Estatinas en enfermedad renal crónica / Statins in chronic kidney disease

La enfermedad renal crónica constituye una patología de prevalencia e impacto creciente en la población mundial por sus múltiples complicaciones, incluyendo un riesgo cardiovascular aumentado, que representa la principal causa de morbimortalidad en pacientes nefrópatas crónicos. Sin embargo, la relevancia de las dislipidemias, especialmente, la hipercolesterolemia LDL, en el deterioro de la función renal y desarrollo de ateroesclerosis en sujetos con daño renal crónico no ha sido claramente establecida. Esta situación ha generado controversia sobre el beneficio real del uso de hipolipemiantes en estos pacientes. En base a la evidencia disponible, incluyendo estudios clínicos recientes, la recomendación más apropiada sugiere que el uso de terapia hipolipemiante basada en estatinas (con o sin ezetimiba) es beneficioso desde un punto de vista cardiovascular en nefrópatas crónicos con insuficiencia renal leve a moderada antes de la diálisis. Por otro lado, no existe evidencia definitiva para apoyar el uso rutinario de este tipo de hipolipemiantes en el manejo del deterioro de la filtración glomerular y/o la proteinuria. Basándose en la evidencia analizada en esta revisión, las futuras guías clínicas para el manejo del daño renal crónico deberán incorporar el uso de estatinas y/o ezetimiba como un elemento más dentro del armamento terapéutico de este tipo de pacientes.(AU)

Chronic kidney disease is a condition of increasing prevalence and impact on the world population by its many complications, including increased cardiovascular risk that represents the leading cause of morbidity and mortality in chronic nephropathy patients. However, the relevance of dyslipidemia, especially high LDL cholesterol, in the impairment of renal function and development of atherosclerosis in subjects with chronic kidney disease has not been clearly established. This situation has generated controversy regarding the real benefit of use of lipid-lowering therapy in these patients. Based on available evidence, including recent clinical studies, the most appropriate recommendation suggests that the use of lipid-lowering therapy based on statins (with or without ezetimibe) is beneficial from a cardiovascular standpoint in chronic nephropathy with mild to moderate renal failure before dialysis. On the other hand, there is no definitive evidence to support the routine use of lipid lowering drugs in the management of impaired glomerular filtration and/or proteinuria. Based on the evidence discussed in this review, future clinical guidelines for management of chronic renal damage should incorporate the use of statins and/or ezetimibe as a key element in the therapeutic armamentarium to be applied in these patients.(AU)

La biblioteca actual en la educación médica: un rol en evolución / The current library in medical education: an evolving role

Las bibliotecas biomédicas han mostrado una evolución acelerada en las últimas décadas, aparejadas al desarrollo tecnológico por una parte y a la velocidad acelerada del desarrollo del conocimiento, por otra. Los niveles de organización de la información han superado los textos en formato de libro y artículo y se han generado bases de datos, que han permitido una organización y presentación del conocimiento en forma distinta. Por otra parte, la portabilidad de la información ha transformado a las bibliotecas en estructuras más parecidas a redes neurales que a extensiones del aula de clases. Estos avances determinan, y lo harán más aun en el futuro, cambios sustantivos en los procesos de enseñanza-aprendizaje en medicina, con alumnos que se encuentran en la práctica rodeados de un aura informática que les acompaña en su quehacer cotidiano, haciendo más eficientes las tomas de decisiones e idealmente, disminuyendo los errores.(AU)

Medical libraries have quickly evolved in the last decades associated with technological progress on one side and the continuing rapid advance in knowledge on the other. The levels of information management have moved beyond simple textbooks and papers into databases, which have allowed us to organize and communicate knowledge in different ways. On the other hand, data mobility have made libraries evolve into structures comparable to neural networks more than extensions of our old classrooms. All this improvements have produced ­and they will accomplish much more in the future- important changes within teaching-learning processes in Medicine. Medical students are now surrounded by digital fields that are constantly available during their daily tasks, improving their clinical decisions and hopefully reducing errors (AU)

Desensibilización rápida en pacientes con hipersensibilidad a aspirina sometidos a angioplastía coronaria: Reporte de cuatro casos / Rapid aspirin desensitization in patients with a history of aspirin hypersensitivity requiring coronary angioplasty: Report of four cases

Background: Aspirin use is necessary after a coronary angioplasty. It should not be used in patients with a history of hypersensitivity. However, rapid desensitization protocols have been reported to allow its use in such patients. One of these protocols consists in the administration of progressive doses of aspirin, from 1 to 100 mg in a period of 5.5 hours, in a controlled environment. We report four male patients aged 45,49, 59 and 73 years with a history of aspirin hypersensitivity, who were subjected to a coronary angioplasty. In all, the rapid aspirin desensitization protocol was successfully applied, allowing the use of the drug after the intervention without problems.

Lipoprotein [a] is a feature of the presence, diffuseness, and severity of coronary artery disease in Saudi population

To study lipoprotein[a] [Lp[a]] levels in Saudi patients with angiographically defined coronary artery disease and to see its relationship with its severity and diffuseness. This cross sectional study was carried out at King Khalid University Hospital, Riyadh, Saudi Arabia in 2006-2007. One hundred and forty-seven individuals with coronary artery disease [CAD] and 49 healthy individuals matched for age and body mass index were studied. Among CAD patients, 133 underwent angiography. Blood samples were analyzed for total cholesterol [TC], triglycerides [TG], low density lipoprotein [LDL] and high density lipoprotein [HDL] and Lp[a]. Coronary artery disease patients had higher Lp[a] levels than controls [25.78 +/- 25.09mg/dl versus 14.57 +/- 11.81 mg/dl, p=0.0030]. Patients without stenosis [10.97 +/- 8.06mg/dl] and one vessel involvement [19.67 +/- 17.33mg/dl] had significantly lower levels of Lp[a] compared to double [31.88 +/- 32.17mg/dl] and triple [29.70 +/- 28.12mg/dl] vessel disease. Lipoprotein[a] levels correlated significantly with coronary vessel score [r = 0.234, p = 0.033] and Gensini score [r = 0.256, p = 0.02]. Smoking [odds ratio [OR]: 1.86; 95% confidence interval [CI]: 1.020-2.510; p=0.04], TG levels [OR: 2.04; 95% CI: 1.251-4.932; p = 0.03] and Lp[a] levels [OR: 1.56; 95% CI: 1.033-3.687; p = 0.025] significantly predicted CAD severity. High risk levels of Lp[a] >/= 30 mg/dL were present in 66.7% of CAD patients. Lipoprotein[a] levels are significantly higher in Saudi patients with CAD compared to healthy individuals, and are associated with more severe and diffuse blockage of the coronary vessels

Oral contraceptives in gall stone diseases.

A cross sectional study was under taken to evaluate the prevalence of gallstone in fertile women who are taking oral contraceptives. The aim of study was to determine any significant association between oral contractive use and Cholelithiasis. Total number of patient was 340. A standard written questioner, which is dully filled by concerned doctor and examination done. History of use of oral contraceptive pills, duration of use and time of taking oral contraceptives drugs whether before, in between pregnancy or after family completion is recorded. Total number of patient was 340 of them 186 patient taken contraceptives and 154 patients without contraceptives. Incidence of gallstone shows that with contraceptives the 21-30 years age group 72(39.13%) without contraceptives 22(14.28%), in 31-40 years age group with contraceptives 74 (40%), without contraceptives 28(18.8%) where as in 41-50 years age group with contraceptives 37(20.10%) and without contraceptives 44(28.57%), 51 years and above age group with contraceptives is 01(0.54%) and without contraceptives is 60(38.96%). Significantly higher incidence of gallstones found in younger patient taking oral contraceptives than without contraceptives, but in older age group incidence is more in-patients without contraceptives than with contraceptives. Oral contraceptives increase the incidence of gallstones disease in younger women especially in early part of their use of oral contraceptives.

Utilidad de isosorbide sublingual en la reversibilidad de la hipertensión pulmonar reactiva, en pacientes candidatos a trasplante cardíaco / Usefulness of sublingual isosorbide to assess the reversibility of pulmonary hypertension in cardiac transplant candidates

Background: Continuous infusion of short life vasodilators are employed to test reversibility of pulmonary hypertension in cardiac transplant candidates. Sublingual isosorbide administration has not been described in the literature and it might be a simpler alternative. Aim: To evaluate sublingual isosorbide administration as a test of reversibility of pulmonary hypertension in heart failure. Patients and Methods: Prospective evaluation of patients referred for cardiac transplant evaluation. Patients underwent right catheterization for hemodynamic measurements at baseline and after repeated doses of 5 mg sublingual isosorbide every 5 minutes until observing a decrease in pulmonary vascular resistance decrease or symptomatic hypotension. Results: Twenty one patients, 18 men, age 49±15 years, were studied. Fourteen (66%) were transplanted. The mean sublingual isosorbide dose was 15±5 mg. After isosorbide administration, there was a significant decrease in mean arterial pressure (80±8.5 to 71±6.6 mmHg, p <0.0001), mean pulmonary artery pressure (38±11 to 26±7.8 mmHg, p <0.0001), systemic vascular resistance (1540±376 to 1277±332 dyn*s/cm5 p <0.001), pulmonary vascular resistance (3.5±2.2 to 2,5±1.6 Wood Units, p <0.05) and transpulmonary gradient (13±7 a 10±4 mmHg, p <0.004). The cardiac output increased from 3.96±0.7 to 4.38±0.9 L/min, p=0.05. The relation between pulmonary and systemic vascular resistance before and after isosorbide was 0.17 and 0.15, respectively (p=0.04). One transplanted patient with partial reversibility of pulmonary hypertension developed acute right heart failure. Conclusions: Sublingual isosorbide administration is useful and well tolerated to evaluate the reversibility of pulmonary hypertension prior cardiac transplant.

Streptococcal antibodies among rural school children in Bangladesh.

The upper limit of normal values of group A streptococcal antibodies should be known for a population concerned because it is influenced by many local conditions. As yet the reference value of the these antibodies has not been determined by using a quantitative method among Bangladeshi children. We determined the reference value of anti-streptolysin O and anti-deoxyribonuclease B among 361 apparently healthy rural Bangladeshi primary school children (aged 5 to 14 years, mean 9.2 years). Anti-streptolysin O was measured by an auto-analyzer and antideoxyribonuclease B was measured by microtitre method. The geometric mean titres for the entire group was 241 IU/ml and 222 IU/ml for anti-streptolysin O and anti-deoxyribonuclease B respectively. The upper limit of normal values (80th percentile) was 390 and 340 for anti-streptolysin O and anti-deoxyribonuclease B, respectively. These limits should be of value to physicians, epidemiologists and clinical laboratory personnel as well.

Monitoring efficacy of commonly used antimalarials by a 14-day in-vivo test in a new settler's camp in endemic zone at Cox's Bazar.

The study was done in a new settler's camp "Barachara" under Sadar thana of Cox's Bazar district. It has a total population of 784 of all age groups, registered in the middle of the study period. A prospective evaluation of all cases of fever were done over 12 months, to see the pattern of febrile illness among the population and to compare the therapeutic efficacy of two alternative drug regimens for uncomplicated falciparum malaria (UM). Blood for malarial parasite (MP) was done in all cases of fever and was treated in line with the new clinical case definitions and treatment guidelines for malaria in Bangladesh. Slide positive UM cases were subjected to a "14-day in-vivo test" for therapeutic efficacy testing of antimalarial agents. The two drug regimens were randomised by lottery--a) 3 days oral chloroquine plus single dose sulphadoxin/pyrimethamine (CQ + SP) and, b) 3 days oral quinine plus single dose sulphadoxin/pyrimethamine (Q3 + SP). Drug administration was supervised by the field assistant and was followed up on days 3, 7 and 14 for blood slide examinations and clinical assessment. Sensitive response was observed in 79% of the cases in the CQ + SP group and 84% in the Q3 + SP group. Early treatment failure (persistently febrile and parasitaemic on days 3 or 7) was observed in 16% in the CQ + SP group and 9% in the Q3 + SP group. Both the evaluated drug regimens had less than 20% failures and can be used as alternative first line agents and Q3 + SP regimens can also be used as the second line agents for treatment failure (to chloroquine and/or SP) UM cases in the study area.

Epidemiological study of endemic cretinism in a hyperendemic area.

A cross sectional survey was carried out to detect prevalence of cretinism in two rural areas of Bangladesh (one hyperendemic and the other non-endemic area). The size of the study population was four thousand five hundred and nine, the age ranged from 2 to 45 years. The prevalence of cretinism was 0.6% in the hyperendemic area, while there were no case of cretinism in the non-endemic zone. Of the 27 cretins, 18 (67%) were of the neurological type and 9 (33%) of mixed type. Males were more likely to be affected than females (p < 0.05). Cretinism was more prevalent in the 2-9 years age group. The hyperendemic area was deficient of iodine in food and the cretins were underweight. These observations call for a need for coordinated public health actions to control this serious problem.

Respuesta cardiovascular al ejercicio a gran altura en trabajadores crónicamente expuestos a hipoxia hipobárica intermitente / Cardiovascular response to exercise at high altitude in chronically exposured workers to intermittent hypobaric hypoxia

The isottonic work perfomance was assessed in 34 workers aged 35 ñ 5.8 years old that had working of four days at 4500 m over the sea level and resting periods of other four days at the sea level during at least two years. Subjects were assessed in one occasion at the sea level, and at the first and fourth day of the working shift at 4500 m over the sea level. resting arterial oxygen saturation in theses three periods was 97 ñ 1.1, 88 ñ 18 and 91 ñ 1.1 percent respectively (p<0.01) and markedly decreased during maximal and submaximal exercise at 4500 m over sea level. Evercise duration in the three periods was 931 ñ 210, 775 ñ 105 and 778 ñ 105 seg respectively (p<0.001). Heart rate in the resting period was at least 10 percent higher and maximal and submaxilmal rates were lower at the high altitude. No differences in blood pressure or packed red cell volume were observed. Exercise duration correlated inversely with age (r=-0.49 p=0.03) and directly with maximal heart rate (r=0.44 p=0.009) at the sea level. No correlation between aerobic capacity and other measured parameters was observed. These results show no differences in the cardiovascular response to exercise between the first and fourth day of stay at high altitude in workers chronically exposed to intermittent hypobaric hypoxia

Mielodisplasias: experiencia clínica en 35 pacientes / Myelodysplasia: an analysis of 35 patients

Myelodysplasia, characterized by varied reductions of peripheral blood elements with normal or hypercellular bone marrow, is reltively frequent among older patients and may evolve to acute leukemia. We reviewed findings in 35 patients whon, according to the FAB classification were distributed as follows: simple refractory anemia (RA) 34%, sideroblastic refractory anemia (SRA) 14%, refractory anemia with excess blast forms (RAEB) 31%, chromic myelomonocytic leukemia (CMML) 12% and refractory anemia eith excess blast forms in transformation (RAEBT 9%). Cytogenetic studies performed in 16 patients were abnormal in 5(31%), al among patients with poor prognosis forms of the disorder. All patients had anemia; thrombopenia and neutropenia were more frequent in subtypes RAEB, CMML and RAEBT). Mean survival rate was 30 months, significantly greater in RA and SRA comapred to the other groups. Infections and development of acute leukemia were the causes of death

Taponamiento cardíaco hemorrágico sin rotura cardíaca en el curso de infarto del miocardio: caso clínico / Hemorrhagic cardiac tamponade without cardiac rupture during an evolving myocardial infarction: case report

Cardiac tamponade during acute myicardial infarction is a lif threatening complication that can be confounded with right ventricular infarction. The most frequent cause of this complication is cardiac rupture. We report here a patient with acute myocardial infarction that developed cardiac tamponade on day 7, after receiving late systemic thrombolysis. The diagnosis was suspected with echocardiography and confirmed with hemodynamic measurements. The tamponade was partially relieved with pericardiocentesis but afterwards required emergency surgery. No cardiac rupture was found but an hemorragic infarction. We conclude that in this case the hemorragic tamponade was probably related both to late thrombolysis and to post infarction pericarditis

Remodelamiento miocárdico post infarto del miocardio: desde los datos experimentales a la prevención de insuficiencia cardíaca / Myocardial remodeling post myocardial infarction: from experimental data to prevention of heart failure

Structural and biochemical modifications of the myocardium (remodeling) occur after acute myocardial infarction. An important part of this process of myocardial remodeling takes place in the intersticial compartment which is comjposed mainly of fibrillar collagen. These remodeling changes are associated with modifications in left ventricular geometry and function that could be deletereous and have significant clinical manifestations. Some salutatory effects of the treatment are related to modifications of the process of intersticial remodeling. Clinical studies with calcium channel antagonists, nitrtes and, specially converting enzyme inhibitors have shown significant in the degree of ventricular dilation, hemodynamics and exercise tolerance as a comapred to palcebo treated patients. Ongoing clinical studies will provide us with more definite information on the effects of converting enzyme inhibitors on long term prongnosis as vell as on myocardial remodeling after acute myocardial infarction

Comparación de los efectos clínicos y neurohumorales de Milrinona y Captopril en pacientes con insuficiencia cardíaca crónica / Clinical and neuroendocrine response of Milrinone vs. Captopril in heart failure

En el presente estudio hemos comparado los efectos de Milrinona (M), un nuevo fármaco inótropo, positivo con un inhibidor de enzima convertidora, Captopril (C), en la condición clínica y respuesta adrenérgica al esfuerzo físico leve en pacientes con insuficiencia cardíaca congestiva (ICC) en CF III. El estudio randomizado, cruzado y doble ciego evaluó los efectos de M, 10 mg c/6 hr. o C 50 mg c/8 hr. durante 9 semanas, comparados con placebo, en 16 pacientes con ICC (6 de causa isquéemica, 10 por miocardiopatíia dilatada), que recibían digital y diuréticos. Se determinó un score clínico (SC), que incluía síntomas, examen físico y Rx. tórax, (rango 0-14), la fracción de eyección radio isotópica (FE) y la actividad de renina plasmática (ARP). La noradrenalina plasmática (NAD) se midió en reposo (r) y a iguales niveles de esfuerzo físico leve (e) (6 min. Naughton, VO2 8-9 ml/kg/min.). El score clínico mejoró en forma significativa y similar por efectos de ambas drogas (5.2+-0.4 a 4.4+-0.5, 4.1+-0.4 respectivamente, p<0.01). Lo mismo ocurrió con la fracción de eyección de VI que aumentó de 23.6+-2.6% por efecto de milrinona y a 28.6+-3.2% por efecto de captopril, (p<0.01). La respuesta neurohumoral fue diferente ya que no hubo modificaciones de la ARP o NAD en reposo y esfuerzo por efecto de Milrinona. La ARP aumentó (1.6+-0.5 a 5.3+-1.5 ng/ml/hr y la NAD en esfuerzo disminuyó (1228+-158 a 820+-100 pg/ml) por efecto de Captopril (p<0.01). La elevación de ARP y la menor respuesta adrenégica al esfuerzo físico observada con C confirma un diferente efecto humoral con respecto de M e indican que favorece una mejor adaptación al esfuerzo físico en pts. con ICC

Further study on the effect of norethisterone enanthate, an injectable contraceptive on body functions.

One hundred and fortythree healthy Bengali women have received norethisterone enanthate, as injectable contraceptive in doses of 200 mg. intramuscularly at intervals of 10 to 12 weeks. The drug have been found to be almost 100 percent effective in the control of fertility. Menstrual disturbance, e.g. amenorrhoea, irregular bleeding and spotting, appeared to be the main complaints of the clients during the initial period of the therapy; but these did not persist long. There was no ill effect of the drug on lactation. No significant change in body weight, blood pressure, platelet count, fasting blood sugar, serum cholesterol and total plasma protein level was observed following administration of norethisterone enanthate over one year.