"NASCI case of the month: left ventricular apical hypoplasia"

Left ventricular apical hypoplasia is a rare congenital condition. It can cause nonspecific symptoms and can be accompanied by cardiac conduction system alterations such as bundle branch block, atrial flutter (AF) or atrial fibrillation. The diagnosis mostly is made by imaging.

Quiste de duplicación gástrico en paciente adulto: Reporte de caso y revisión de la literatura

Introducción. Los quistes gástricos de duplicación son malformaciones congénitas muy infrecuentes del tracto gastrointestinal. Se definen como una lesión quística tapizada por epitelio gastrointestinal que comparte una capa de músculo liso con la pared gástrica. Se han propuesto diferentes teorías sobre su patogénesis, sin embargo, los eventos embriológicos que conducen a la malformación no han logrado ser dilucidados. Debido a su localización y presentación clínica, el diagnóstico se realiza con mayor frecuencia durante los primeros años de vida y existen pocos casos reportados en adultos, en quienes el hallazgo suele ser incidental. Caso clínico. Se presenta el caso de una mujer de 65 años quien consultó por dolor abdominal crónico y síntomas digestivos inespecíficos. Por medio de Tomografía Axial Computarizada se evidenció una lesión quística en contacto con el páncreas y la pared gástrica. Se realizó exploración quirúrgica que, junto con los hallazgos histopatológicos, confirmó el diagnosticó de quiste de duplicación gástrico. Discusión. Los quistes de duplicación gástrica son anomalías excepcionales que se localizan más frecuentemente en la curvatura mayor. Su tratamiento es quirúrgico y la confirmación del diagnóstico se realiza mediante la histología.

Tumescent local anesthesia versus general anesthesia for subcutaneous implantable cardioverter-defibrillator implantation

BACKGROUND

Subcutaneous implantable cardioverter-defibrillator (S-ICD) is an effective alternative to transvenous implantable cardioverter-defibrillator. General anesthesia (GA) is considered the standard sedation approach because of the pain caused by the manipulation of subcutaneous tissue with S-ICD implantation. However, GA carries several limitations, including additional risk of adverse events, prolonged in-room times, and increased costs.

OBJECTIVE

The purpose of this study was to define the effectiveness and safety of tumescent local anesthesia (TLA) in comparison to GA in patients undergoing S-ICD implantation.

METHODS

We performed a prospective, nonrandomized, controlled, multicenter study of patients referred for S-ICD implantation between 2019 and 2020. Patients were allocated to either TLA or GA on the basis of patient's preferences and/or anesthesia service availability. TLA was prepared using lidocaine, epinephrine, sodium bicarbonate, and sodium chloride. All patients provided written informed consent, and the institutional review board at each site provided approval for the study.

RESULTS

Sixty patients underwent successful S-ICD implantation from July 2019 to November 2020. Thirty patients (50%) received TLA, and the rest GA. There were no differences between groups with regard to baseline characteristics. In-room and procedural times were significantly shorter with TLA (107.6 minutes vs 186 minutes; P < .0001 and 53.2 minutes vs 153.7 minutes; P < .0001, respectively). Pain was reported less frequently by patients who received TLA. The use of opioids was significantly reduced in patients who received TLA (23% vs 62%; P = .002).

CONCLUSION

TLA is an effective and safe alternative to GA in S-ICD implantation. The use of TLA is associated with shorter in-room and procedural times, less postprocedural pain, and reduced usage of opioids and acetaminophen for analgesia.

Advanced Therapies for Ventricular Arrhythmias in Patients With Chagasic Cardiomyopathy: JACC State-of-the-Art Review

Chagas disease is caused by infection from the protozoan parasite Trypanosoma cruzi. Although it is endemic to Latin America, global migration has led to an increased incidence of Chagas in Europe, Asia, Australia, and North America. Following acute infection, up to 30% of patients will develop chronic Chagas disease, with most patients developing Chagasic cardiomyopathy. Chronic Chagas cardiomyopathy is highly arrhythmogenic, with estimated annual rates of appropriate implantable cardioverter-defibrillator therapies and electrical storm of 25% and 9.1%, respectively. Managing arrhythmias in patients with Chagasic cardiomyopathy is a major challenge for the clinical electrophysiologist, requiring intimate knowledge of cardiac anatomy, advanced training, and expertise. Endocardial-epicardial mapping and ablation strategy is needed to treat arrhythmias in this patient population, owing to the suboptimal long-term success rate of endocardial mapping and ablation alone. We also describe innovative approaches to improve acute and long-term clinical outcomes in patients with refractory ventricular arrhythmias following catheter ablation, such as bilateral cervicothoracic sympathectomy and bilateral renal denervation, among others.

[Surgical complications in cirrhotic patients. Analysis of 102 cases]

BACKGROUND

Cirrhotic patients have an increased surgical risk due to potential intra and postoperative complications.

AIM

To describe the clinical characteristics and surgical complications of cirrhotic patients undergoing surgery in a Chilean university hospital.

PATIENTS AND METHODS

Review of medical records of 102 cirrhotic patients aged 60 ± 11 years (52% males) who underwent elective or urgency surgery at an university hospital between 2010 and 2016. General, pre-surgical, and post-surgical complications were recorded.

RESULTS

The main etiologies of cirrhosis were non-alcoholic steatohepatitis (31%), and alcoholic cirrhosis (28%). Child-Pugh scores were A, B and C in 50, 28 and 22% of cases respectively. Median MELD (Model for End-stage Liver Disease) score was 11 (interquartile range: 10-15). The surgical procedure was elective in 71% of cases, with predominance of abdominal surgery (86%). The American Society of Anesthesiologists (ASA) score was three or more in 52% of patients. The frequency of any adverse outcome was 62%. The frequency increased along with the severity of cirrhosis and when surgery was urgent. The most common complications were acute renal failure (24%), increased ascites (23%) and encephalopathy (22%). Admission to intensive care unit occurred on 26% of patients, with six hospital deaths.

CONCLUSIONS

In these patients, surgical complications were common, although with low mortality.

Interstitial lung disease and microscopic polyangiitis in chilean patients

Objective:

To describe the clinical and serological patients characteristics with Microscopic Polyangiitis (MPA) and Interstitial lung disease (ILD).

Methods:

Of all the patients with AAV diagnosed between 2007-2017 at the Hospital Clinico Universidad de Chile, those with MPA and ILD were selected and studied retrospectively.

Results:

All patients were Hispanic; median age at diagnosis 65 years (32-84). 59% were female. All were positive for p-ANCA, 16 patients for MPO. Most common manifestations were constitutional symptoms, weight loss and fever. CT-Scans patterns were Usual Interstitial Pneumonia (UIP) in 10 patients, Nonspecific Interstitial Pneumonia (NSIP) in 6 and fibrosis not UIP or NSIP pattern in 1. In 6 cases, ILD was diagnosed 0.5-14 years before MPA and concomitantly in 11.

Conclusions:

Although infrequent, Microscopic Polyangiitis should be suspected in patients with ILD particularly if extra-pulmonary manifestations that rise the possibility of a systemic illness are present, regardless of the time elapsed between the latter and the diagnosis of this type of lung involvement. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (1): 37-42)

Radiologic assessment of gastric emptying of water-soluble contrast media: New data security from a longitudinal study

BACKGROUND AND OBJECTIVES

Practice guidelines for preoperative fasting have not clearly established the fasting time needed after oral administration of water-soluble contrast media. The aim of this study was to determine the time required for the gastric emptying during the water-soluble contrast media in patients with acute abdominal pain.

METHODS

This prospective longitudinal study included sixty-eight patients older than 18 years of age with acute abdominal pain, who required a water-soluble contrast media enhanced abdominal computed tomography study. Plain radiographs were obtained hourly until complete the gastric emptying. Patients with probable bowel obstruction were not included in the study.

RESULTS

A total of 31 (45,6%), 54 (79,4%), and 64 (94,1%) patients achieved a complete gastric clearance of barium in 1, 2 and 3 hours, respectively. All patients achieved complete emptying of water-soluble contrast media within 6 hours. Gastric emptying time was not associated with gender (P=0,44), body mass index (P=.35), fasting time prior to water-soluble contrast media intake (P=0,12), administration of opioids in the emergency room (P=0,7), and the presence of comorbidities (P=0,36).

CONCLUSION

Ninety-four percent of the patients with acute abdominal pain achieved complete gastric emptying within 3hours after the administration of water-soluble contrast media. All of them achieved complete gastric emptying within 6hours. The results suggested 6hours after oral intake of the contrast media is enough to complete transit of water-soluble contrast media through the stomach and avoid unnecessary risks.

[Spontaneous clearance of hepatitis C virus after liver transplantation: Report of two cases]

The spontaneous clearance of hepatitis C virus infection is rare, especially after liver transplantation, condition in which recurrence is almost universal. We report two cases in which clearance of the virus was achieved after liver transplantation. We reviewed the literature and described possible mechanisms explaining this phenomenon, with emphasis on therapeutic implications.

[Aortitis: report of three cases]

Aortitis is a nonspecific term that describes an inflammation of the aortic wall caused by inflammatory, infectious, paraneoplastic and idiopathic diseases. The symptoms are variable and nonspecific; therefore a high level of clinical suspicion is required to diagnose it. It is often an incidental finding while looking for other diagnoses and it is confirmed mainly through imaging studies. We report three cases of aortitis: A 29-year-old woman presenting with alopecia, oral and nasal ulcers and positive antinuclear antibodies. A CAT scan showed a segmental thickening of thoracic aorta, with dilated and stenotic areas. She was successfully treated with steroids, hydroxychloroquine, cyclophosphamide and azathioprine. A 41-year-old male presenting with dorsal pain and cough. The CAT scan showed an extra-intimal thickening of the descending aorta and stenosis of the celiac artery. The final diagnosis was a polyangiitis and was treated with steroids, cyclophosphamide and azathioprine. A 28-year-old woman presenting with pain in the left upper abdomen. Imaging studies showed a thickening of the aortic arch and subclavian artery. The final diagnosis was sarcoidosis and the patient was treated with prednisone.

[Skin manifestations in adults with a liver allograft]

BACKGROUND

Skin manifestations after liver transplantation are increasing due to long term immunosuppressive therapy along with an increase in patient survival. Several studies have reported dermatologic complications following renal transplant, but few have studied dermatologic problems after liver transplantation.

AIMS

To describe the different types of cutaneous lesions encountered in adults receiving a liver allograft. To evaluate the frequency of cutaneous manifestations of patients in the liver transplant waiting list.

MATERIAL AND METHODS

Eighty patients submitted to a liver transplant and 70 patients in the liver transplant waiting list were evaluated with a complete dermatological physical examination.

RESULTS

Sixty one percent of patients with a liver allograft had at least one skin manifestation. Of these, 34% had superficial fungal infections, 31% had viral infections, 20% had cutaneous side effects due to immunosuppressive treatment, 10% had malignant lesions, 2% had bacterial infections and one patient had a graft versus host disease. Only 28% of patients in the liver transplant waiting list had dermatologic problems, and the vast majority were lesions linked to liver cirrhosis.

CONCLUSIONS

Cutaneous infections were the most common skin problems in liver transplant patients. Although neoplastic lesions are the most commonly mentioned lesions in the literature, only a 10% of our liver transplant patients presented these type of lesions.

[C-Reactive protein levels in patients with chronic obstructive pulmonary disease]

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) have elevated serum levels of ultrasensitive C reactive protein (CRPus). This raise may be related directly to COPD and its associated systemic inflammation or secondary to other factors such as smoking status, disease severity, acute exacerbations, or associated complications.

AIM

To evaluate the potential causes of raised levels of CRPus in stable COPD patients.

PATIENTS AND METHODS

Cohorts of 133 mild-to-very severe COPD patients (41 current smokers), 31 never-smokers, and 33 current smoker controls were compared. Clinical assessments included body mass index (BMI), fat (FM) and fat-free mass (FFM) measurement by DEXA, forced expiratory volume in one second (FEV1), arterial oxygen tension (PaO2), six-minute walking test (SMWT), emphysema (EMPH) and right thigh muscle cross-sectional area (TMCSA), both quantified by high resolution computed tomography.

RESULTS

Serum CRPus levels were significantly higher in COPD patients than in controls (7 ± 4.2 and 3.7 ± 2.7 mg/L respectively; p < 0.0001). Being smoker did not influence CRPus levels. These levels were significantly correlated with FM (r = 0.30), BMI (r = 0.21), FEV1 (r = -0.21), number of acute exacerbations of the disease in the last year (r = 0.28), and PaO2 (r = -0.27). Using multivariate analysis FM, PaO2, and number of acute exacerbations of the disease in the last year had the strongest association with CRPus levels.

CONCLUSIONS

CRPus is elevated in COPD patients, independent of smoking status. It is weakly associated with fat mass, arterial oxygen tension and frequency of exacerbations.

Ultrasound-guided excision combined with intraoperative assessment of gross macroscopic margins decreases the rate of reoperations for non-palpable invasive breast cancer

AIMS

The standard technique for intraoperative tumour localization of clinically occult tumours is wire-guided localization (WGL). This, however, this has several disadvantages. The aim of the present work is to report our single-centre experience with intraoperative ultrasound-guided (IOUS) excision, performed by surgeons, combined with intraoperative assessment of macroscopic pathologic and ultrasound margins in non-palpable invasive cancers indicated for conservative breast therapy.

PATIENTS AND METHODS

Two-hundred and twenty-five non-palpable invasive breast cancers were subjected to excision with IOUS. The lesion was located in the operating room with a high-frequency ultrasound probe (8-12 MHz), which was then used to guide surgical removal. The specimen margins were estimated by ultrasonography and macroscopic pathologic examination. The sensitivity of IOUS and effectiveness in the characterization of the specimen margins were evaluated, assessing the need for reoperation.

RESULTS

Pathologic tumour size was 12.0 ± 6.7 mm and 13 lesions (6.4 %) were <5 mm. The sensitivity of IOUS localization was 99.6% (224/225 cases). Only one cancer of less than 5 mm was not localized. The average weight of the specimens was 26.1 g. A second operation was required to remove margins in the 4% of cases (9/225). In 5 cases remains of in situ or invasive carcinoma were found. In two cases, conservative surgery was converted to mastectomy.

CONCLUSIONS

IOUS excision combined with the intraoperative assessment of the macroscopic margins of non-palpable breast cancers is a safe, useful, and efficient technique. We obtained an excellent characterization of tumour margins with moderate removal of breast tissue and consequently a lower number of reoperations were required and good cosmetic results were obtained. We believe that use of this technique in conservative breast cancer surgery should be recommended.

[Hepatitis B virus immunoglobulin on demand to prevent infection recurrence among liver allograft recipients: report of three cases]

Infection recurrence rates among hepatitis B virus infected liver allograft recipients, may be as high as 80%. Immunoprophylaxis with anti HBVgammaglobulin may reduce these rates and improve survival. The dose of anti HBV gammaglobulin that must be used is not clearly defined. The most commonly accepted protocol uses 10,000 units during the anhepatic phase and 10,000 units daily during one week, followed by weekly doses of 10,000 units during one month and maintenance with 10,000 units monthly, without measuring anti hepatitis B surface antigen antibodies (antiHBs). Some reports recommend the use of immunoglobulin on demand, to maintain antiHBs titers between 100 and 250 U/l. The infection recurrence rates among patients treated with immunoglobulin and Lamivudine fluctuates between 0 and 10%, during follow up periods of 13 to 30 months. We report three liver allograft recipients that received immunoglobulin on demand, using a mean of 41,000 units, maintaining adequate antiHBs titers.

[Palliative treatment for locally advanced or metastatic gallbladder cancer: conclusions of the Latin American Consensus meeting for the management of gallbladder cancer]

Gallbladder cancer is a rare disease in Western developed countries, but it is a highly prevalent and lethal disease in Chile and other countries in Latin America. No randomized controlled trials have been performed in gallbladder cancer to establish standard treatments. We therefore performed the first Latin American consensus meeting for the management of gallbladder cancer. In this article we present the conclusions of the panel of experts for the palliative treatment of unresectable or metastatic gallbladder cancer based on a review of the literature, the discussion of the participating experts and the opinion of the assistants. The topics reviewed included: (1) Gallbladder cancer and cholangiocarcinoma--are they the same disease?; (2) Palliative chemotherapy: indications, drugs and schedules; (3) Palliative radiotherapy; (4) Palliative Surgery; (5) Management of malignant biliary obstruction.

[Endoluminal excision of an esophageal fibrovascular polyp. Report of one case]

We report a 47-year-old woman presenting with dysphagia. A chest CAT scan and barium swallow showed an endoluminal mass that extended to four vertebrae. An endoluminal sonography localized the pediculum of the mass, that was excised endoscopically. The pathological study disclosed a fibrovascular polyp. After 18 months of follow up, the patient is asymptomatic.

Organizing pneumonia in patients with severe respiratory failure due to novel A (H1N1) influenza

The authors describe two cases that developed organizing pneumonia (OP) associated with novel influenza A(H1N1) virus. These patients were admitted to intensive care unit (ICU) because of severe respiratory failure. After initial clinical improvement, both patients worsened their condition during their second week of ICU stay, presenting fever, increasing in inflammatory parameters and worsening in oxygen exchange and respiratory mechanics. Chest x-rays and computed tomographies showed an increment on lung infiltrates, given by areas of consolidation and ground glass opacification. Although broad-spectrum antibiotics were administered, patients showed no improvement. All cultures, including bronchoalveolar lavage samples, were negative. In both cases, an open lung biopsy was performed, and histopathological examination of the specimen was compatible with OP. Both patients were successfully treated with high-dose corticoids. The aim of this report is to alert about the possibility of OP associated with novel influenza virus in patients with severe respiratory failure.

[Bilateral foreign bodies in the airway. Report of one case]

Inhaled foreign bodies can be a life-threatening emergency and requires immediate intervention. We report a 40-year-old man who came to the ER complaining of chest pain and cough. He had lost his dental prosthesis. Chest X-Rays showed two foreign bodies, one at the intermediate bronchus and the other at the left posterior basal segmental bronchus. By fibrobronchoscopy, porcelain fused to a metal dental crown of six teeth was extracted from the right side, and a cast of metal from the left side.

[Minimally invasive hemodynamic monitoring with esophageal echoDoppler]

Hemodynamic monitoring is a key element in the care of the critical patients, providing an unquestionable aid in the attendance to diagnosis and the choice of the adequate treatment. Minimally invasive devices have been emerging over the past few years as an effective alternative to classic monitoring tools. The esophageal echoDoppler is among these. It makes it possible to obtain continuous and minimally invasive monitoring of the cardiac output in addition to other useful parameters by measuring the blood flow rate and the diameter of the thoracic descending aorta, which provides a sufficiently extensive view of the hemodynamic state of the patient and facilitates early detection of the changes produced by a sudden clinical derangement. Although several studies have demonstrated the usefulness of the esophageal Doppler in the surgical scene, there is scarce and dispersed evidence in the literature on its benefits in critical patients. Nevertheless, its advantages make it an attractive element to take into account within the diagnostic arsenal in the intensive care. The purpose of the following article is to describe how it works, its degree of validation with other monitoring methods and the role of esophageal echoDoppler as a minimally invasive monitoring tool for measuring cardiac output in the daily clinical practice, contributing with our own experience in the critical patient.

[General considerations, indications and contraindications for liver transplantation in Chile: a multicenter consensus development document]

Liver transplantation is an excellent therapeutic option for terminal liver disease. During the last decades the results of liver transplantation have improved significantly with a patient survival rate of nearly 90% at one year and 80% at 5 years of follow-up. The main indications for liver transplantation include: end-stage liver disease associated to cirrhosis, acute liver failure, and hepatic tumors (mainly hepatocarcinoma). The absolute contraindications for a transplant are less frequent than in the past, and include: severe co-morbidity (cardiac or pulmonary), sepsis, advanced HIV disease and extra-hepatic malignancy. This document presents a Consensus of the main groups performing liver transplantation in Chile, about its indications and contraindications. It also reviews general aspects of liver transplantation, including the selection and referral of liver transplant candidates, allocation of organs and the evaluation of severity of liver disease.

[Predictive values for mortality in pulmonary embolism, of embolic load and right/left ventricular diameter ratio, measured by computed tomography]

BACKGROUND

In pulmonary embolism, the computed tomography (CT) images can be used as a prognostic index measuring the embolic load, according to the location and size of thrombus and the right/left ventricular diameter ratio.

AIM

To assess the predictive value of embolic load and right/left ventricular diameter ratio for early and late mortality in acute pulmonary embolism (PTE).

MATERIAL AND METHODS

The pulmonary CT of 418 patients with suspected PTE was reviewed. Embolic load was assessed by three independent evaluators and the right/left ventricular diameter ratio was measured in those exams that were positive for PTE. A logistic regression analysis was done between these parameters and mortality. Reproducibility was calculated using Bland and Altman analysis.

RESULTS

There was a high concordance between raters to calculate embolic load (r =0,95, p <0,001). Only the right/left ventricular diameter ratio and the presence were predictive of global mortality. The predictive value for embolic load was below the significance level, No parameter was predictive of early mortality.

CONCLUSIONS

The concordance between raters for the assessment of embolic load was high in this study. However no imaging parameter had a predictive value for early mortality. The right/left ventricular diameter ratio had a predictive value for global mortality at three months.

Oral Ulcers Produced by Mycophenolate Mofetil in Two Liver Transplant Patients

Oral ulcers are a frequent problem in transplant medicine. It is important to consider infectious etiologies, exacerbated by the immunosuppressive treatment, but other etiologies are also possible, like adverse drug reactions. Mycophenolate mofetil (MMF) is an immunosuppressive medication that has been used in combination with calcineurin inhibitors and steroids. Reports of renal transplant patients with oral ulcers related to MMF have appeared lately and herein we have described 2 cases in liver transplant patients. Their oral ulcers resolved quickly after suspension of the medication. Our 2 cases in liver transplant patients represented a unique setting for this type of complication.

Histidines 13 and 14 in the Abeta sequence are targets for inhibition of Alzheimer's disease Abeta ion channel and cytotoxicity

The fact that Alzheimer's beta amyloid (Abeta) peptides forms cation channels in lipid bilayers was discovered during the course of our experiments in the laboratory of "Guayo" Rojas at NIH in Bethesda, Maryland (USA). Recently, we found that the Abeta ion channel could be blocked selectively with small peptides that copy the amino acid sequence of the predicted mouth region of the Abeta channel pore. We now have searched for the essential amino acid residues required for this blocking effect by mutations. We found that the ability of peptides to block Abeta channel activity could be lost by replacement of histidines 13 and 14 by alanine or lysine. The amino acid substitution also resulted in the loss of the capacity of the peptides to protect cells from Abeta cytotoxicity. These data thus contribute to the definition of the region of the Abeta sequence that participates in the formation of the channel pore. Additionally, these data support the hypothesis that the ion channel activity of Ab contributes significantly to the cytotoxic properties of Abeta. These data also emphasize the potential value in using inhibition of Abeta ion channel activity as an end point for Alzheimer's disease drug discovery.

[Effects of gastric bypass on weight, blood glucose, serum lipid levels and arterial blood pressure in obese patients]

BACKGROUND

Type 2 diabetes, hypertension and serum lipid abnormalities are common among obese people and they should improve with weight reduction.

AIM

To study the outcome of these abnormalities after bariatric surgery in morbid obesity patients.

MATERIAL AND METHODS

Two hundred thirty two morbid obese patients subjected to gastric bypass, were evaluated in the preoperative period and every three months after surgery, during a minimum of 12 months. Clinical evolution, blood glucose, serum insulin, insulin resistance measured with the homeostasis model assessment (HOMA) and serum lipid levels were analyzed.

RESULTS

In the preoperative period, 17% had type 2 diabetes, 49% had abnormal serum lipid levels and 25% had high blood pressure. Sixty six percent had at least one of these abnormalities and 20% had more than one. During follow up, body mass index decreased from 44 to 29.3 kg/m2. Total and HDL cholesterol, blood glucose and insulin resistance significantly decreased from the third month after surgery. Diabetes disappeared in 97% of diabetic subjects, blood pressure normalized in 53% of subjects with hypertension and serum lipid levels returned to normal in 88% of subjects with dyslipidemia.

CONCLUSIONS

Gastric bypass in morbid obese patients achieves a significant and important weight reduction that results in significant reductions in the frequency of diabetes, dyslipidemia and hypertension among operated obese subjects.

METABOLIC TRANSFORMATION OF DINOPHYSISTOXIN-3 INTO DINOPHYSISTOXIN-1 CAUSES HUMAN INTOXICATION BY CONSUMPTION OF O-ACYL-DERIVATIVES DINOPHYSISTOXINS CONTAMINATED SHELLFISH

This paper describes for the first time a massive intoxication episode due to consumption of shellfish contaminated with 7-O-acyl-derivative dinophysistoxin-1, named Dinophysistoxin-3 (DTX-3). 7-O-acyl-derivative dinophysistoxin-1, a compound recently described in the literature, was found in shellfish samples collected in the Chilean Patagonia fjords. This compound does not inhibit Protein Phosphatases and also does not elicit the symptoms described for Diarrheic Shellfish Poisoning (DSP). The data showed here, give evidence of metabolic transformation of 7-O-acyl-derivative dinophysistoxin-1 (DTX-3) into Dinophysistoxin-1 (DTX-1, Methyl-Okadaic acid) in intoxicated patients. This metabolic transformation is responsible for the diarrheic symptoms and the intoxication syndrome showed by patients that consumed contaminated shellfish, which showed only the presence of 7-O-acyl-derivative dinophysistoxin-1. Patients fecal bacterial analysis for the presence of enteropathogens was negative and the mouse bioassay for DSP, performed as described for regulatory testing, was also negative. The HPLC-FLD and HPLC-MS analysis showed only the presence of DTX-3 as the only compound associated to DSP toxins in the contaminated shellfish samples. No other DSP toxins were found in the shellfish sample extracts. However, the patient fecal samples showed DTX-1 as the only DSP toxins detected in fecal. Moreover, the patient fecal samples did not show DTX-3. Since 7-O-acyl-derivative dinophysistoxin-1 (DTX-3) was the only compound associated to DSP toxins detected in the shellfish samples, an explanation for the diarrheic symptoms in the intoxicated patients would be the metabolic transformation of DTX-3 into DTX-1. This transformation should occur in the stomach of the poisoned patients after consuming 7-O-acyl-derivatives dinophysistoxin-1 (DTX-3) contaminated bivalves.

[Albumin dialysis MARS (Molecular Adsorbent Recirculating System) as a bridge for liver transplantation in acute liver failure. Report of three cases]

The most successful therapy for acute liver failure is liver transplantation. However, due to the low number of donors, organ support therapies need to be used as a bridge to liver transplantation. Molecular Adsorbents Recirculating System (MARS) is a dialysis treatment that uses a recirculating dialysate containing albumin. This allows the removal of both hydrosoluble and albumin-related substances. This system improves hepatic encephalopathy, renal dysfunction and some clinical parameters in acute liver failure, but there is no clear decrease in mortality. We report three women aged 23, 21 and 61 years, that were subjected to liver transplantation, in whom this therapy was successfully used.

[Community acquired pneumonia in a hospitalized community: etiological study]

BACKGROUND

Community-acquired pneumonia (CAP) that requires hospitalization, is a common and serious disease. A permanent assessment in specialized centers, to define therapeutic guidelines according to local epidemiological factors, is mandatory.

AIM

To study the etiology of CAP requiring hospital admission.

PATIENTS AND METHODS

Adult patients with CAP, admitted to the Clinical Hospital of the University of Chile between 1999 and 2001 were studied. A clinical, radiological and microbiological assessment was done in all patients. Blood and sputum cultures and serology for Chlamydia and Mycoplasma pneumoniae were performed.

RESULTS

Thirty one patients aged 62 +/- 18 years, 12 female, met inclusion criteria. An etiologic diagnosis was made in 74% of cases, (52% definitive, 22% probable). Frequency of definitive diagnosis was: 25% Mycoplasma pneumoniae, 19% Chlamydia pneumoniae and 13% Streptococcus pneumoniae. Mixed etiology was found in 16% and a final diagnosis was not obtained in 26% of the cases. No correlation was found between clinical and radiological patterns, and the etiologic agent. C reactive protein and erythrosedimentation rate were significantly higher in CAP due to Chlamydia and Streptococcus pneumoniae.

CONCLUSIONS

The higher frequency of Mycoplasma and Chlamydia pneumoniae, than previously reported, suggests that atypical agents should be considered in the initial antimicrobial therapy prescribed to these patients.

[Obesity: risk factor for steatohepatitis and hepatic fibrosis]

BACKGROUND

Nonalcoholic fatty liver (NAFL) has been recognized as a cause of chronic liver disease. Its main risk factor is obesity.

AIM

To describe the clinical and liver pathological findings in a group of patients who underwent surgery as obesity treatment.

PATIENTS AND METHODS

Sixty eight patients with severe or morbid obesity were subjected to surgery as obesity treatment. Each patient was evaluated with a complete clinical and laboratory medical assessment. A wedge of liver was excised during surgery. Liver biopsies were analyzed without knowledge of clinical and laboratory findings. The presence of steatosis, inflammation (portal or lobular), fibrosis and cirrhosis were recorded in the pathological analysis. Age and body mass index (BMI) were correlated with pathological data. Significance was set at a p value of less than 0.05.

RESULTS

Ninety one percent of patients had steatosis, 45% inflammation and 47% fibrosis. One patient had cirrhosis (1.4%). There was a statistically significant association between BMI and moderate or severe steatosis (p < 0.03). There was also an association between BMI and portal (p = 0.017) and lobular inflammation (p = 0.034). A BMI over 40 kg/m2 (morbid obesity) was significantly associated with the presence of fibrosis (p = 0.032). Moreover, the presence of moderate or severe steatosis was a risk factor for the development of hepatic fibrosis (p = 0.026).

CONCLUSIONS

Obesity is a major and independent risk factor for steatohepatitis and fibrosis. The degree of steatosis in the liver biopsy, is a risk factor for the development of fibrosis.

Early and late results of the acid suppression and duodenal diversion operation in patients with barrett's esophagus: analysis of 210 cases

The usual surgical treatment for patients with Barrett's esophagus (BE) is a classic Nissen fundoplication or posterior gastropexy with cardial calibration. However, some surgical reports as well as our experience suggest that the rate of failure of the Nissen fundoplication or Hill's posterior gastropexy in patients with BE is significantly higher than in those with reflux esophagitis without BE, probably due in part to the persistence of duodenal reflux into the esophagus. Our aim was to determine the late subjective and objective results of an operation consisting in "acid suppression" (vagotomy-partial gastrectomy) and "duodenal diversion" (Roux-en-Y anastomosis) as a primary surgical procedure for patients with BE. Altogether, 210 patients were subjected to this technique. It consisted in a primary operation in 142 patients and revision surgery in 68. They underwent complete clinical, radiologic, endoscopic, histologic, and manometric studies. In some cases 24-hour pH studies, Bilitec studies, gastric emptying, and gastric acid secretion evaluations were performed. There were two deaths (0.95%), and postoperative morbidity was low (5.3%). The late mean follow-up (58 months) for 146 patients who completed a follow-up longer than 24 months showed Visick I and II grades in 91.1% of the cases. In 14.9% of the cases 24-hour pH monitoring showed excessive acid reflux 1 year after surgery. No dysplasia or adenocarcinoma has appeared up to now. Functional studies showed significant alleviation of lower esophageal sphincter (LES) incompetence, with abolition of duodenal reflux into the esophagus. Gastric emptying of solids was normal, and basal and peak gastric acid output remained at a low level 8 to 10 years after surgery. In patients with BE, with severe damage of the LES and esophageal peristalsis, the "suppression diversion" operation completely abolishes the reflux of injurious components of the refluxate and improves sphincter competence. This effect is permanent and avoids the appearance of dysplasia or adenocarcinoma.

[Preliminary results of laparoscopic video esophagomyotomy in patients with esophageal achalasia]

BACKGROUND

Laparoscopic esophagomyotomy is becoming a good alternative to pneumatic dilatation, injection of botulinic toxin or classical surgery in the treatment of achalasia.

AIM

To report the results of laparoscopic esophagomyotomy in patients with achalasia.

PATIENTS AND METHODS

Nineteen patients with achalasia, nine women, aged 9 to 66 years old, operated between 1996 and 2001 are reported.

RESULTS

There was no surgical mortality. One patient had a subphrenic abscess due to an unnoticed tear of the esophageal mucosa. During surgery, esophageal mucosa was perforated in 4 patients, that was sutured in three. One patient with an extensive tear of the mucosa required conversion to classical surgery. Patients were followed for 2 to 48 months. Radiological controls showed a significant increase in the diameter of gastroesophageal junction and a diameter reduction of the mid third esophageal segment. Lower esophageal pressure was significantly reduced. All patients experienced a weight increase and reduction of dysphagia.

CONCLUSIONS

Laparoscopic esophagomyotomy is a safe an effective therapeutic alternative for achalasia.

Dietary flavonoid and isoflavone glycosides are hydrolysed by the lactase site of lactase phlorizin hydrolase

Lactase phlorizin hydrolase (LPH; EC 3.2.1.62) is a membrane-bound, family 1 beta-glycosidase found on the brush border of the mammalian small intestine. LPH, purified from sheep small intestine, was capable of hydrolysing a range of flavonol and isoflavone glycosides. The catalytic efficiency (k(cat)/K(m)) for the hydrolysis of quercetin-4'-glucoside, quercetin-3-glucoside, genistein-7-glucoside and daidzein-7-glucoside was 170, 137, 77 and 14 (mM(-1) s(-1)) respectively. The majority of the activity occurred at the lactase and not phlorizin hydrolase site. The ability of LPH to deglycosylate dietary (iso)flavonoid glycosides suggests a possible role for this enzyme in the metabolism of these biologically active compounds.

[Preliminary results of horizontal gastroplasty with Roux in Y anastomosis in patients with severe and morbid obesity]

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.

[VIGILA: a tool for the epidemiologic surveillance of transmissible diseases]

It is described an instrument for the epidemiological surveillance of communicable diseases (VIGILA) that is based on the generalization of a modification of the statistical model proposed by Serfling for the prognosis of the endemic levels of the rates of communicable diseases in a period of 52 weeks (1 year). The comparison made between the observed rates and the prognosticated rates allows to detect unusual patterns of this indicator. The observation of rates over the higher limit of the prognosis interval during successive periods is suggested as a signal of alert. The introduction of this method in a computer program allows its application in the epidemiological surveillance units at the different levels of the health system.

Long-term results of classic antireflux surgery in 152 patients with Barrett's esophagus: clinical, radiologic, endoscopic, manometric, and acid reflux test analysis before and late after operation

BACKGROUND

The classic surgical procedure for patients with Barrett's esophagus (BE) has been either Nissen fundoplication or posterior gastropexy with calibration of the cardia.

METHODS

The purpose of our study was to determine late subjective and objective results of these classic surgical techniques in a large number of patients with BE. A total of 152 patients were included in this prospective protocol.

RESULTS

There was 1 death (0.7%) after operation. The late follow-up of 100 months demonstrated a high percentage of failures among patients with noncomplicated BE (54%) and an even higher figure in patients with complicated BE (64%). In 15 patients low grade dysplasia appeared at 8 years of follow-up and an adenocarcinoma in 4 patients. Twenty-four-hour pH monitoring demonstrated a decrease in acid reflux into the esophagus, and Bilitec studies also demonstrated a decrease of duodenoesophageal reflux, but in all cases with a higher value than the normal limit.

CONCLUSIONS

Classic antireflux surgery in patients with BE results in a high percentage of failures at very late follow-up because it cannot completely avoid acid and duodenal reflux into the esophagus.

Histological findings of gallbladder mucosa in 95 control subjects and 80 patients with asymptomatic gallstones

The histological appearance of gallbladder mucosa in 95 control subjects and in 80 patients with asymptomatic gallstones separated according to age and sex was determined in a prospective study. The number and size of stones in the latter group were also analyzed. Among controls, 33% showed abnormal histological findings, mainly chronic cholecystitis, which increased with age and was frequently seen among women. All patients with asymptomatic gallstones showed chronic cholecystitis and/or cholesterolosis, and 5% showed acute inflammatory changes. In 55% of them a single stone was found. These findings suggest that chronic inflammatory changes can occur in the gallbladder mucosa prior to the appearance of macroscopic stones at the gallbladder.

A new physiologic approach for the surgical treatment of patients with Barrett's esophagus: technical considerations and results in 65 patients

OBJECTIVE

To determine the results of a new surgical procedure for patients with Barrett's esophagus.

SUMMARY BACKGROUND DATA

In addition to pathologic acid reflux into the esophagus in patients with severe gastroesophageal reflux and Barrett's esophagus, increased duodenoesophegeal reflux has been implicated. The purpose of this study was to establish the effect of a new bile diversion procedure in these patients.

METHODS

Sixty-five patients with Barrett's esophagus were included in this study. A complete clinical, radiologic, endoscopic, and bioptic evaluation was performed before and after surgery. Besides esophageal manometry, 24-hour pH studies and a Bilitec test were performed. After surgery, gastric emptying of solids, gastric acid secretion, and serum gastrin were determined. All patients underwent highly selective vagotomy, antireflux procedure (posterior gastropexy with cardial calibration or fundoplication), and duodenal switch procedure, with a Roux-en-Y anastomosis 60 cm in length.

RESULTS

No deaths occurred. Morbidity occurred in 14% of the patients. A significant improvement in symptoms, endoscopic findings, and radiologic evaluation was achieved. Lower esophageal sphincter pressure increased significantly (p < 0.0001), as did abdominal length and total length of the sphincter (p < 0.0001). The presence of an incompetent sphincter decreased from 87.3% to 20.9% (p < 0.0001). Three of seven patients with dysplasia showed disappearance of this dysplasia. Serum gastrin and gastric emptying of solids after surgery remained normal. Basal and peak acid output values were low. Twenty-four hour pH studies showed a mean value of 24.8% before surgery, which decreased to 4.8% after surgery (p < 0.0001). The determination of the percentage time with bilirubin in the esophagus was 23% before surgery; this decreased to 0.7% after surgery (p < 0.0001). Late results showed Visick I and II gradation in 90% of the patients and grade III and IV in 10% of the patients.

CONCLUSIONS

This physiologic approach to the surgical treatment of patients with Barrett's esophagus produces a permanent decrease of acid secretion (and avoids anastomotic ulcer), decreases significantly acid reflux into the esophagus, and abolishes duodenoesophageal reflux permanently. Significant clinical improvement occurs, and dysplastic changes at Barrett's epithelium disappear in almost 50% of the patients.

[Subjective and objective evaluation of the results of laparoscopic antireflux surgery in patients with gastroesophageal reflux]

BACKGROUND

Laparoscopic antireflux surgery is a minimally invasive procedure that should have similar results than classical surgical treatment.

AIM

To report the results of a prospective study of laparoscopic antireflux surgery in patients with gastroesophageal reflux.

PATIENTS AND METHODS

Thirty two patients with gastroesophageal reflux and without Barret's esophagus, were subjected to endoscopy, manometry and measurement of intraesophageal pH before and after laparoscopic surgery.

RESULTS

There were no postoperative deaths or complications. Gastroesophageal sphincter pressure and abdominal sphincter length increased from 9.1 +/- 3.9 to 13.0 +/- 3.5 mm Hg and from 8.1 +/- 6.2 to 13.5 +/- 5.4 cm after surgery (p < 0.01). There was a decrease in acid reflux in 82% of patients.

CONCLUSIONS

Laparoscopic antireflux surgery reproduces exactly the results of open surgical procedures.

A computer system for epidemiological surveillance

In epidemiological surveillance, it is imperative that any unusual increase in reported cases be detected as quickly as possible. In the surveillance unit at "Pedro Kourí," it was necessary to create a computer system for the surveillance of transmissible diseases in order to manage such variables as morbidity, mortality, and the circulation of causal agents. As usage flexibility is a fundamental requirement, we developed VIGILA as a system readily adaptable to any level of the country's health organizations (national, provincial, or municipal). VIGILA permits the storage, validation, and statistical analysis of morbidity and mortality data, and it also allows the user to apply these features to causal agent information. These manipulations are all performed in the context of a specific transmissible disease. The stored information can be displayed in different types of statistical formats, such as calculated rates, accumulates and medians. The user can also design his/her own tables for display. In addition, the program offers graphics that depict the endemic forecast for a specific region and age group. Reliable forecasts based on temporal models of an epidemiological indicator are necessary for the prediction of the non-epidemic indicator and for the elaboration of an alert threshold. The endemic forecast or endemic channel is calculated by means of a modified version of R. Serfling's model [1] which adapts to data series with stationary characteristics. In this case, the model is fixed for the medical attention protocol and the circulation of agents of a specific transmissible disease. The parameters of the model are estimated by the least square method. The confidence limits are calculated with the T-Student distribution [2]. To enter information about a specific disease and level of health concern, the user must define the disease under analysis, the principal territory under surveillance and its dependencies, the causal agents of the disease, and the frequency with which the disease is reported. This system stores the number of cases (morbidity) and death (mortality) that occurred in the territories and age groups defined during entry. To facilitate the calculation of morbidity and mortality rates, information pertaining to the number of territory habitants and their age groups is also stored. The laboratory data includes the number of analyzed samples in the territories and age groups defined in the data entry, and the samples that were positive to the defined agents. Among the principal uses of the system are: calculation of cumulative cases, rates, and cumulative rates for the specific period of analysis, territory, and age group; comparison of these health indicators with the previous year's indicators or with the median of the previous years' indicators' calculation of the endemic forecast that permits the user to observe the epidemiological situation by territories and age groups; and the early detection of an increase in disease occurrence. The system also offers a geographical representation of the epidemiological situation in the territories, showing a map with the evaluation of each territory with respect to four possible risk factors. VIGILA is available in both DOS and WINDOWS 3.1 formats. This system allows the evaluation of the situation at a specific point in time in the analyzed territories, and may alert the infection control team to an epidemic early enough to allow implementation of control measures.