one stimulus polarity and repetition rate but not with another combination were present in 24 cases for polarity dependent changes (64.9%) and in 25 (67.4%) cases for repetition rate dependent ones. Generally 30/sec repetition rate yielded longer latencies when repetition rates were kept constant. The combination of condensation clicks and high repetition rates revealed a strong correlation with higher latencies.