Hiperplasia nodular regenerativa del hígado secundaria a uso de azatioprina por trasplante renal previo, tratado con trasplante combinado hepático y renal / Combined hepatic and renal transplant after nodular regenerative hyperplasia of the liver secondary to azathioprine in renal transplant patient

Nodular regenerative hyperplasia is an uncommon condition, characterized by the presence of regenerative nodules with minimal or absence of fibrosis, which can lead to non-cirrhotic portal hypertension. There are numerous diseases, conditions and drugs that can cause it. Thiopurines, a group of immunosuppressors used in transplanted patients, has been linked to this entity. We report a case of a renal transplant woman, who has been on chronic therapy with azathioprine and that develops portal hypertension and end-stage renal disease, undergoing combined hepatic and renal transplant. Histological examination of the explanted liver was compatible with nodular regenerative hyperplasia. How azathioprine causes this entity is unknown, but endothelial vascular damage in a dose-dependent manner is postulated as the main mechanism. To our knowledge, this is the first case report of a renal transplant patient who develops nodular regenerative hyperplasia of the liver in association with azathioprine, and undergoes combined hepatic and renal transplant, with a favorable outcome 5 years post procedure.

La hiperplasia nodular regenerativa es una entidad infrecuente, que se caracteriza por la presencia de nódulos hepáticos con ausencia o mínima fibrosis y que puede llevar a hipertensión portal de origen no cirrótico. Existen diversas enfermedades, condiciones y medicamentos que la causan, destacando entre estos últimos las tiopurinas, inmunosupresores utilizados habitualmente en trasplantados. Se presenta el caso de una paciente trasplantada renal usuaria crónica de azatioprina, que desarrolla hipertensión portal además de deterioro de la función renal, requiriendo de un doble trasplante hepático y renal, destacando en la biopsia del explante hallazgos histológicos compatibles con hiperplasia nodular regenerativa. Los mecanismos de daño por azatioprina en esta entidad son desconocidos, pero se postula al daño endotelial dosis-dependiente como principal causa. La revisión de la literatura demuestra que este caso corresponde al primero de hiperplasia nodular regenerativa secundaria a azatioprina en trasplantado renal, que requiere de doble trasplante hepático y renal con evolución favorable hasta 5 años post trasplante.

Caracterización del nivel de dependencia al alcohol entre habitantes de la Ciudad de México

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Summary: The dynamic and scope of the consumption of alcoholic beverages, in Mexico, have been known by household surveys, since the last third of the last century. Nowadays those surveys describe alcohol use as one of the main public health tasks nationwide, due not only to its consequences but also to the damage on the different areas of individual's everyday life. A number of indicators have been highlighted by the first survey on 1988, such as teetotalism rates, the alcohol consumers proportion, age of first use, and problems associated with alcohol consumption. As a public health problem, alcohol consumption represents high costs to health institutions because of the problems related to the consumption. So, it requires undertaking certain actions that would be deal with this problem on primary and structural attention, as well as in the individual susceptibility as prevention, or attention levels, diagnosis and treatment. All actions to face this problem are practically impossible in the absence of instruments to establish differential diagnosis between heavy drinking and alcohol dependence. Along the study of alcoholism, have been distinguished two issues to establish differential diagnosis. First is a traditional version of dependence diagnosis by DSM criterions, defined as disadaptative pattern of alcohol consumption that produces significant malaise, expressed trough one year long. The second diagnosis issue quantifies the individual differences of physical, psychological and social damage degrees, caused by the alcohol consumption. From this, appears the motion of Multiple Alcoholism Syndrome. From this last point of view, The Alcohol Use Inventary by Skinner, Horn and Wanberg (1983), is compose by 147 items self administrated, clusted in 24 scales. Time latter, as of many researches done by this research group, aroused The Multiple-syndrome Alcohol Model as The Alcohol Use Inventary simplified version, used as a useful differential diagnosis questionnaire in alcoholics. There for, last version has been done many researches that agree on characterize the alcohol use inventory as screening questionnaire useful to detect problematic drinking to implement primary intervention. Those authors suggest the use of this questionnaire at different stages and populations, with different cut points. Antecedent's use of the questionnaire in Mexico, by Ayala et al., made the adapted version, however, researches seems to be not enough to know the validity of diagnostic instruments on ethanol dependence. The Alcohol Dependence Scale (ADS) consider the dependence as a continuum of four levels, depending on the damage degree associated with alcohol consumption, on the different areas of physical, intellectual, social and psychiatric functioning. In the questionnaire 1 is the minimum cut point for dependence diagnostic and 48 as the highest point, this rank lets differentiate with respect to low dependence, moderate dependence, substantial dependence and severe dependence. This article pretends to diffuse the EDS's validity on inhabitants in Mexico City. As methodology, a case design and 1:1 paired controls were used by age and marital status. Through a not intentioned sampling by quotas were selected 240 men of 18 to 50 years old. The cases group was integrated by 120 individuals that voluntarily sought treatment at the Center of Assistance for the Alcoholic and Relatives (CAAF) from June, 1998 to June, 2000. All cases comply with DSM-IV alcohol dependence criterion; they reported the last consumption at one month before the beginning of the research and with basic school as scholar level. In the control group were 120 volunteers that request treatment to CAAF from June, 1998 to June, 2000. They did not comply with alcohol dependence criterion. As gold standard, was considered the DSM-IV criteria to sensibility, specificity and predictive values; the factorial structure and internal consistency of the scale are indicated. Socio-demographic data indicated 34 years old as sample average, just over the half had a partner at the time of the study; the predominant education level was secondary school (35%). In the cases the 86% covered 6 to 7 criteria for ethanol dependence in the DSM-IV; the predominant dependence level was moderate at 37%, while 53% of the control group had no evidence of dependence. The heterogeneity test showed significant statistics differences on dependence levels in cases and controls (t=23, df=238 and p=0.00). The ADS displays overall internal consistency of 0.96, based on the Cronbach Reliability Coefficient, a higher level of consistency than that reported in previous studies. With a factorial analysis by varimax rotation and maximum likelihood extraction, revealed the presence of three factors with 56.5% of variance explained: intoxication (48.3%), abstinence (5.6%) and delirium tremens. In the application manual, the authors specify 13/14 as values to use the DAS as a diagnosis questionnaire, and 9 for a screening instrument. While other authors suggest less cut points 13/14 to 2/3 to reduce the false-negative; however, on Mexico City inhabitants, such cut points were inappropriate. The most suitable cut point to detect a significant dependence on clinical was at 8 points, with 96% sensitivity, 98% specificity and a 94% likelihood of making correct diagnoses. These findings show that DAS is a suitable screening instrument for using on Mexico City inhabitants. We suggest including items to evaluate social area or any other scale to complement the ADS.

Preparacion de los reactivos para la determinacion de amonio plasmatico usando una resina de intercambio ionico. / Preparation of reagents for determination of plasma ammonium using ion exchange resins

Se prepararon los reactivos para la determinacion de amoniaco plasmatico. La resina empleada es una resina cationica fuertemente acida (amberlita 252 de la casa Rohm and Haas) y como reaccion de color se empleo la reaccion de Berthelot. Se correlacionaron los de una casa comercial obteniendose una correlacion de 0,93 con una recuperacion de 97, 104, 76 por ciento para valores bajos, intermedios y altos respectivamente y cumpliendose la ley de Beer y Lambert en nuestras condiciones de trabajo hasta 400 microgramas por cien mililitros

Sistema subregional de adiestramiento como mecanismo para satisfacer necesidades intitucionales de capacitacion. / The subregional training system as a means of meeting institutional training needs

El documento presenta los antecedentes que originaron creacion del Comite de Gerentes y Directores de las Instituciones de Agua Potable y Saneamiento de Centro America y Panama, asi como informacion sobre su composicion, responsabilidades y mecanismos de operacion. Describe como se definieron las necesidades y prioridades en este campo y la formulacion de un sistema de capacitacion de personal tecnico no profesional. Da cuenta de las negociaciones entabladas con organismos nacionales e internacionales para obtener apoyo financiero para el proyecto de adiestramiento correspondiente, cuyo objetivo final es establecer unidades de adiestramiento de deteccion de fugas de agua en los siete paises del area centroamericana y en la Republica Dominicana y capacitar en 19 meses 630 tecnicos mediante cursos a dictarse en dichos paises. Asimismo, se ofrece informacion sobre la planificacion estrategica, gerencial y operacional del proyecto y se incluye un esquema funcional y el mecanismo de evaluacion de las actividades del mismo