Déficit de vitamina D. Revisión epidemiológica actual / Vitamin D deficiency. Current epidemiological review

Vitamin D is a liposoluble hormone that exists in two molecular forms. Ergocalciferol (vitamin D-2) and colecalciferol (vitamin D-3). Vitamin D-3 is produced in the skin by the action of UV-B radiation. Both forms are metabolized by the liver to 25-hydroxy-Vit D (25OHD) and later in the kidney to the active form 1,25-dihydroxy-Vit D. This form promotes bone mineralization by intestinal absorption of calcium and phosphate. Normal levels of 25OHD are associated with less fracture, normal neuromuscular and immune function and possibly have a preventive effect on certain types of cancer. The Endocrine Society's Clinical Practice Guidelines recommends that optimal plasma levels of 25OHD are above 30 ng/ml, insufficiency between 21 and 29 ng/ml and deficiency below 20 ng/ml. The prevalence rate of 25OHD deficit is about 2 to 90% in different populations. Risk factors of Vitamin D deficit like year season, skin pigmentation, sunlight exposition, use of sunblock and inadecuate Vitamin D ingestion, together with different measurement techniques explain the variability of results between epidemiological studies. An important risk group is the health professionals that are not exposed to sunlight. There are no studies that describe the prevalence in this population in Chile. (AU)

Epidemiología y factores de riesgo de mortalidad de las bacteriemias intrahospitalarias por bacilos gramnegativos / Nosocomial bloodstream infections caused by gram-negative bacilli: epidemiology and risk factors for mortality

Nosocomial bacteremia is a major cause of hospital infection, associated with high rate of morbidity and mortality, prolonged hospital stay and higher costs. However, few prospective studies analyse the prognostic factors associated with mortality of gramnegative rods bloodstream infections in hospital wards outside of intensive care units. A prospective/descriptive study was conducted from March to December 2006. All patients with nosocomial-acquired bloodstream infection due to gramnegative rods were included. Epidemiology and clinical features were analysed as potential prognostic factors for mortality. During the study period, 84 cases were detected, being A. baumannii, Burkholderia sp and E. coli the most frequent isolates, with a mortality of 48 percent>. Bacteremia derived from a high-mortality associated septic focus (RR 4.9, IC95 percent> 1.3 - 18.8) and admissionto intensive care unit (RR 4.78, IC95 percent> 1.7- 13.1) were independent variables associated with mortality. Inappropriate empirical antibiotic treatment was not associated with greater risk of mortality. Nosocomial gramnegative bloodstream infections in our series were mainly due to non-fermentative bacilli and were associated with high mortality rates when their origin was a high risk septic focus or the patient was admitted to intensive care unit.

La bacteriemia nosocomial es una causa importante de infección intrahospitalaria, asociada a alta morbi-mortalidad, pero pocos estudios examinan en forma prospectiva las bacteriemias por bacilos grammne-gativos (BGN) más allá de las áreas de cuidados intensivos. Se realizó un estudio descriptivo, prospectivo desde marzo a diciembre del 2006, reclutando todos los pacientes con bacteriemia por BGN de origen intra-hospitalario. Se analiza la epidemiología y características clínicas como potenciales factores pronósticos de mortalidad. En el período de estudio se detectaron 84 casos (los más frecuentes A. baumannii, Burkholderia sp. y E. coli), con una mortalidad de 48 por ciento. La bacteriemia derivada de un foco infecciosos asociada a alta mortalidad (RR 4.9, IC95 por ciento 1,3-18,8) y la internación en UCI (RR 4,78, IC95 por ciento 1,7-13,1) fueron variables independientes predictoras de mortalidad. El tratamiento antimicrobiano empírico inadecuado no se asoció a mayor mortalidad. La bacteriemia nosocomial por BGN en nuestra serie se debió principalmente a bacilos no fermentadores y ésta se asoció con alta mortalidad cuando el origen fue un foco de alto riesgo o el paciente se encontraba internado en la UCI.

Mortalidad materna y anestesia / Maternal mortality and anesthetic procedure

La revisión de la mortalidad materna es de importancia relevante, si se considera que las complicaciones relacionadas con la anestesia ocupan entre el sexto y noveno lugar como causa de muerte materna, según diferentes autores. Se comparan las causas de muerte materna entre países industrializados y en vías de desarrollo, enfatizando la gran diferencia en tasas de mortalidad en relación directa al grado de desarrollo humano de las regiones, establecido por las Naciones Unidas. Se hace un análisis de un amplio y reciente estudio realizado por Hawkins y cols. entre 1979 y 1990, en E.U; donde se concluye que el número de muertes maternas relacionadas con la anestesia ha permanecido estable; el reporte indica una disminución en el porcentaje de muertes maternas, con aumento en las complicaciones de cesáreas bajo anestesia general, quizás debido a que la técnica es la más usada en embarazos de alto riesgo asociadas a obesidad, hipertensión, eclampsia y urgencias. Al final se consideran las coincidencias en los signos de un embolismo aéreo y la toxicidad por anestésicos locales bajo anestesia peridural que pueden confundir el diagnóstico con alteración de las estadísticas. Se muestra la estadística de morbilidad y mortalidad materna en la Clínica de la Mujer en Bogotá, reclamando de las autoridades hospitalarias el establecimiento de Unidades de Cuidados Intensivos Obstétricos para el manejo adecuado y precoz de las patologías y complicaciones maternas

Nuevas técnicas de analgesia para la conducción del trabajo de parto: ventajas y desventajas / Profits and disvantadges of different techniques to find and appropiate anesthesia for obstetrical population

La analgesia epidural lumbar continua ha sido por muchos años la técnica de elección para el control del dolor durante el trabajo de parto. En la última década han aparecido otras técnicas que buscan mejorar la calidad de la analgesia y disminuir los inconvenientes de la peridural lumbar continua en bolos. Esta conferencia analiza los beneficios y desventajas de los distintos medios para alcanzar una analgesia adecuada durante anestesia neuroaxial conductiva con peridural lumbar continua aplicada, a demanda por el anestesiólogo, según requerimiento de la paciente y el obstétra, con infusión continua mediante bombas de infusión, con infusión peridural mediante Analgesia Controlada por el paciente. (PCEA) y con la técnica espinal epidural combinada con narcóticos intratecales y anestésicos locales a bajas dosis. Se presentan las estadísticas de cinco años de analgesia obstétrica en una Institución de carácter privado de Bogotá, que atiende un estrato alto de la población de la ciudad y también se analizan dos trabajos realizados en otras dos clínicas que tienen servicio de obstetricia para estratos altos y medios de la población. Analizamos las cuatro características de una analgesia obstétrica ideal y las desventajas de la técnica tradicional de epidural lumbar continua en bolos

Utilidad de la cintigrafía de glándulas salivales en el síndrome de Sjogren y su relación con el resultado de la biopsia de labio: estudio comparativo con una población control / Salivary gland scintigraphy and lip biopsy in patients with Sjogren syndrome and normal controls

Background: Salivary gland scintigraphy allows a non invasive, morphological and functional assessment of parotid and submaxillary salivary glands. Aim: To describe the main features of salivary gland scintigraphy in patients with Sjögren syndrome, rheumatic fibromyalgia and normal controls and compare the results with lip biopsy. Patients and methods: Sixty one normal controls, 66 patients with Sjögren syndrome and 18 patients with rheumatic fibromyalgia were studied. For the diagnosis of Sjögren syndrome and fibromyalgia rheumatica, the Modified European and American College of Rheumatology criteria were used, respectively. Lip biopsies were obtained in 52 patients with Sjögren syndrome. Scintigraphy was done with a gamma camera and computer after the administration of 99mTc-pertechnetate, obtaining images during 30 min and creating time/activity curves. Scintigraphy was classified as normal, with mild or severe alterations. Results: Scintigraphy was normal in 74 percent of control subjects and in 26 percent, it had mild alterations. In 72 percent of patients with rheumatic fibromyalgia, scintigraphy was normal whereas in 28 percent, it had mild alterations. In 27 percent of patients with Sjögren syndrome, scintigraphy was normal, in 27 percent it had mild alterations and in 46 percent, severe alterations. There was a positive and significant correlation between pathological alterations of salivary glands and scintigraphic alterations (r=0.642, p < 0.001). Conclusions: Severe scintigraphic alterations of salivary glands strongly support the diagnosis of Sjögren syndrome. Mild alterations are non specific and anormal scintigraphy does not exclude the diagnosis

Acidosis tubular renal distal y litiasis renal en tres casos de síndrome de Sjögren primario / Distal renal tubular acidosis and renal lithiasis in 3 cases of primary Sjögren's syndrome

Tubulo interstitial nephritis, the main manifestation of renal involvement in Sjögren syndrome, may lead to a tubular dysfunction that is usually subclinical. We report 3 women, aged 32, 35 and 35 years old, with a primary Sjögren's syndrome and symptomatic type I or distal tubular acidosis. Two patients had nephrolithiasis and one a nephrocalcinosis. Two had a basal hyperchloremic metabolic acidosis. The ammonium chloride acidification test was abnormal in all, demonstrating a distal tubular defect. None had proximal tubular dysfunction. All had an urinary pH over 6.5 and hypocitraturia and none had hypercalciuria. Renal calculi were composed of calcium oxalate and calcium phosphate in 2 patients and calcium phosphate and ammonium phosphate in the other. All women had positive antinuclear antibodies with mottled pattern, 2 had anti Ro antibodies and positive rheumatoid factor and 1 had hypergammaglobulinemia. None had anti La antibodies, crioglobulinemia or monoclonal proteins

Condromatosis sinovial: revisión de 25 casos monoarticulares / Synovial chondromatosis: review of 25 monoarticular cases

We report 25 patients (20 female) aged 34 to 74 years old, with monoarticular synovial chondromatosis. Affected joints were tha knee in 25 cases, the ankle in one case and the elbow in one case. Chronic articular pain was the main symptom, followed by swelling, limitation in motion range, free palpable bodies and symptomatic popliteal cysts. X ray examination showed free calcified osteochondroid bodies in 48 percent of patients and secondary osteoarthritis in 36 percent. Bone scintiscan showed an increased focal uptake. All pathological samples had chondroid or osteochondroid nodules; 64 percent had small blood vessels, thickened with concentric collagen laminae and 20 percent had isolated chondrocytes. Malignant degeneration was not observed. Surgical or artroscopic synevectomy was the procedure of choice in 20 knees. In the affected elbow and ankle, extraction of free bodies was the sole procedure. No recurrences were observed. It is concluded that synovial chondromatosis must be considered in the differential diagnosis of chronic articular pain and monoartritis

Sinovectomía radioactiva con yttrium 90 y rhenium 186, en artritis reumatoídea: seguimiento a largo plazo y efecto en la membrana sinovial / Radiation synovectomy with yttrium 90 and rhenium 186 in rheumatoid arthritis: long term follow up and effects on synovial membrane

Despite the progress in the treatment of rheumatoid arthritis (RA), many patients continue to suffer from persistent and painful synovitis. We assessed the clinical results of 64 intraarticular injections of Yttrium 90 in the knee and 56 injections of Rhenium 186 in the wrist in 71 patients with RA, older than 40 years, without relief of synovitis after six months of systemic or local treatment and with a radiological stage I or II of the joints. We obtained good results in 75 percent of knees and 100 of wrists during a follow up period of 8 to 60 months. A repeat histological examination of the synovial membrane of 14 joints in which good results were obtained disclosed a reduction in inflammation and transitory synovial cell hyperplasia that ended in a dense fibrosis. It is concluded that radiation synovectomy continues to be an effective therapy for selected patients with RA and synovitis. The observed histopathological changes may aid the interpretation of magnetic resonance imaging of the treated joints

Osteoporosis regional migratoria: efecto de tratamiento con calcitonina: presentación de 2 casos / Regional migratory osteoporosis: effect of calcitonine treatment: report of 2 cases

We report two cases of regional migratory osteoporosis. One is a 41 years old male, with the classical form, presenting with succesive episodes of painful osteoporosis lasting for 5 months at the hip, knee and distal epiphysis of the right metatarsophalangeal joints. The second case is a 40 years old female presenting with an unusual disseminated form, lasting for 30 months, with succesive and simultaneous episodes of polyarticular and costal painful osteoporosis. An increased bone fraction of serum alkaline phosphatases and urine hydroxyproline/creatinine and calcium/creatinine ratios were detected. Imaging showed localized periarticular or costal oateoporosis. Bone biopsies disclosed a severe osteopenia with accelerated bone reabsorption. Bone scintigraphy precociously detected location, migration and evolution of lesions. Patients were treated with subcutaneous calcitonin, 100 U/day during 1 month and on alternative days posteriorly; this treatment alleviated pain but did not prevent the appearence of new crisis. Our observations suggest that regional migratory osteoporosis presentation may range from oligoarticular to disseminated forms and that calcitonin has a precocious and persistent analgesic effect

Evaluación del dolor postoperatorio en cirugía de hemiabdomen superior bajo cinco esquemas de analgesia / Evaluation of postoperatory pain in upper hemiabdominal surgery under 5 schemes of analgesia

Sesenta y nueve pacientes ASA I y II sometidos a cirugía de hemiabdomen superior, fueron asignados al azar a uno de 5 esquemas analgésicos, iniciados en la inducción anestésica y mantenidos durante 24 horas: I: ketoprofeno 100 mg IV c/8 horas. II: fentanyl 4 µg/kg en bolo + infusión de 1 µg/kg-1/h-1. III: morfina 4 mg vía peridural lumbar. IV: metadona 0,1 mg/kg IM c/8 h. V: morfina 0,1 mg/kg en bolo + infusión de 10 µg/kg-1/h-1. Fueron evaluados por un observador entrenado que desconocía el esquema utilizado, a través de: 1) Escala visual análoga (EVA); 2) Escala de valoración verbal (EVV) en reposo; 3) Fascie del paciente en reposo y en movimiento; 4) EVV retrospectiva; 5) Número de analgésicos adicionales; 6) Aceptabilidad al método. Las evaluaciones se hicieron a las 2, 4, 6, 12, 24, 36, 48 horas de iniciado el esquema, consignándose además: FR, PA, FC, presencia de náuseas, vómitos, retención urinaria, prurito y grado de sedación. Se controló gases en sangre arterial a las 2, 12 y 24 horas. Se hizo ANOVA + t-Test o Chi cuadrado, según correspondía. Todos los grupos fueron comparables. Hubo mejor analgesia en los grupos II, III y IV, habiendo diferencia significativa para el grupo II. Todos lod grupos requirieron analgésicos adicionales, siendo el promedio menor en el grupo II. No hubo diferencia intergrupo en cuanto a náuseas, vómitos y retención urinaria. La aceptabilidad al método fue buena. La PaO2 fue similar en todos los grupos. No hubo retención de CO2 en ningún grupo, siendo la PaCO2 significativamente menor en el grupo I. Hubo alivio del dolor con los 5 esquemas utilizados, siendo mejor el esquema II. Tuvimos buena aceptación al método y no hubo complicaciones inherentes a él