[Associating prognostic factors with clinical results in locally advanced breast cancer]

Background

Breast cancer is the most frequent malignant tumor in women.

Objective

To identify clinico-pathological and molecular markers as predictors of survival in patients with locally advanced breast cancer (LABC).

Methods

Retrospective and observational study. The clinical factors of clinico-pathological and molecular predictors in relation with overall survival (OS) were assessed by the survival function, baseline hazard with smoothing and Cox regression.

Results

126 patients were assessed. OS at five years was significantly superior in patients with clinical stage IIIA (87%; p < 0.001), grade 2 tumor (81%; p < 0.001), pathological node stage (ypN0: 90%; p < .001), low-risk Nottingham prognostic index (86%; p < 0.001) and luminal A subtype (88%; p = 0.022). Baseline hazard with smoothing exhibited an increase in the mortality rate at 50 months for the luminal B/ HER2+ subtype compared with other subtypes. The multivariate analysis ascertained that the stage ypN2-3 (hazard ratio [HR] = 7.3; 95% confidence interval [95% CI]: 2.2 to 23.9) and the HER2+ nonluminal (HR = 7.8; 95% CI: 2 to 29.6) and triple negative (HR = 5.4; 95% CI: 1.7 to 17.2) subtypes were associated with a poor OS.

Conclusions

The comprehensive evaluation of the molecular marker and clinico-pathological factors provides more accurate predictive and prognostic information. The nodal stage and molecular subtype are suitable clinical parameters on survival for LABC patients.

Maternal serum adipokines and inflammatory markers at late gestation and newborn weight in mothers with and without gestational diabetes mellitus

OBJECTIVES

Maternal obesity increases the risk of gestational diabetes mellitus (GDM) and is positively correlated with neonatal obesity increasing the risk of adiposity in both young and adult offspring. Maternal secreted factors from adipose tissue such as adipokines and inflammatory cytokines may regulate fetal growth. This study investigated associations between maternal adipokines and inflammatory markers at late gestation, and neonatal anthropometric characteristics in mothers with and without GDM.

MATERIAL AND METHODS

The study included 65 women with GDM and 65 pregnant women with normal glucose tolerance evaluated at the time of term elective Caesarean section. Adiponectin, leptin, resistin, adipsin, neutrophil gelatinase-associated lipocalin (NGAL), nerve growth factor (NGF), monocyte chemotactic protein-1 (MCP-1) and tumor necrosis factor-alpha (TNF-alpha) concentrations were measured in maternal serum by the multiplex immunoassay using Magpix technology. C-reactive protein (CRP) was measured with a particle-enhanced turbidimetric immunoassay and neonatal anthropometric variables were assessed. The association of birthweight with individual biomarkers was analyzed using multivariate logistic regression adjusted for maternal factors.

RESULTS

Adiponectin, leptin, resistin, adipsin, NGAL and NGF were not significantly associated with higher birthweight. The maternal factors in association with higher birthweight observed in GDM were CRP, MCP-1 and TNF-alpha levels. Regression analysis showed that TNF-alpha was an independent risk factor for higher birthweight (p = 0.046).

CONCLUSIONS

These results suggest an involvement of maternal inflammatory markers at late gestation and fetal growth in mothers with GDM, and that TNF-alpha could play a major role.

[Coronavirus disease 2019 and pregnancy]

Historically, viral respiratory infections in pregnant women have shown an increase in the risk of morbidity and mortality. With regards to COVID-19, information is limited and a greater risk of severe morbidity or mortality has not been shown, when compared to general population; however, pregnant women with comorbidities such as obesity, type 2 diabetes mellitus and hypertension have shown a greater severity of the disease, consistent with the general population with these comorbidities. The risk of vertical transmission appears to be low: it has not been demonstrated in any case during the current outbreak of COVID-19 in China, nor in previous epidemics of similar coronaviruses (SARS-CoV and MERS-CoV). Existing studies have not demonstrated the presence of the virus in genital fluid, amniotic fluid or maternal milk. Described cases of infection in newborns probably come from horizontal transmission, which suggests breastfeeding with respiratory hygiene measures. Given that COVID-19 is a new disease that has extended around the world and that current knowledge is still insufficient, it is mandatory the continued accumulation of data to discover in depth the action mechanisms of SARS-CoV-2 virus, responsible for the disease, and constant update of means of prevention and handling of the disease.

Immune tolerance at the maternal-placental interface in healthy pregnancy and pre-eclampsia

AIM

The objective of this review is to describe the immunological mechanisms which facilitate maternal tolerance at the maternal-placental interface, and to discuss how these mechanisms are disrupted in pre-eclampsia.

METHODS

A literature review was performed based on the analysis of papers available on PubMed. The most important and relevant studies regarding the immunological mechanisms which facilitate maternal tolerance in healthy pregnancy and pre-eclampsia are presented in this article.

RESULTS

The maternal-placental interface is the site where the immune tolerance begins and develops. Within the innate immunity, natural killer cells, macrophages and dendritic cells play a pivotal role in tolerance through regulation of inflammation. On the other hand, within the adaptive immunity, the correct increase of regulatory T cells is crucial for ensuring immune tolerance toward placental cells. Disturbances in maternal tolerance can lead to the appearance of pregnancy complications such as pre-eclampsia, which has a considerable impact on perinatal morbidity and mortality.

CONCLUSION

Our partial knowledge of immunological mechanisms involved in tolerance at the maternal-placental interface indicates that pre-eclampsia is characterized by alterations of this maternal immune tolerance, which could represent the origin of the disease.

[In memory of Dr. Arturo Zárate Treviño, pioneer in the study of gynecological endocrinology in Mexico]

No abstract

Placental Proinflammatory State and Maternal Endothelial Dysfunction in Preeclampsia

OBJECTIVE

To evaluate the placental and decidual gene expression and maternal and umbilical serum concentrations of tumor necrosis factor alpha, interleukin 6 (IL-6), IL-8, IL-10, IL-1 receptor antagonist (IL-1RA), intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 (VCAM-1), along with the proinflammatory/anti-inflammatory cytokine ratios in women with preeclampsia (PE) vs. women with normal pregnancy (NP), and to analyze PE classified as early- (EO) and late-onset (LO).

METHODS

This cross-sectional study was performed with 50 women with PE (EO n = 30, LO n = 20) and 50 women with NP. Tissue gene expression levels were measured by real-time RT-PCR. Cytokines and adhesion molecules serum concentrations were measured by immunoassays.

RESULTS

In PE, placental expression of IL-10 and IL-1RA was lower, while placental IL-8/IL-1RA ratio and maternal concentrations of VCAM-1 were higher vs. NP. In EO, placental expression of IL-10 was lower, while placental IL-8/IL-10 and IL-8/IL-1RA ratios were higher than LO and NP. Maternal concentrations of IL-6 were higher in LO than EO and NP. Throughout PE, maternal VCAM-1 concentrations were higher vs. NP. No significant differences were observed in the decidual expression and umbilical concentrations of the markers between the groups.

CONCLUSION

PE associates with a proinflammatory placental state; however, EO associates with a proinflammatory placental state, while LO associates with systemic maternal inflammation. Both subtypes associated with maternal endothelial dysfunction.

[Persists the controversy concerning the rutinary use of diagnostic tests in asymptomatic persons]

Currently, in medicine there is an environment replete with controversy and debate, partially due to the popular concept Evidence-Based Medicine, and to the development of technological advances and, apparently, better therapeutic resources. This has led to the establishment of an over-diagnosis epidemic and to an excess of therapeutic interventions, which do not necessarily lead to a longer life expectancy. Some medical controversies, which have called the attention of physicians and even of common people are those related with dislipoproteinemias, pre-diabetes and detection of cancer in asymptomatic persons. The debate and the controversy will surely continue and that is why it is very important to emphasize that clinical practice should be personalized, taking into account risks and implied benefits.

[Dienogest usefulness in pelvic pain due to endometriosis. A meta-analysis of its effectiveness]

BACKGROUND

Endometriosis is the presence of functional endometrial tissue in the pelvic peritoneum and it affects several age groups. That is why the impact of endometriosis in quality of life is considerable. The objective of this study was to evaluate the effectiveness of dienogest in patients with pelvic pain associated to endometriosis (PPAE).

METHODS

The evaluation of the effectiveness was carried out through a systematic review using the Cochrane methodology. It was used Markov model, which considers two states of health (with and without PPAE), with the possibility of weekly transition. Women between 18 and 45 years with PPAE were included, in a temporary horizon of 26 weeks. A level of statistical significance of 95% was used for a p < 0.05, with a multivariate probabilistic analysis of sensibility, as well as a univariate analysis of sensibility in several scenarios.

RESULTS

The probability that the female patient did not experience PPAE with the initial treatment was 87.91% with dienogest, 80.07% with danazol, 84.93% with medroxyprogesterone (injectable and oral) and 89.17% with gosereline. The probability that the female patient abandoned her initial treatment was 9% with dienogest, 12.07% with danazol, 9.6 and 6.75% with medroxyprogesterone injectable and oral, respectively, and 10.8 and 3.6% 3-monthly and monthly with gosereline.

CONCLUSION

Compared to danazol, medroxiprogesterone and gosereline, dienogest is the most efficient alternative to treat PPAE.

[Debate persists over the use of mammogram in the detection of breast cancer in asymptomatic women]

In this opinion article, it is discussed the importance of questioning the use of mammogram in the detection of breast cancer in asymptomatic women.

[Evaluation of visceral adipose tissue and lipid level in premenopausal and postmenopausal women's]

BACKGROUND

Postmenopausal women present weight gain and intensification of obesity, especially visceral adipose tissue (VAT) increases in postmenopausal women. But it is still not clear whether abdominal fat increases during this stage independently of body weight.

OBJECTIVE

compare the VAT and lipid profile between postmenopausal and premenopausal Mexican women.

METHODS

A case control study in postmenopausal women matched for BMI with premenopausal women. Anthropometric and laboratory measurements as well as body composition analysis were performed.

RESULTS

VAT was increased in postmenopausal women in contrast with premenopausal women (114.8 ± 39.5 vs 97.3 ± 29.0, p<0.05). Compared with premenopausal women, postmenopausal women showed higher total cholesterol (231 .6 ± 56.1 vs 206.8 ± 29.5 p <0.05), and LDL-cholesterol levels (145.9 ± 48.3 vs 121.7 ± 34.1, p < 0.05), whereas H DL-cholesterol remained unchanged.

CONCLUSION

The results of the present study have demonstrated that Mexican postmenopausal women had a significant increment in visceral adipose tissue and in other metabolic risk factors, independent of the body mass index.

Morphological changes of red blood cells in peripheral blood smear of patients with pregnancy-related hypertensive disorders

BACKGROUND AND AIMS

Pregnancy-related hypertensive disorders are complications in which risk factors are identified such as nulliparity, age, malnutrition, obesity and social issues. Those statements are explained by theories of abnormal placentation, immunological inadequacy, genetics and oxidative stress, but all theories converge in endothelial damage, which is able to mechanically deform and hemolyze erythrocytes as they pass through the capillaries. Given the effects of endothelial damage, the aim of the study was to determine erythrocyte alterations in peripheral blood smear of patients with hypertensive disorders of pregnancy that could be used as prognostic condition.

METHODS

We performed a prospective, descriptive and observational study where all patients with hypertensive disorders admitted to the obstetrics and gynecology service of a specialty hospital were recruited. Patients who provided signed informed consent underwent peripheral blood smear. Results were tabulated in percentage graphics and analyzed with Cramer's V based on χ(2). The peripheral blood smear consisted of an extended drop of peripheral blood from the patient with subsequent hematological staining done with Romanowsky stain.

RESULTS

A total of 119 samples were analyzed; 74% showed abnormal morphology of erythrocytes and the most frequent abnormality was the presence of schistocytes in up to 39% of samples. Descriptive analysis showed a degree of association to independent variables with Cramer's V = 0.41 value (p <0.05).

CONCLUSIONS

A high percentage of patients with hypertensive disorders of pregnancy show some morphologic alterations of erythrocytes in peripheral blood smear.

[Rapid Response obstetrics Team at Instituto Mexicano del Seguro Social,enabling factors]

BACKGROUND

There are barriers and enablers for the implementation of Rapid Response Teams in obstetric hospitals. The enabling factors were determined at Instituto Mexicano del Seguro Social (IMSS) MATERIAL AND METHODS: An observational, retrospective study was conducted by analysing the emergency obstetric reports sent by mobile technology and e-mail to the Medical Care Unit of the IMSS in 2013. Frequency and mean was obtained using the Excel 2010 program for descriptive statistics.

RESULTS

A total of 164,250 emergency obstetric cases were reported, and there was a mean of 425 messages per day, of which 32.2% were true obstetric emergencies and required the Rapid Response team. By e-mail, there were 73,452 life threatening cases (a mean of 6 cases per day). A monthly simulation was performed in hospitals (480 in total). Enabling factors were messagés synchronisation among the participating personnel,the accurate record of the obstetrics, as well as the simulations performed by the operational staff. The most common emergency was pre-eclampsia-eclampsia with 3,351 reports, followed by obstetric haemorrhage with 2,982 cases.

DISCUSSION

The enabling factors for the implementation of a rapid response team at IMSS were properly timed communication between the central delegation teams, as they allowed faster medical and administrative management and participation of hospital medical teams in the process.

CONCLUSION

Mobile technology has increased the speed of medical and administrative management in emergency obstetric care. However, comparative studies are needed to determine the statistical significance.

Treatment of menopausal symptoms with three low-dose continuous sequential 17β-estradiol/progesterone parenteral monthly formulations using novel non-polymeric microsphere technology

OBJECTIVE

To analyze the short-term efficacy and safety over menopausal symptoms of three low-dose continuous sequential 17β-estradiol (E)/progesterone (P) parental monthly formulations using novel non-polymeric microspheres.

METHODS

This was a multicenter, randomized, single blinded study in which peri- and postmenopausal women were assigned to receive a monthly intramuscular injection of 0.5 mg E + 15 mg P (Group A, n = 34), 1 mg E + 20 mg P (Group B, n = 24) or 1 mg E + 30 mg P (Group C, n = 26) for 6 months. Primary efficacy endpoints included mean change in the frequency and severity of hot flushes and the effect over urogenital atrophy symptoms at 3 and 6 months. Safety variables included changes in the rate of amenorrhea, endometrial thickness and histopathology, and local and systemic adverse events.

RESULTS

Compared to baseline at month 6, the three treatment schemes significantly decreased the rate of urogenital atrophy symptoms and the frequency (mean number per day) and severity (mean number graded as moderate and severe per month) of hot flushes. No differences in studied efficacy parameters were observed between studied groups at baseline or at the end of the study. For all groups the most frequent adverse event was pain at the injection site; however they were all rated as mild. At the end of the study peri- and postmenopausal women displayed no significant changes in endometrial thickness or histopathology in all treated groups. The rate of amenorrhea at the end of the study decreased for all studied groups yet was less evident among postmenopausal women as compared to perimenopausal ones.

CONCLUSIONS

The three low-dose continuous sequential intramuscular monthly treatments of E/P using novel microsphere technology were effective at reducing menopausal symptoms at short-term with a low rate of adverse events. More long-term and comparative research is warranted to support our positive findings.

[Perinatal complications and serotonin level (5-HT) associated with low birth weight]

BACKGROUND

Studies in human and in experimental models suggest that interaction among the adverse prenatal and postnatal environment increases susceptibility for chronic diseases. This environment could induce changes in the metabolism balance.

OBJECTIVE

To analyze how the low birth weight (LBW) influences on the perinatal complications and serotonin serum concentration associated with the possible changes in the alimentary behavior.

MATERIAL AND METHODS

A prospective, longitudinal and descriptive study was made during 6 months of the obstetric events to know the frequency and complications of LBW. To evaluate if these complications could have some relationship with the serotonin concentration we measured through their metabolite 5-hidroxitriptamina (5-HT) and the possible chronic illnesses of the adult life.

RESULTS

From 1,418 obstetric events attended during the study period, 506 patients with viable pregnancies and met the inclusion criteria were included, 26.8% had LBW and the immediate clinical complications were presented in 52.2% of them and serum concentration 5-HT of 362.2 ± 21.8 vs 82.1 ± 13.6 ng/mL.

CONCLUSION

Low birth weight, besides causing perinatal complica- tions, also conditions permanent changes in the expression of satiety neurotransmitters and some tissues, that alter the regulation mechanisms to maintain the energy balance leading to metabolic stability, which is needed to the proper endocrine functioning in the adult life of these individuals.

[Clinical practice guideline. Diagnosis and treatment of postmenopausal and perinemopausia]

Post-menopause is the period of life where a deep decline occurs in circulating estrogen levels, inducing the appearance of psycho and somatic symptoms. The classification to understand the chronology of reproductive aging in women (known as STRAW) determines the clinical and endocrine changes contemplating menstrual cycles, symptoms, measurements of FSH, LH, inhibin B, anti-Mullerian hormone , and follicular account. The diagnosis of menopause is established by the absence of menstruation for 12 months or more. The most frequent clinical manifestations of the climacteric syndrome transition to menopause are menstrual disorders, vasomotor symptoms (flushes and/or sweats) and genitourinary manifestations. The assessment of women in the peri- or postmenopause aims to develop: cervicovaginal cytology , lipid profile , serum glucose, basal Mammography at least a year before, pelvic ultrasound, urinalysis, serum TSH, Densitometry in patients older than 60 years if there is no recourse can be applied and FRAX. Drug therapy for the treatment of disorders of the transition to menopause or menopause is divided into: hormone therapy (HT) based estrogens and progestin hormone not being the most recommended the serotonin reuptake inhibitors and norepinephrine, clonidine, gabapentin or veralipride.

[Usefulness and risks of routine mammography for the detection of breast cancer]

It has been accepted that preclinicall detection of breast cancer by means of the routine practice of mammography could discover the disease at its initial stage; therefore, practicing a mammography annually became widespread as a preventive health measure to diagnose the disease and prevent death due to breast cancer. Over time, the benefit of detection tests has been questioned and demonstration of their benefit, as well as that of the undesirable effects they might cause, has been demanded. There is recent information with regard to an absence of difference in terms of breast cancer mortality as final index between women with or without routine mammography. Additionally, a 20 % frequency has been observed in false-positive diagnoses, with high numbers of women undergoing unnecessary diagnostic procedures due to suspicion of a non-clinically apparent presumed cancer. In Mexico, from 2004 on, the popularity of mammography to detect and effectively cure cancer has increased. Acceptance can be attributted to how easily detection campaigns can be promoted, since most women accept that mastography can offer the opportunity of receiving an early treatment that reduces dissemination and prevents early mortality. The age at which it is convenient to perform the first mammography, how frequently it should be repeated and even the age for its discontinuation is still under debate and no consensus has been reached.

[Hematocervix, a new variety of hematometra. A case report]

The hematometra should be suspected in a patient with amenorrhea and recurrent pain in low stomach. It is conditioned by anatomical obstruction of the exit way from menstrual bled, that can release the presentation forms described as hematocolpos, hematometra and hematosalpinx. Report does not exist where alone the cervix is affected, for what the case is described with connotation of hematocervix. Patient of 32 years, regular menstruation, begins symptoms 25 days later to the menstruation, characterized by intense abdominal pain, for what goes to the service of gineco-obstetrics urgencies, where it is hospitalized under diagnose of abdominal painful syndrome. The transvaginal sonographic reports long cervix and with distention for a collection liquidates, the intern cervical hole open, the external minimally dehiscent, scarce flow of the contained endocervical toward the vaginal way through the external hole, for its ecographic aspect compatible with hematic material. The diameters anteroposterior and transverse of the cervix of 2.50 and 4.57 cm respectively. Was passed to surgical room, CEH with fibrosis that hindered the open dilation, for what were take both lips of the cervix and proceeded to dilation with Hegar until number 6, begin glide of dark and dense blood approximately in 60 mi. The evolution was good, since later to the anesthetic event, she referred remission of the pain and the sonographic control demonstrated cervix of normal anatomical characteristic, inclusive until year of follow. A wide diversity of symptoms and clinical data have been demonstrated that should have present for the hematometra diagnosis, among those that are the urinary retention, tennesmus and presence of painful pelvic mass, but the recurrent abdominal pain is the constant in all the cases.

[Cornual ectopic pregnancy]

This paper reports the case of a 16-year old patient, with menstrual delay of 9 weeks, with positive pregnancy test, who went to the hospital due to expulsion of organized material, as well as pain colic type in hypogastrium. It was carried out laparotomy, finding ectopic pregnancy in right horn, being carried out miometrial incision and trophoblast aspiration, with presence of multiple endometriosic focuses in later face of uterus. In later pregnancies, there are not studies about the solidity of the scar after the horn resection and uterine breaks have been described in the second and third trimester.

[Incidence of preterm births in the IMSS (2007-2012)]

BACKGROUND

The birth of a premature child implies an expense raised for the families and the systems of health for the possibilities of visual, auditory disability and problems of learning. The rate of premature births, according to the WHO, goes from 5 to 18 %, for what it was found that it will have to diminish.

OBJECTIVE

Knows the behavior of the incident of the childbirth pretérmino in the Mexican Institute of the Social Insurance (IMSS) during the period 2007-2012 in the hospitals of the second and third level of attention ginecoobstétrica.

MATERIAL AND METHOD

Descriptive and retrospective study in which there was analyzed the existing information of the cases brought of birth pretérmino in the IMSS (2007-2012). Proved: the total of births was of born 3,135,755 alive, of this 7.7 % they were pretérmino in all the conditions of the Republic, which on having differed with the second level of attention existed 188,715 (6.8%) born pretérmino and the third level of attention (Medical Units of Alta Especialidad, UMAES) with 51,635 (13.7%) born pretérmino (p < 0.05).

RESULTS

The total of births was of born 3,135,755 alive, of this 7.7% they were pretérmino in all the conditions of the Republic, which on having differed with the second level of attention existed 188,715 (6.8%) born pretérmino and the third level of attention (Medical Units of Alta Especialidad, UMAES) with 51,635 (13.7%) born pretérmino (p < 0.05).

CONCLUSIONS

The strategies to approach the problem of the prematurez are the prevention of the childbirth and the care perinatal to diminish the mortality of the baby and to increase his quality of life for what it is necessary to reinforce the contraceptive Council in the teenagers, to spread the births, as well as the detection and treatment of the infections genitourinarias.

[Convenience clinic redefine polycystic ovary syndrome (Stein-Leventhal)]

In 1935 during a medical meeting behalf in New Orleans was presents a study that included seven cases of women that suffered menstrual dysfunctions, hirsutism and sterility, for laparotomy the description of the ovaries had a pearly white color and it was hypertrophic, the cuneiform resection in both ovaries resulted in correction of the menstrual dysfunction and two of them got pregnancy later on, receiving the name of polycystic ovary syndrome (PCOS). The technological advance facilitates the hormonal analyses demonstrating the hyperandrogenism existence and the mechanism of the anovulation, the PCOS showed to be heterogeneous, reason why it was hindered to define it, this advanced the current trend to question the existence of the PCOS and to accept the convenience, either to change the name or to redefine it, leaving it as a simple syndrome with several phenotypes. The endocrine component includes abnormal secretion of insulin and consequently outlying resistance to this hormone, likewise is hyperandrogenism, dislipoproteinemia and obesity. The hormonal exams are unnecessary for the diagnostic and treatment; it is convenient to demonstrate for sonography the ovarian growth. Other dysfunctions like the congenital suprarenal hyperplasia, hyperprolactinemia and hypotiroidism should be discarded. The treatment should be individualized with relationship to the reason of the consultation and the patients age. It has not been demonstrated that the sensibilitizers use to the insulin avoids long term cardiovascular illness and diabetes. Therefore, the phenotype is heterogeneous with a fickle metabolic component and for it has arisen the restlessness of a better definition of the SPO.

[Current position about the use of estrogen therapy in women during the climacteric period]

The hormonal therapy should begin only in order to control the symptoms of the climacteric in women; its use is not recommended to prevent other types of affections associated to the posmenopause, because, despite some other recognizable benefits have been described, many of them have not been demonstrated. Before beginning the treatment of hormonal therapy, it is recommended to analyze the risk factors for heart attack or other cardiovascular diseases, and also estimate risk for osteoporosis and breast cancer. Diverse presentations and ways of administration of the hormonal therapy have been used, with which outcome have been obtained that vary in connection with predominant symptoms. Recently, the introduction of the concept based on the combined use of an estrogen associated to selective estrogen receptor modulator (SERM), the tissue selective estrogen complex (TSEC), allows a better clinical profile for the patient. With this combination it is obtained endometrial protection and positive action about the changes that the menopause produces. The decision to continue the hormonal therapy should be individualized, based on the severity of the symptoms and recurrence, considering the risk-benefit foreseen with the woman in the clinic.

[Estimate of the variability in the evaluation of semen analysis]

BACKGROUND

Masculine Infertility diagnosis continues depending in a great number of cases of the analysis of the semen. However, appropriate interpretation of the seminal analysis implies to consider two factors, the dependability of the laboratory and the medical knowledge about the meaning of the seminal alterations.

OBJECTIVE

Compare the results of the semen analysis among clinical laboratories.

MATERIAL AND METHODS

It was used the semen samples of the patients that need a semen analysis for their study. The sample was collected in the biological fluids assessment laboratory (A) and was evaluated the sperm count, morphology and motility. They were distributed to the other laboratories, andrology laboratory (B) and Assisted Reproduction laboratory (C). It was calculated the coefficients of variation intra-observer and inter-observer and descriptive statistics.

RESULTS

It was analyzed 28 semen samples by one technician in laboratory A, one in laboratory B and four in the laboratory C, using the World Health Organization (WHO) recommendations for reporting sperm count, motility and morphology. There is an inter-laboratory variability of the parameters studied in the sperm morphology with statistical difference (p < 0.001). The observed mean coefficients of variation intraobserver (CVs) were 3.6% for sperm count, 20.3%for motility and 9.4% for sperm morphology. The mean CVs inter- laboratory results were as follows: 25.7% for sperm concentration, 52.2% for sperm motility and 82.6% for sperm morphology.

CONCLUSIONS

There is an inter-laboratory variability for the analysis of the semen samples between the 3 laboratories studied for the semen parameters studied.

[Decreased insulin resistance with amino acids, extracts and antioxidants in patients with polycystic ovary syndrome]

BACKGROUND

The polycystic ovary syndrome (PCOS) it is a metabolic disorder with insulin resistance associated. Have been recently described contributor factors in the presence of insulin resistance that need to be studied. These factors can be the nutrients in the daily diet, final products of the advanced glycated end-products (AGEs), reactive derivatives of non enzymatic glucose-protein reactions either produced endogenously or ingested from dietary sources. The aim was to modifies the food intake to know the contribution on improve insulin resistance.

OBJECTIVE

Compare different diets and changes in insulin resistance in patients with polycystic ovary syndrome.

MATERIAL AND METHODS

As longitudinal, prospective and descriptive study, were included women with age among 18 to 40 years who received a compound with amino acids, extracts and anti-oxidants to dose of 660mg every 8 hours for 6 months. The inclusion approaches included the insulin resistance presence HOMA-IR > 2.6, elevated LH, and presence of ovaries with cysts by ultrasound. Statistical analysis with ANOVA one way to p <0.05.

RESULTS

Were included a total of 30 patients, of which 28 patients had improvement in the insulin resistance from the 3 months, but until the 6 months they had significant difference (p<0.05), compared with 24 women from control group.

CONCLUSION

With this result is demonstrated that it is necessary to modify the diet and to offer alimentary support to avoid the oxidative stress that takes impairment the insulin signaling with the subsequent insulin resistance.

[Clinical improvement of diabetic neuropathy with carbamazepine or diclofenac treatment]

BACKGROUND

diabetic neuropathy (DN) affects diverse aspects of a patient's life and there is not an optimal treatment. We did a comparative study of clinical improvement of DN with carbamazepine versus diclofenac.

METHODS

a prospective and longitudinal study of two groups with signs and symptoms of DN was done. One group had 30 patients who used carbamazepine with an initial dose of 200 mg, every 24 hours for one week, with a gradual increase of up to 200 mg every 6 hours for 10 months. The other group had 29 patients who used diclofenac sodium 100 mg every 12 hours. Bimonthly evaluations were made to graduate the pain according to the patients' perception and laboratory studies that included glucose and lipids profile. The statistical test used was ANOVA.

RESULTS

the patients who used carbamazepine presented absence of pain after 10 months compared with the diclofenac group (p < 0.01). The presence of cramps, muscular strength, pulses, perception of temperature and pressure improved significantly (p < 0.05) with the use of carbamazepine. On the other hand, muscular strength, tact and perception of temperature were deteriorated with the use of diclofenac.

CONCLUSIONS

it is important to provide the appropriate treatment to diabetic patients with DN.

[Clinical practice guideline. Traumatic urethral stenosis in males]

The incidence of urethral stenosis in Mexico had not been documented. At the Centro Médico Nacional La Raza, during the year 2010, 629 patients with urethral stenosis were attended as outpatient consultation: 85 % with previous urethral stenosis and 15 % with urethral treatment complication. Urethral stenosis is a chronic illness, with multiple etiological origins and the handling is controversial. It has a great negative impact for the patients and the recurrence reaches 85 %. The treatment consisted of an invasive approach (urethral dilations, endoscopy procedure) and open surgery (urethroplasty). The World Health Organization and World Alliance take the world challenge about the urinary tract infections associated with the attention of patients, focused on urethral stenosis. The objective of the following clinical guide is to offer to the health professional a clinical tool for making decisions in the handling of the hardship or masculine urethral stenosis, based on the best available evidence, carrying out in systematized form with bibliographical research using validated terms of the MeSH: urethral structures, in the databases Trip database, PubMed, Guideline Clearinghouse, Cochrane Library and Ovid.

[Conservative treatment of subcapsular hematoma in preeclampsia and HELLP syndrome: a case report]

BACKGROUND

Liver hematoma is a rare and serious complication of pregnancy associated with preeclampsia-eclampsia and HELLP syndrome.

CASE REPORT

27 years old patient with two pregnancies, first pregnancy with eclampsia, admitted with 36.5 weeks of gestation, blood pressure of 140-100 mmHg, epigastric pain, shoulder pain without peritoneal irritation and increased tendon reflexes. The requested preeclamptic profile supports the diagnosis of severe preeclampsia and HELLP syndrome. It was decided to terminate the pregnancy by abdominal route. Male product was obtained alive, 2,060 g, Apgar 8/9, gestational age of 38.2 weeks Capurro. A review did not report liver parenchymal. The evolution during mediate puerperium was torpid, the patient presented epigastric pain and shoulder pain, and there was a rise in transaminases (AST 687 U/L, ALT 813 U/L), progressive thrombocytopenia (113, 103/ pL), decreased hemoglobin, proteinuria and hypovolemic shock. Abdominal CT scan was requested, and it confirmed a heterogeneous liver image (117 x 85 x 104 mm) with a volume of 694 cc, suggesting hepatic hematoma. Serialized control of abdominal CT indicated liver hematoma resorption after 25 days of hospitalization. Seven days after discharge transaminase levels were normal.

CONCLUSION

To consider in the diagnosis of preeclampsia and HELLP syndrome the likelihood of liver hematoma as an acute complication; early treatment improves the prognosis.

[Pap test used for detection of cellular changes associated with human papillomavirus]

Human papilloma virus can infect any mucous of the body and can cause cancer of the uterine cervix. This suggests recommending the Papanicolaou smear combined with a test for detection of human papillomavirus with a frequency interval of 3 years, since it grants greater information and fidelity to the result. The detection studies should begin at the age of 21 years and should stop at 65 years age. Until recently specific treatments did not exist to treat human papilloma virus, but recently some drugs that have demonstrated good effectiveness in curing the infection of human papilloma virus. One example is glycirrhicinic acid, which has demonstrated fewer adverse effects, as well as the possibility that its systemic employment allows treatment of lesions that are difficult to approach. The medical recommendations should be in constant revision, since a clinical trial can modify the interpretation of what is necessary to individualize each patient's treatment.

[Pregnancy and breast cancer]

INTRODUCTION

association of breast cancer and pregnancy is not common. The objective of this investigation was to evaluate the pregnancy, young age, stage, treatment, prognosis and mortality of women with breast cancer during pregnancy.

METHODS

retrospective analysis from March 1992 to February 2009, 16 patients were included with breast cancer and pregnancy. They were analized: histological characteristic of tumor, therapeutic response of the oncological treatment, evolution of the pregnancy. From of baby born: Apgar and weight. The woman's mortality with breast cancer during pregnancy was evaluated for age group and for interval of time between late pregnancy and diagnosis posterior of breast cancer and pregnancy.

RESULTS

characteristic predominant clinicohistological: stage III (81.2%), T3-T4 (75%), N+ 93.7%, invasive ductal carcinoma (87.5%), histological grade 2-3 (93.7%), receptor estrogeno positive (43.7%); RPpositive (25%); HER-2/neu positive (31.2%). 27 chemotherapy cycles were applied with 5-fluorouracil, epirubicin and cyclophosphamide during the second or third trimester of the pregnancy, there were not severe adverse effects for the mothers and the baby born exposed to chemotherapy. The mean time to disease recurrence was 18.8 months (range, 6-62 months). The rate of mortality for specific age (< 35 years) was of 31.3% (p = 0.358). From the 16 patients, 7 have died and 9 were live without evidence of disease.

CONCLUSIONS

the advanced stage and the number of affected axillary lymph node more than the age was predictors of worse pronostic influencing the relapse and mortality of the young patients with breast cancer and pregnancy.

[Consensus conference of the Mexican Association for the Study of Climateric on veralipride prescription for patients with vasomotor symptoms]

Vasomotor symptoms are one of the main reasons for climateric women to consult a physician. Hormone therapy is the first treatment choice, but it is not indicated to all patients. Veralipride is an option for those who cannot or will not try hormone treatment. The Mexican Association for the Study of Climateric (AMEC) assembled an interdisciplinary group of medical experts so that they revised the medical literature on the subject and reached a consensus on veralipride indication, doses, counterindications and safety. The recommendations of the consensus conference on veralipride are: (1) Physicians must be familiar with its indication, side effects, pharmacokinetics and dosage. (2) Patients must be informed on other therapeutical options. (3) Patients' mental and neurological state must be evaluated, in particular to identify movement disorders, extrapyramidal symptoms (tremor or dystonia), anxiety and depression that can be mistaken for climateric symptoms. (4) Any adverse effect associated with the drug must be reported. (5) A random multicenter trial must be carried out in order to identify the frequency and severity of side effects, and (6) Written information on possible health risks when using the drug must be provided.

Effect of a Polyphenol-Rich Extract from Aloe vera Gel on Experimentally Induced Insulin Resistance in Mice

Insulin resistance, which precedes type 2 diabetes mellitus (T2DM), is a widespread pathology associated with the metabolic syndrome, myocardial ischemia, and hypertension. Finding an adequate treatment for this pathology is an important goal in medicine. The purpose of the present research was to investigate the effect of an extract from Aloe vera gel containing a high concentration of polyphenols on experimentally induced insulin resistance in mice. A polyphenol-rich Aloe vera extract (350 mg/kg) with known concentrations of aloin (181.7 mg/g) and aloe-emodin (3.6 mg/g) was administered orally for a period of 4 weeks to insulin resistant ICR mice. Pioglitazone (50 mg/kg) and bi-distilled water were used as positive and negative controls respectively. Body weight, food intake, and plasma concentrations of insulin and glucose were measured and insulin tolerance tests were performed. The insulin resistance value was calculated using the homeostasis model assessment for insulin resistance (HOMA-IR) formula. Results showed that the polyphenol-rich extract from Aloe vera was able to decrease significantly both body weight ( p < 0.008) and blood glucose levels ( p < 0.005) and to protect animals against unfavorable results on HOMA-IR, which was observed in the negative control group. The highest glucose levels during the insulin tolerance curve test were in the negative control group when compared to the Aloe vera extract and pioglitazone treated mice ( p < 0.05). In conclusion, Aloe vera gel could be effective for the control of insulin resistance.

[Diagnosis of premature menopause measuring circulating anti-Müllerian hormone]

The production of anti-müllerian hormone for the ovarian follicles begins near the puberty and the circulating levels begin to descend progressively in the stage of the pre-menopause coinciding with the depletion follicular and in consequence the menstrual cycles become irregular, frequently anovulatories. Therefore, concentration of anti-müllerian hormone shows a close correlation with follicular reserve and reproductive capacity, more than FSH and estradiol measurements. We described two patients that developed premature ovarian failure without previous diagnosis and therefore just were treated pharmacologically with estrogen-progestagen to induce menstrual bleeding. In blood of both patients was found low levels (< or = 4 ng/mL) of anti-müllerian hormone, and by means of sonography the absence of follicles was demonstrated in the ovaries. Has intended that premature ovarian failure could be of a chromosomal dysfunction, similar to other gonadal dysgenesias, another explanation of the mechanism is that it could be for development of some autoimmunity dysfunction. Therefore, the combined hormonal substitution of estrogen with progestagen should stay during several years to avoid the complications for the lack of estrogens; in some cases, could be informed on offering the pregnancy possibility by means of the attended fertilization using ovules donor.

[Care of insulin resistance in polycystic ovary syndrome]

Polycystic ovary syndrome (PCOS) constitutes the main cause of anovulatory sterility with a near occurrence to 7 %. The PCOS have not a constant hormonal profile, for it has been necessary the employment of approaches like those of Rotterdam to establish the presence of this dysfunction. A surprising discovery was the demonstration of the effect of the insulin on the ovary, that which modified the concept of the specificity in the action of the insulin on certain tissues, therefore a resistance stage to the action of insulin induces a compensatory hyperinsulinism to try to stimulate all the tissues, but in secondary form increases the dysfunction of the ovarian steroidogenesis. There are drugs known as "insulin sensitizers", used in the treatment of certain forms of diabetes mellitus, among those are metformin and tiazolidinediones (roziglitazone and pioglitazone), recently a compound has been used with formulation of amino acids and oligoelements (Diamel) that neutralizes the free radicals reestablishing the intracellular signs of the insulin at cellular level. It is important to guide that long term without correct the PCOS could have back effect since the insulin resistance is associates to a higher risk of increasing impaired glucose, diabetes, dyslipidemia, atherosclerosis and vascular disease. Therefore, preventive measures should be implemented that at present time are to the reach.

[Genetic and hormonal effects on sexual differentiation. Paradoxically women require androgens and men estrogens]

It had been established that the sexual structure of a person was determined by the type of hormonal production, what gave biological specificity of the estrogens to women and androgens to men, but recently this functional specificity has lost base due to the biological activity described in different tissues of men and women, today known as endocrine paradox. There are hormonal events that show the need of estrogens to correct development in men and androgens to women. In men the absence of effect of the estrogens produces deficient ossification of skeleton, persistence of the growth cartilage and osteoporosis in adult men. In women the production of androgens by suprarenal glandules is required to obtain the complete feminization. In women with chirurgic-induced menopause, the relation between androgens and the stimulation of sexual response has been established. It has been described a hormone called kisspeptin, that it is attributed the potential to initiate the puberty because stimulates the hypothalamus; in absence of this hormone the women do not present their secondary sex characters, remaining immature sexually. The understanding of individuals needs of androgens and estrogens contribute to improve the control and care of the patient with hormonal deficiencies in any phase of the life.

[Eclampsia, obstetric hemorrhage and heart disease as a cause of maternal mortality in 15 years of analysis]

BACKGROUND

It has been described that 70% of all maternal deaths are provoked by obstetrical hemorrhage, infections, abortions, hypertension and delivery dystocies. Poverty, social exclusion, low level education and violence are important causes of maternal mortality.

OBJECTIVE

To establish the changes in the maternal mortality in a term of 15 years in a hospital of assistance obstetrical complicated.

MATERIAL AND METHOD

A retrospective and descriptive study, in which the number and causes of obstetrical death was analyzed, occurred from 1991 to 2005. The comparison was done by five-year periods using descriptive statistics to analyze frequency of results.

RESULTS

The number of maternal deaths was 105, 97 and 42 by each one of the three five-year periods, the mortality rate x 10,000 decreased from 28.7 to 16.4 in the last quinquennium and was found from 6.1 just including the last year. In the first and second quinquennia the eclampsia occupied the first place as cause of death, followed by the hemorrhage and the infections. In the third quinquennium the eclampsia also occupied the first place with a rate of 8.6, followed by the cardiopathy (2.3) and the infections (1.9), but the hemorrhage with a rate of 1.5 was displaced to the fourth place.

CONCLUSIONS

The maternal mortality has diminished in a general way; the eclampsia has occupied the first place as cause of death from 1991 to 2005. The death by obstetrical hemorrhage has diminished in important form, possibly due to the specific groups of medical attention by modules, which has also helps the decrease of mortality by other causes. The increment of the deaths by cardiopathy should be considered as a possibility of risk, associate undoubtedly to the present style of life from our society.

[Frequency of symptoms of the climacteric syndrome]

BACKGROUND

Menopause is the descent in circulating estrogens that manifests clinically for the climacteric symptoms. These symptoms motivate the patient to consult to the physician.

OBJECTIVE

To know which are the symptoms that motivate women in the climacteric to begin hormonal therapy.

MATERIAL AND METHOD

Atransverse study was settled, 692 patients from the menopause cohort of Endocrine Research Unit, Centro Médico Nacional, IMSS participated. All patients signed the letter of informed consent. Complete clinical evaluation and taking samples of veined blood for the hormonal determinations of LH, FSH and estradiol were carried out. The approach of evaluation of the clinical symptoms was made with the scale of Greene that values six components: psychological, anxiety, depression, somatic, vasomotor and sexual, which quantifies the presence and intensity of the climacteric symptoms.

RESULTS

The four main symptoms that accompany the climacteric are: hot flushes, irritability, edginess and sickness. With the registered symptoms, the punctuation of the components in the scale of Greene showed a bigger frequency statistically with difference significant (p < 0.05) for the vasomotor and the depressive component compared with the rest of the components that integrate all the symptoms.

CONCLUSIONS

Hot flushes and irritability are the symptoms found in the first time interview, also these are presented in more than half of the patients, therefore these symptoms can be considered as main cause to begin hormonal therapy. In accordance with the scale of Greene that allowed us to evaluate the symptoms in integrated form, the sexual component was a smaller frequency, maybe to that great number of patient does not dare to comment the sexual dysfunctions. However, at the moment has a wide therapeutic arsenal and forms of administration of estrogen therapy that have demonstrated to have a clinical-benefic effect for the control of the climacteric symptoms.

[Estrogen therapy in menopause. Clinical study in evolution (KEEPS) to explain the risk-benefit dispute to administration]

The Kronos Early Estrogen Prevention Study (KEEPS) is a randomized clinical and controlled study, with the objective of clarifying the controversy that arisen previous studies about the risk-benefit factor with use of estrogens in postmenopausal women. Healthy women aged 42-58 years who are within 36 months of their last menstrual period have been recruited to receive either oral estrogens or patches of estradiol; in addition both groups are given oral micronized progesterone for 11 days of each month. Outcomes will be carotid intimae medial thickness and the accrual of coronary calcium; collaterally subrogate outcomes will be lipoproteins concentrations, coagulation markers, bone densitometry, mammography, skin characteristics and cognitive evaluation. The hypothesis consists in the presence of a window of therapeutic opportunity for the use of estrogens in low dose in healthy women with recent menopause.

[Breast cancer and subsequent pregnancy. Infertility, death risk and survival]

BACKGROUND

The chemotherapy commonly used for the treatment of breast cancer affect the fertility and could cause premature ovarian failure. The subsequent pregnancy to the breast cancer therefore it is not habitual.

OBJECTIVE

The purpose of this study was to identify the effects of the chemotherapy in the women reproductive life; to evaluate the frequency of the women that experienced a later pregnancy after treatment of cancer, as well as the effects of the subsequent pregnancy on the breast cancer. We report our experience in the 14 year period.

MATERIAL AND METHOD

As retrospective design, of 14 cases with breast cancer and subsequent pregnancy, from March 1994 to June 2008; demographic variables, clinical presentation, histopathological data, diagnostic procedures, treatments and results of the pregnancy were identified.

RESULTS

The mean (M +/- SD) age of gestational women was of 31.5 +/- 5.2 years; the 83.3% women received adyuvant chemotherapy with antraciclines; the patients with regional illness (> 4 N+) and advanced illness had an adverse presage; the systemic relapse and progression showed in 42.8% of the cases. The pregnancy to term was presented in half of the cases in the first two years and in a third part, later to the 2 years of having concluded the oncological treatment; of the fourteen patients with breast cancer presented a total of 16 pregnancies: 9 were of term, 3 of preterm and 4 abortions.

CONCLUSIONS

The study founds are based on a series of cases, which do not suggest that the pregnancy after the diagnosis and treatment of breast cancer has some adverse effect in the patients survival, for what the patients can conceive later to the oncological treatment. However, in this study it was observed that the effect of the advanced stage and positive axillary ganglion (> 4) influence in the relapses.

Risk factors associated with histological alterations of the female genital tract in patients attending a first-level medical care facility

BACKGROUND

We undertook this study to determine risk factors for histological alterations of the female genital tract in an open population who attend a first-level care medical facility.

METHODS

We conducted a case/control cohort study that included patients from outpatient consultation who responded to a cervical cancer control and prevention program. We studied 1933 patients; 88 patients (cases) had cellular alterations and were matched with 88 patients without alterations (controls). Statistical analysis was carried out with one-way ANOVA for comparison between groups and association of variables with relative risk for 95% confidence interval; p <0.05.

RESULTS

Mean age of the case group was 36.1 +/- 1.6 years and the control group had a mean age of 35.8 +/- 2.1 years. Diagnoses obtained in the case group showed a greater frequency of ectropion, human papilloma virus infection and CIN1. Risks factors analyzed in these patients showed statistical differences in number of gestations >2 (RR = 2.33) and the early initiation of sexual activity (<19 years) (RR = 1.14) for experiencing histological problems of the female genital tract.

CONCLUSIONS

Prevention of cervical cancer can be accomplished through timely and opportune detection in order to avoid the disease or to decrease risk factors by using condoms, delaying initiation of sexual activity and limiting the number of sexual partners. These are all strategies that the general population should be aware of.

[Endometriosis. Pathophysiological background for treatment]

Endometriosis is the third cause of gynecological morbidity and the complications are associated to ectopically endometrial tissue implantation. The interest on this disease is the functional disability and its association with sterility. It has been established that endometrial growth is estrogen-dependent and that progesterone inhibits the cellular proliferation mediated by estrogens, therefore in endometriosis there is not an adequate response to hormonal signals that control the proliferative activity. It has been described that peritoneal fluid in women with endometriosis has high concentrations of cytokines, growth factors and activated macrophages, which have been shown to have adverse effects on fertility. Therefore, these are not the only causes of infertility since it has been described that women with endometriosis seem to have poor ovarian reserve and ovular quality. When there is infertility, the tendency is to treat the endometriosis due to the changes caused by ectopic tissue presented at the immunological level and in the structure of genital organs, which disturbs the conception process. It has been observed that endometriosis recurs after a surgical procedure. For this reason we should be consider all therapeutic possibilities.

[Mesenteric cyst. A case report]

Mesenteric cysts are rare, it had been reported a frequency of 1 in 250,000 hospital admissions. We present a case of a 17-year-old female, attended at gynecology service with 8 weeks amenorrhea and diffuse pain in all abdominal regions. Without preceding pathological history of importance, menarche at 14 year, menstrual cycles of 30-45 x 5, nuligesta. She had negative immunology pregnancy tests, and sonography showed left ovary with anecoique ovoid area of approximately 15 x 8.8 x 7 cm. Physical examination showed a soft abdomen, depressible, with pain on the left side, where presence of a tumor of approximately 8 cm was perceived. Vaginal examination showed cervix of 3 x 2 cm, not painful to mobilization, uterus in a head position of 6 x 5 x 4 cm, a tumor of 18 x 10 cm was delimited in left salpinge, not painful to the compressedness. It was carried out a laparotomy with diagnostic of cyst in left ovary, but it was a tumor of 18 x 14 x 10 cm of cyst aspect that was dependented of mesenterious at sigmoid colon level, which could be eradicated without difficulty. Mesenteric tumors are difficult for diagnosis, and can be asymptomatic or to be suspect as cause of recurrent abdominal pain, abdominal tumor or acute abdomen. Unfortunately, it is difficult to establish the diagnosis with precision before surgery, still employing diagnostic resources of high technology, as sonography and tomography.

[Catecholamines level variation during pregnancy in women with diabetes and preeclampsia]

BACKGROUND

In obstetrical service it is frequent to find women with acute renal failure during second trimester of pregnancy. Main causes are related to hypertensive alterations, hemorrhage, sepsis, intrinsic renal disease and some rare disorders that produce high maternal morbidity and mortality.

OBJECTIVE

[corrected] To evaluate changes of adrenal function in pregnancy as well as its associated repercussions in diabetic and preeclamsic patients.

PATIENTS AND METHODS

Prospective study in 56 patients. Groups included women with normal pregnancy, patients with diabetes type 2, and women with preeclampsia. It was requested basic exams and samples from urine of 24 h for catecholamines determinations; as well as after two months of delivery. Catecholamines were measured with Bertler immune-fluorescent procedure.

RESULTS

Levels of catecholamines has statistically significant difference in all groups of study during the gestation. There was high quantity in the group of patients that developed preeclampsia 4535.5 +/- 356.4 microg/24 h (p < 0.05), compared with 31.2 +/- 9.2 microg/24 h in normal pregnancy; however, those with diabetes has a trend to increas 45.6 +/- 3.7 microg/24 h, without statistical differences. Two months after pregnancy levels shown 17.1 +/- 4.9 microg/24 h in normal pregnancy group, with preeclampsia 17.2 +/- 8.7 microg/24 h, and mild permanent increase 33.8 +/- 4.7 microg/24 h in the group with diabetes (p = 0.537).

CONCLUSIONS

An important catecholamines elevation is related with progress or severity of preeclampsia, and could be due to less adrenal injury associated with pregnancy, and contribute to renal failure. Longer studies are necessary to evaluate this approach in renal function.

[Clinical effects of the alterations that emerge in the signaling mechanisms of the insulin receptor]

Phosphorilation of subunit beta from insulin receptor induced mainly by insulin, it begins a series of intracellular complex signaling in cascade. Through this way establish multiple effects, which permits to the cell initiate its biological activity. This activity include the glucose metabolism, the regulation of ions and amino acids transport, lipids metabolism, glycogen synthesis, genetic transcription, mRNA expression, synthesis and degradation of proteins, as well as synthesis of DNA. Therefore, a modification in anyone of the proteins involved in the insulin signaling, can take place a dysfunction in the glucose metabolism. The impaired glucose can be due because there are many proteins, ions and enzymes that participate in the downstream pathways of the insulin signaling, it has become difficult to find a single phatophysiologic level as cause of diabetes. In spite of the advances in the study of this disease, it has been reached the conclusion that the glucose control is not enough to impede the complications that characterize to type 2 diabetes, since the organic worsening does not stop, which indicates that insulin signaling dysfunction is directly involved in all cellular process, and a better understanding in the communication ways of this hormone will take to new forms of treatment to impaired insulin response.

[Basic aspects for the control of gestational diabetes]

The female population in conditions of greater demand of insulin production, as in the case of pregnancy, can develop gestational diabetes (DG); therefore, the preconceptional attention in patients with suspects of development of DG should include the confirmation that blood glucose is found within the normal range, as well as the indication of a controlled diet. Glucose posprandial determinations two hours after food intake is advisable in patients that need insulin administration, which avoids determinations four times a day. The diet should include between 35 and 40 % of carbohydrates per day, supervised by a dietitian and based on the needs of each woman and the characteristics of the gestation. The combination of ultra-rapid acting insulin associate to ultra-slow acting insulin for application as a unique dose per day has been successfully used, but it is still necessary to determine the best diet for an adequate control of glucose. Oral hypoglycemic medications are not recommended as a DG treatment, since they were traditionally described as having theratogenic activity, by maintaining long hypoglycemic periods. Vaginal delivery is not contraindicated, although to avoid obstetrical complications, a cesarean section can be practiced, taking into account the antecedents of prior birth weight and the characteristics of bone pelvis. After delivery, a monthly posprandial determination at 2 hours should be carried out, where concentrations under 140 mg/dL are considered normal and it should be repeated every year. Insulin resistance can be a physiological state of pregnancy, but the beta-cells of maternal pancreas can be altered from the fetal life and therefore, cause the impossibility to respond to such a metabolic effort as pregnancy.

[Hormonal replacement therapy and breast cancer. A case-control study]

AIMS

Breast cancer is the second more frequently neoplasia in the woman and the first cause of mortality after 35 years old. It is considered a multifactorial illness, since is influenced for genetic, dietary and endocrine factors. Among these, hormonal replacement therapy (HRT) have been assigned benefits effect, as well as risks to increase the breast cancer incidence, because presence of estrogens receptor in the neoplasia cells makes think that the estrogens and other sexual hormones constitute a factor promoter of this cancer.

OBJECTIVE

The objective of this study was to determine the association of HRT as risk factor in the incidence of breast cancer, in women from oncology-gynecological service.

PATIENTS AND METHOD

Was carried out this descriptive study in patients that used HRT, considering as cases patients with breast cancer confirmed by hystophatological study and controls the patients without breast cancer. To statistical analysis took mean occurrence using the momios reason (MM), with confidence interval of 95% (CI), and chi2 test of Mantel-Haenszel, for a significant value of p < 0.05.

RESULTS

Were included successively 250 patients, in 100 of these were confirmed diagnosis of breast cancer, 60 patients (37.5%) used HRT with mean of 3 years and 40 patients (44.4%) did not use HRT (Cases), the other 150 patients did not have breast cancer, 100 of these used HRT and 50 patients did not use HRT (Control). The statistical analysis showed that the HRT had a MM 0.75 (IC 95% 0.62-1.15) p=0.28, the maternal nursing with MM 0.68 (IC 95% 0.59-1.08) p=0.05, the multiparity with MM 0.42 (IC 95% 0.16-1.87) p=0.26, obesity MM 1.67 (IC 95% 0.99-1.54) p=0.05, familial history with MM 1.23 (IC 95% 0.83-1.54) p=0.05.

CONCLUSIONS

These results show that does not exist a direct association between HRT and breast cancer. Therefore, whenever takes the decision to use the HRT should be considered the possible risks and benefits individualizing the patient, also the mammography should be present in mind, same that frequent physical examination, autoexploration and the use of HRT smaller to 5 years.

[Maternal and perinatal surgical complications in low platelet count for HELLP syndrome in severe preeclampsia-eclampsia in intensive care]

The preeclampsia is the first cause of maternal morbility, with increase in the obstetric complications when it is associated to HELLP syndrome, for the low platelets that even involves to the neonate. This study was carried out in the patients accepted in the intensive Adults Cares Unit in the period of one year, surgical complications and the perinatal results were determined in women with low platelet count for HELLP syndrome in preeclampsia-eclampsia. Three groups were formed according to the platelets account and then were analyzed using chi square to determine association among these groups of patients, as well as mean and standard deviation (M +/- DE) to describe results. Forty patients were studied with low platelets by HELLP syndrome in preeclampsia-eclampsia, where the distribution for the group with platelets < 50,000 were 12 patients (30%), in the group among 51,000-100,000 of 18 cases (45%), and of 101,000-150,000 were of 10 cases (25%). The mean of gestas was of 2.3 +/- 1.2, more frequent delivery was for cesarean section in 39 cases (97.5%) and a single case for vaginal via (2.5%), a maternal death was presented (8.3%). The surgical reintervention was observed with more frequency in the group of < 50,000 platelets, the most frequent cause in these reinterventions was the hipovolemic shock. Also in this group the perinatal mortality was presented in 3 cases (25%) and the asphyxia at the birth with Apgar < 6 was presented in 5 cases (41.7%). A bigger morbility was observed inversely proportional to the account platelets, being the renal failure the cause most frequent of this morbility in the three groups. The low platelets account contribute in a direct way in the obstetric complications, since there are more surgical reinterventions, with bled in the transsurgical and increase in the days of intrahospitalary stay. Also with smaller account platelet, there are bigger prematural index, asphyxia and perinatal mortality in the newborn of mothers with HELLP syndrome.

[Efficacy of elective cerclage in patients with cervical incompetence and associated risk factors]

Cervical incompetence (CI) is considered as a defect of the cervical estroma that takes to the inability of the uterine neck to retain an intra-uterine pregnancy until the viability of the fetus, with an incidence from 0.05% to 1% of all the pregnancies. This defect in the cervix is due to obstetrics trauma, such as disfunctional and anatomical causes. The failure of cervical cerclage have been reported up to 20%, this study was carried out to determine the baby born and procedure complications. All patients demanding attention at the Gynecology and Obstetrics Hospital of the Medical Center La Raza, with diagnosis of CI were included in this study. Thus, 36 patients were included, with 30.1 +/- 4.2 (M +/- SD) year-old age; the cerclage was performed in the second trimester, in order to extend the pregnancy with an average of 18.1 +/- 6.5 weeks until the moment of the interruption of the pregnancy. The 61.1% arrived to the term gestation, in 23 of the cases (63.8%) were born with more than 2500 g of weight, and 24 cases also presented a recurrence among 2 to 5 abortions. The most frequent complication was the threat of preterm childbirth and in patient with antecedents of previous obstetric complications was obtained a relative risk (RR) of 3.8 to present CI, moreover it was also observed at the beginning and the end of the obstetric life the probability of CI has a RR 1.6, with a positive correlation between the gestational age at the application of the cerclage and the continuation of the pregnancy (p < 0.05) after the week 16 of gestation. The cerclage application in the second trimester of pregnancy overcomes the risks of the surgical procedure and does not have adverse effects on the product. The main indicators of success are the cerclage application to smaller gestational age, into the second and third gestation, as well as the presence of the smallest number of complicated obstetric events, therefore great part of the obstetric decision to apply a cerclage should be based on previous obstetric life of each patient.