Síndrome de hipersecreción de lipasa y lesiones óseas en el cáncer de células acinares del páncreas / Lipase hypersecretion syndrome and bone lesions in acinar cell cancer of the pancreas. Report of one case

Lipase hypersecretion syndrome (LHS) is a rare paraneoplastic syndrome, associated with acinar cell carcinoma of the pancreas (ACCP) in 10% to 15% of patients. Clinically, LHS manifests itself with the appearance of subcutaneous fibrocystic nodules, associated with trophic changes in the overlying skin, such as ulcers or fistulas that are difficult to manage, mainly affecting the lower extremities. Additionally, lipolysis near the joints and in the intraosseous adipose tissue can cause bilateral arthralgias, especially of the knees and ankles. We report a 57-year-old man, with a history of insulin resistance and allergic rhinitis, who presented in June 2019 with multiple subcutaneous nodules in the lower extremities, predominantly in both ankles, associated with arthralgia in that region. Additionally, a CT scan of the abdomen revealed a significant abdominal mass, measuring approximately 17 cm and in contact with the body and tail of the pancreas, pathologically compatible with an ACCP. Treatment with capecitabine was started with a favorable progression. The patient currently presents a small left lateral retro malleolar fistula, which, given the analyzes, studies and reviewed literature is concluded to be a lesion in the context of LHS.

Reproducción asistida en Chile: una mirada global para el desafío de ofrecer un acceso oportuno / Assisted Reproduction in Chile: a global overview of the challenge of providing an opportune access

En el año 2018 se conmemoraron 40 años desde el primer resultado exitoso producto de una fertilización in vitro (FIV), el nacimiento de Louise Brown en Inglaterra. Se estima que a la fecha han nacido más de 8 millones de seres humanos gracias a las tecnologías de reproducción asistida (TRA), técnicas que están en constante avance y desarrollo. Sin embargo, a pesar de ser cada vez más relevantes como tratamiento de la infertilidad, su acceso todavía es muy limitado y poco equitativo, alcanzando menos del 15% de la población a nivel global. En esta revisión analizamos los aspectos epidemiológicos de la infertilidad y exponemos el contraste entre la necesidad teórica de TRA y los ciclos realizados a nivel mundial, reflejando el bajo acceso a los tratamientos. Se enfatiza la realidad latinoamericana y con especial detalle la chilena, explorando tanto su dimensión histórica como actual, perfilando los desafíos que como país deberemos enfrentar en los próximos años.

The 40-year anniversary of the first in vitro fertilization (IVF) newborn, Louise Brown in England, was celebrated in 2018. To date, over 8 million children have been born with assisted reproductive technologies (ART), a group of techniques in continuous development. Despite the increasing relevance of such technologies as treatments for infertility, the access to ART has been limited to less than 15% of the world population.In this review, we analyze the epidemiological aspects of infertility and present the contrast between the theoretical demand and the actual number of ART cycles performed worldwide, reflecting the low access to infertility treatments. We put emphasis on the Latin American historic and current context, then provide more details on the Chilean reality, and finally outline the challenges Chile will face in the future regarding access to ART.

A retenção da cápsula endoscópica e suas situações de risco: análise em 215 exames consecutivos e revisão das condutas de prevenção e tratamento / The retention of the endoscopic capsule and its risk situations: analysis in 215 consecutive exams and review of the prevention and treatment conduits

Introdução: lesões estenosantes do intestino delgado (ID), e suas neoplasias em especial, são patologias de difícil diagnóstico. A Cápsula Endoscópica (CE) representou notável avanço no reconhecimento das mesmas. Porém a retenção da CE nestas lesões estenosantes representa risco potencial que deve sempre ser evitado. Objetivo: efetuar uma revisão dos aspectos preventivos das situações em que a CE pode vir a ficar retida, das condutas terapêuticas quando a retenção ocorre e, principalmente, analisar, numa sequência de 215 exames com a CE, quais as situações que representaram risco de retenção e quais aquelas em que realmente houve a retenção. Casuística: 215 exames endoscópicos consecutivos do delgado com a cápsula foram objetos de análise. Material e Métodos: endoscopia digestiva alta (EDA) e colonoscopia (CO) foram os exames que todos os 215 pacientes efetuaram antes de se submeterem ao exame da CE. Diversas foram as indicações dos exames com a CE, mas 85% deles foram indicados por hemorragia digestiva de causa obscura (sangramento digestivo com EDA e CO negativas) ou anemia de causa a investigar. Nenhum paciente apresentava queixas ou sinais de suboclusão antes de efetuar o exame. A CE utilizada em todos os pacientes foi da marca GIVEN (Yokenan, Israel), modelos M2A e PillCam SB. Foi considerada retida a CE que, após três semanas da realização do exame, não havia sido eliminada, e exame radiológico comprovava sua presença no intestino delgado. Resultados: 141 lesões foram identificadas nestes 215 exames com a CE, sendo 112 delas no intestino delgado e 29 fora do delgado. Em 26,6% (37 casos) dos 112 casos com lesões no delgado, havia alterações que promoviam algum grau de estreitamento da luz do delgado, a saber: 10 casos de neoplasia maligna (3 linfomas, 2 adenocarcinomas, 2 casos de metástases de melanoma, 2 casos de tumor carcinoide e 1 tumor estromal ­ GIST), 8 casos de Doença de Crohn, 4 casos de úlcera/estenose por uso de AINES, 1 caso de enterite actínica e 14 casos de pólipos do delgado de diâmetro suficiente para promover algum grau de estreitamento luminar. Nestes 38 casos, em 5 deles (13,4%) a CE ficou retida: 2 casos de Doença de Crohn, 2 casos de estenose e úlcera por uso de AINES e 1 caso de enterite actínica. Conclusões: estreitamento do lúmen do intestino delgado pode ter diversas causas, algumas reversíveis outras não, algumas progressivas, outras estáveis, e muitas delas, dependendo de sua causa e de seu grau, podem promover a retenção da CE. As causas de retenção observadas nesta casuística vão ao encontro com as principais causas de retenção apresentadas na literatura e destaca-se o fato de que, dos 10 casos de neoplasia, em nenhum deles a CE ficou retida.

Introduction: stenosing Injury of small intestine (ID), and their tumors in particular, are difficult to diagnose diseases. Endoscopic capsule (EC) represented notable advance in the recognition of same. However the EC in these stenosing lesions represents a potential risk that should always be avoided. Objective: to carry out a review of the preventive aspects of the situations where the EC could be retained, the therapeutical when retention occurs, and, mainly, to analyze, in a sequence of 215 cases with the EC, which the situations that represented retention risk and what those in which really happened to retention. Series: endoscopic examinations of 215 consecutive exams with the capsule were objects of analysis. Material and methods: upper gastrointestinal Endoscopy (UGE) and colonoscopy (CO) were the tests that all 215 patients effected before undergoing the examination. Several were the indications of the exam with the EC, but 85% of them were nominated by obscure cause gastrointestinal bleeding (digestive bleeding with UGE and CO negative) or to investigate cause anemia. No patient presented complaints or sub-oclusion signs before the exam. The EC used in all patients was of the mark GIVEN (Yokenan, Israel), M2A models and PillCam SB .Was considered retained the EC that, after three weeks of the completion of the examination, had not been eliminated, and radiological examination proved their presence in the small intestine. Results: 141 lesions were identified in these exams with 215 EC, 112 of them in the small intestine and 29 out of small intestine. In 26.6% (37 cases) of 112 cases with injuries in small intestine, there were changes that were promoting some degree of narrowing of the light of small intestine, namely: 10 cases of malignant neoplasm (3 adenocarcinomas , 2 lymphomas, 2 cases of metastasis of melanoma, 2 cases of carcinoid tumor and 1 stromal tumor-GIST), 8 cases of Crohn's disease, 4 cases of ulcer/stenosis by use of NSAIDS, 1 case of Actinic enteritis and 14 cases of polyps of small intestine of a suitable diameter to promote some degree of narrowing luminary. In these 38 cases, in 5 of them (13.4%) the EC was retained: 2 cases of Crohn's disease, 2 cases of stenosis and ulcers by use of NSAIDS and 1 case of Actinic enteritis. Conclusions: Narrowing of the lumen of the small intestine can have several causes, some not, some other reversible progressive other stable, and many of them, depending on their cause and their degree, can promote EC retention. The causes of observed retention in this series meet with the main causes of retention presented in the literature and highlights the fact that the 10 cases of neoplasia, in none of them the EC was retained.

Impact of autologous blood transfusion on the use of pack of red blood cells in coronary artery bypass grafting surgery / Impacto da transfusão autóloga no uso de concentrado de hemácias em cirurgias de revascularização do miocárdio

OBJECTIVE: To evaluate the impact of Cell Saver autologous blood transfusion system (CS) on the use of packed red blood cells (pRBC) in coronary artery bypass grafting (CABG) surgery. METHODS: We carried out a retrospective cross-sectional study in 87 patients undergoing primary elective CABG with miniaturized cardiopulmonary bypass (miniCPB), divided in two groups: 44 without-CS and 43 with-CS. We investigated the necessity of absolute use and the volume of packed red blood cells (pRBC) in each group, as well as cardiovascular risk factors, presurgical variables and intraoperative surgical parameters. All data were collected from medical records and there was no randomization or intervention on group selection. Statistical analysis was performed with Student t-test, Mann-Whitney U-test and χ² test, with a 5% significance level. RESULTS: There were no significant differences between the two groups in terms of cardiovascular risk factors and pre and intraoperative variables. Evaluating the absolute use of pRBC during surgery, there was a statistically significant difference (P=0.00008) between the groups without-CS (21/44 cases; 47.7%) and with-CS (4/43 cases; 9.3%). There was also a statistically significant difference (P=0.000117) in the volumes of pRBC between the groups without-CS (198.651258.65ml) and with-CS (35.061125.67ml). On the other hand, in the early postoperative period (up to 24h) there was no difference regarding either the absolute use or the volumes of pRBC between both studied groups. CONCLUSION: Autologous erythrocyte transfusion with CS use reduces the use of intraoperative homologous pRBC in coronary artery bypass grafting surgeries associated with miniCPB.

OBJETIVO: Avaliar o impacto do sistema de autotransfusão com hemoconcentração (SAH) no uso de concentrado de hemácias (CH) em cirurgias de revascularização do miocárdio (CRM). MÉTODOS: Foi desenvolvido um estudo transversal, que incluiu 87 pacientes submetidos a CRM eletiva primária com miniCEC, sendo 44 sem uso do SAH e 43 pacientes com uso do SAH. Foi investigada a necessidade de uso e o volume de CH em cada grupo, bem como fatores de risco cardiovascular, variáveis pré-operatórias e parâmetros cirúrgicos transoperatórios por meio de coleta de dados em prontuários. Não houve randomização ou intervenção na seleção dos grupos. Na análise estatística foram utilizados os testes t de Student, teste U de Mann-Whitney, teste do qui-quadrado, com um nível de significância de 5%. RESULTADOS: Em relação a fatores de risco cardiovascular e variáveis pré e transoperatórias, não houve diferença estatística significativa entre os dois grupos. Quando se avaliou o uso absoluto de CH no transoperatório, houve diferença estatística significativa (P=0,00008) entre os grupos sem-SAH (21/44 casos; 47,7%) e com-SAH (4/43 casos; 9,3%). Na análise dos volumes de CH utilizado no transoperatório, também houve diferença significativa (P=0,000117) entre os volumes utilizados no grupo sem-SAH (198,651258,65 ml) e com-SAH (35,061125,67 ml). Já no pós-operatório imediato (até 24 horas), não houve diferença tanto no uso absoluto como nos volumes de CH entre os grupos que usaram ou não o SAH. CONCLUSÃO: A autotransfusão de hemácias possibilitada pelo uso do SAH determina menor uso de CH homólogo no transoperatório de CRM com uso de miniCEC.

Enfermedades afectivas y actividad solar: Seguimiento a 16 años / Association between hospital admissions due to affective disorders and solar activity: Analysis of 16 years

Background: Exposure to solar activity may be associated with incidence of depressive and manic disorders. Aim: To assess the link between solar activity and appearance of affective disorders. Material and Methods: We examined 1862 clinical records of a psychiatric clinic located in Santiago, Chile. Patients with major depression and manic disorders were included in the study, only when they were admitted at the clinic for the first time. Solar activity was calculated using the Wolf number, which is given by the formula R= K(10g+f), where “g” stands for the groups of sunspots and “f ” is the total number of sunspots. We examined the correlation between annual incidence of hospital admissions and average Wolf numbers for the period 1990-2005, which corresponds to approximately one and half solar cycles of 16 years. Results: A total of 450 medical records corresponding to 299 patients (199 women) with depressive symptoms and 151 patients (73 women) with mania, were analyzed. There was a higher number of admissions for depression during the years with lower solar activity. Admissions due to mania tended to increase in the years with high solar activity. There was a negative correlation between the number of hospital admissions due to depression and solar activity (Spearman r =-0.812, p < 0.01). The association between the latter parameter and admissions due to mania did not reach statistical significance. Conclusions: There is a significant negative association between the rate of hospital admissions due to depressive disorders and solar activity.

¿Existen factores predictores de bipolaridad en población de alto riesgo para trastorno bipolar? / Are there foretelling factors of bipolarity in high risk population for bipolar disorder?

Whit the arrival of new treatments for the bipolar disorder, it seams fundamental to be able to diagnose in precious manner and thus avoid the long term consequences, improving the quality of life of the patients. Studies have become more and more frequent which show the phenomenology of the bipolar syndrome in infancy and adolescence, like strategies in treatment. Special populations constitute the children of bipolar parents: it is known that they have higher probabilities in developing the disorder. The objective of this revision is the investigation of the existence of possible early “markers” in children in high risk (children of bipolar parents), in order to identify cases even before the first symptoms. There are available a variety of evaluation instruments, complementary exams which support the diagnose, which are unspecific, that can be use as routine in monitoring, many of them are costly or require special training. It is still of vital importance to have a good anamnesis, giving a complete mental exam realizing family pedigrees which include affected members, used treatments and clinical response. It is important to recognize the prodomic symptoms of the disorder, more so when they are present in this group (bipolar descendants). There are also therapeutic considerations, since they often present problems of attention, hyperactivity and behavior in this group, not making a differential diagnosis, could lead to use of stimulants or antidepressives with the risk of triggering or worsening manic episodes.

Con el advenimiento de nuevos tratamientos para el trastorno bipolar, parece fundamental poder hacer el diagnóstico en forma precoz y así evitar las consecuencias largo plazo, mejorando la calidad de vida de los pacientes. Existen cada vez más estudios que apuntan a conocer la fenomenología del trastorno bipolar en la infancia y adolescencia, así como estrategias de tratamiento. Una población especial la constituyen los hijos de padres bipolares, ya que se sabe que ellos tienen más probabilidades de desarrollar la enfermedad. El objetivo de esta revisión es investigar sobre la existencia de posibles “marcadores” tempranos de bipolaridad en la prole de alto riesgo (hijos de padres bipolares), para lograr identificar tempranamente los casos, incluso previo a los primeros síntomas. Existen disponibles una variedad de instrumentos de evaluación, exámenes complementarios para apoyar al diagnóstico, que son inespecíficos que pudieran ser utilizados de rutina en el seguimiento, muchos de ellos de alto o que requieren de un entrenamiento especial. Sigue siendo importante obtener una buena anamnesis, realizar un examen mental completo, confeccionar pedigríes familiares que incluyan miembros afectados, tratamientos usados y respuesta clínica. Es importante reconocer los síntomas prodrómicos del trastorno, especialmente cuando están presentes en este grupo (prole bipolar). También existen consideraciones terapéuticas, ya que al presentarse frecuentemente problemas de atención hiperactividad o de conducta en este grupo, el no hacer un buen diagnóstico diferencial, puede llevar al uso de estimulantes o antidepresivos con el riesgo de gatillar o empeorar episodios maníacos.

Psicoeducación en el trastorno bipolar: rol del tutor / Psychoeducation in bipolar disorder: tutor role

The present report pretends to evaluate the impact of the application of a psychoeducation model in bipolar patients where the presence of a tutor in incorporated. The protocol consists in the abbreviated version of the bipolar syndrome program of the Clinic Hospital, Barcelona which considers eight sessions with a weekly frequency. Aleatorily, two groups where formed from the University Psychiatric Clinic of the University of Chile. In one group (group 1) the traditional program is applied in the other group (group II ) the tutor in incorporated to the sessions, and who participates during the whole process. Both groups were un by type I bipolar patients. Both the patients from group I and group II maintain eutimic scores at the end of the eight sessions. The application of the Moorfhead-Ardelt test in group I shows an average of + 0.479 which suggests that the group of subjects manifested a better impression of their actual state after the end of the session, while the subjects in group II (with tutor) showed an average of + 0.666 which signals a better appreciation of their state at the end of the sessions compared to group I. In regard to OQ-45.2, the group I showed favorable results, with six subjects from twelve with significant statistical scores ( p<0.05). en group II, four from nine subjects presented significant statistical scores for positive change at the end of the sessions, which in average is slightly superior to the group I scours. There were no significant statistical negative scores observed in either group. In the five month monitoring, the group with a tutor shoed a better evolution, seven out of nine patients were eutimic, while in the group without a tutor just five out twelve maintained in these clinical conditions, which signal a better functioning of the group which incorporated a tutor to the psychoeducational sessions.

El presente informe intenta conocer el impacto de la aplicación de un modelo psicoeducativo en pacientes bipolares donde se incorpora la presencia de un tutor. El protocolo consiste en la versión abreviada del programa de trastornos bipolares del Hospital Clinic, Barcelona que considera 8 sesiones con una frecuencia semanal. Aleatoriamente, se conforman dos grupos de sujetos bipolares atendidos en la Clínica Psiquiátrica Universitaria de la Universidad de Chile. En un grupo (grupo I) se aplica el programa tradicional mencionado, mientras que en el otro grupo (grupo II) se incorpora la presencia de un tutor a las sesiones, el que participa durante todas las jornadas. Los dos grupos estuvieron conformados por bipolares tipo I. Tanto los pacientes del grupo I como del grupo II mantienen al término de las 8 sesiones puntajes de eutimia. La aplicación de la prueba de Moorehead-Ardelt en el grupo I muestra un índice promedio de + 0.479, lo que señala que el conjunto de sujetos manifestó una mejor impresión de su estado actual luego del término de las sesiones, mientras el grupo II (con tutor) mostró un índice promedio de + 0.666, lo que señala un a mejor apreciación de su estado al término de las sesiones con respecto al grupo I. En cuanto al OQ-45-2, el grupo I mostró resultados favorables, con 6 sujetos de 12 con índices estadísticamente significativos (p< 0,05). En el grupo II, 4 de 9 sujetos presentan índices significativos estadísticos de cambio positivo al término de las sesiones, lo que en promedio supera levemente a los apreciados en el grupo I. No se observaron resultados negativos estadísticamente significativos en ningún sujeto tanto del grupo I como del II. En el seguimiento a cinco meses, el grupo contutor mostró una mejor evolución, pues 7 de 9 pacientes mostraron eutimia, mientras que el grupo sin tutor sólo 5 de 12 se mantenían en estas condiciones del grupo en que se incorporó al tutor a las sesiones psicoeducativas.

Diagnóstico de tumor estromal gastrointestinal – GIST através de enteroscopia com duplo-balão: relato de caso / Diagnosis of gastrointestinal stromal tumor – GIST by double ballon enteroscopy: case report

O diagnóstico de tumores estromais gastrointestinais (GIST) de jejuno é raro, pois eles são, na maioria das vezes, localizados no estômago. Podem cursar de forma assintomática, ser encontrados acidentalmente (massa abdominal durante investigação com tomografia computadorizada) ou como etiologia de sangramento digestivo obscuro. O diagnóstico e tratamento de doenças localizadas no intestino delgado é um desafio à prática médica. Atualmente dispomos de um novo instrumento desenvolvido para este fim, o enteroscópio de duplo-balão (EDB), que está disponível no nosso meio. A indicação mais freqüente deste exame é na investigação de sangramento obscuro, cujos diagnóstico e tratamento podem ser realizados em várias ocasiões. Este artigo relata um caso de sangramento digestivo obscuro cuja etiologia foi GIST de jejuno, diagnosticado por enteroscopia utilizando o EDB

Gastrointestinal stromal tumors (GIST) of small bowel are infrequent and diagnosis could be troublesome. The majority of these uncommon tumors are located in stomach. GIST might be asymptomatic but usually present with non-specific gastrointestinal symptoms such as abdominal mass, pain, bleeding, anorexia and bowel obstruction. Double Balloon Enteroscopy is an endoscopic technique for visualization of the small bowel. It allows for visualization of the entire small bowel, for the application of therapeutics, for the sampling or biopsying of small bowel mucosa and for the resection of polyps of the small bowel. This article relates a GIST case of jejunum in which the Double Balloon Enteroscopy is the technique used to diagnose this disease by investigation of obscure gastrointestinal bleeding

Current status of human rabies transmitted by dogs in Latin America

Latin American countries made the political decision to eliminate human rabies transmitted by dogs by the year 2005. The purpose of the current study is to evaluate to what extent this goal has been reached. The epidemiological situation and control measures were analyzed and broken down within the countries by georeferencing. The 27 human cases reported in 2003 occurred in some 0.2 percent of the second-level geopolitical units (municipalities or counties) in the region, suggesting that the disease is a local problem. Several areas within the countries reported no more transmission of rabies in dogs. Nearly 1 million people potentially exposed to rabies received treatment. On average, 34,383 inhabitants per health post receive anti-rabies treatment (range: 4,300-148,043). Nearly 42 million dogs are vaccinated annually. Surveillance is considered fair according to the epidemiological criteria adopted by the study. Samples sent for rabies testing represent 0.05 percent of the estimated canine population (range: 0.001 to 0.2 percent). The countries are quite close to achieving the goal.

Os países da América Latina tomaram a decisão política de eliminar a raiva humana transmitida por cão até 2005, e o objetivo deste estudo é analisar o cumprimento desta meta. A situação epidemiológica e as ações de controle foram analisadas de forma desagregada dentro dos países, utilizando-se georreferenciamento da informação. Os 27 casos humanos relatados em 2003 ocorreram em cerca de 0,2 por cento das unidades de segundo nível geopolítico (municípios) da região. Esse dado sugere que a doença atualmente é muito localizada. Vários países não reportam mais transmissão de raiva em cães. Cerca de 1 milhão de pessoas são potencialmente expostas ao risco da raiva e recebem atendimento médico. Existem em média 34.383 (classe: 4.300-148.043) habitantes por posto de saúde com tratamento anti-rábico. São vacinados cerca de 42 milhões de cães anualmente, 70 por cento deles no Brasil e México. A vigilância epidemiológica para a raiva foi considerada média pelos critérios estabelecidos no estudo, sendo enviada 0,05 por cento da população canina estimada de amostras para diagnostico de raiva. Foi considerado que os países estão muito próximos de alcançar a meta.

Obesidad, diabetes e hiperlipidemia en niños y adolescentes como efecto metabólico de los antipsicóticos atípicos / Obesity, diabetes and hyperlipidemia in children and adolescents as metabolic effect of atypical antipsychotics

Atypical antipsychotics or new generation antipsychotics, introduced since the 90s, have revolutioned therapeutics in child and adolescence psychiatry, being its utility not only applicable to psychotic disorders (schizophrenia), but to affective (mania, bipolar depression) and behavioral disorders. Besides its effectiveness and tolerance they can induce weight gain, diabetes, and hypercholesterolemia; this is the reason why it is necessary to prevent, monitorize and to treat this group of patients. The aim of the present revision, is to alert the general physician about the necessity to maintain a good metabolic control when prescribing this sort of medications, which is a more often issue observed in general practice, specially in the management of irritability, aggressiveness, impulsivity and hyperactivity.

Los antipsicóticos atípicos o de nueva generación, introducidos a partir de los años 90, han revolucionado la terapéutica en psiquiatría infanto-juvenil, siendo su uso aplicable no sólo a trastornos psicóticos (esquizofrénicos), sino afectivos (manía, depresión bipolar) y conductuales. Pese a su efectividad y tolerancia éstos pueden producir aumento de peso, diabetes mellitus e hipercolesterolemia; por lo que se hace necesario prevenir, monitorizar y tratar a ese grupo de pacientes. El objetivo de la presente revisión, es alertar al médico no especialista acerca de la necesidad de mantener un buen control metabólico al prescribir este tipo de medicamentos, hecho cada vez más frecuente en la práctica general, especialmente en el manejo cotidiano de la irritabilidad, agresividad, impulsividad e hiperactividad.

Tratamientos psicológicos eficaces en trastorno bipolar: psicoeducación y terapia cognitiva conductual: descripción de un caso / Effective psychological treatments in bipolar disorder: psychoeducation and behavioral-cognitive therapy: a case report

Se presenta el caso de una paciente que padece de trastorno bipolar tipo II, cuyo abordaje terapéutico inicial se centra en alcanzar una estabilidad anímica con fármacos, para luego integrar intervenciones psicoeducativas y de terapia cognitivo conductual, ambas útiles en la evolución del trastorno bipolar. Interesa mostrar los beneficios que conlleva recibir este tipo de intervención combinada, con relación al modelo médico clásico y a otros modelos psicológicos. Se describen los principales aspectos abordados con los enfoques anteriormente señalados, la evolución del caso, y el estado actual de la paciente. Se ilustran algunas de las dificultades presentadas durante el proceso terapéutico, y se realiza un breve análisis crítico de la intervención realizada.

A case of a female patient with type II bipolar disorder is presented, whose initial approach was focused on reaching a mood stability with medication, continuing with psychological-educational interventions together with behavioral cognitive therapy, both very useful techniques to be used in bipolar disorders. It is our aim to show the benefits that rely on using combined interventions, compared with the classical medical approach and other psychological models. We describe the principal issues treated in this case, together with the outcome of the patient and her actual condition. Difficulties presented during the therapeutical process are presented, and it is done a brief critical analysis of the interventions done in this case.

Privación total de luz en estados mixtos / Total light deprivation in mixed episodes

Los pacientes bipolares presentarían una acentuada vulnerabilidad a los cambios en los ritmos biológicos, a las alteraciones del ciclo vigilia-sueño así como mayor sensibilidad a los efectos de la luz y oscuridad. Existen trabajos preliminares donde se reporta que la oscuridad total se ha usado exitosamente en el tratamiento de manía aguda y ciclación rápida. A tres mujeres diagnosticadas como bipolares tipo I, que cursan recientes estados mixtos, que mantienen el tratamiento farmacológico sin modificaciones, se les agrega oscuridad total durante 14 horas los primeros siete días y 10 horas desde ese momento y durante cuatro meses. Al cabo de tres semanas se alcanza respuesta objetivada con escalas de manía de Young y de depresión de Hamilton y desaparición del perfil mixto en carta diaria de ánimo. Tratamientos cronobiológicos como la oscuridad total pueden ser de utilidad en el tratamiento de estados mixtos, asociándolos a tratamiento en uso.

Bipolar patients tend to be more vulnerable to biological paces changes, as to wakefulness sleep cycle disturbances, and they are more sensitive to the effects of light and darkness. There are preliminary data reports on investigations with total darkness treatment, showing that it is a successful weapon for mood stabilization of manic and rapid-cycling bipolar patients. Three women diagnosed as type I bipolar disorder, whose recent episode was a mixed state, where exposed to total darkness for 14 hours during the first week and 10 hours for the rest of the investigation(4 months), without taking away or changing pharmacotherapy. After three weeks, a response was reached (evaluated with YMRS and the Hamilton Depression rating scale). By the same time, the mixed mood symptoms disappeared on daily mood charts. Chronobiological treatments such as total darkness may be a useful tool in the treatment of mixed states.

El litio como antisuicida / Lihium as an antisuicidal drug

En el TB el litio es la única estrategia farmacológica verdaderamente útil en la prevención del suicidio, logrando aproximarse a tasas semejantes a las reportadas en la población general. Resulta de gran interés observar como esta reducción en la tasa de suicidios involucra no sólo a quienes alcanzan una buena respuesta terapéutica con litio, sino también a aquellos que no la alcanzan. Una vez suspendido el litio, aumenta notablemente el número de actos suicidas, el número de personas que cometen actos suicidas y la tasa de mortalidad; siendo el primer año post-suspensión un período crítico, puesto que todas las tasas se incrementan incluso por sobre lo reportado antes de haber iniciado la terapia con litio, disminuyendo estos valores a las tasas originales a partir del segundo año.

Lithium is the only pharmacological strategy proven to be useful in the prevention of suicide, reaching similar mortality rates than those reported by general population. It is very interesting to observe how this rate drops, issue that does not involve only patients who reach a good response to lithium, but also those who do not reach the therapeutical response. Once lithium is suspended, suicidal acts increase, and the number of patients that commit suicidal acts and the mortality rate also arise. The first year of suspension is a critical period, where all rates are elevated, even higher than those reported before the use of lithium, having the rates again decreased in the second year after suspension of the drug.

La perspectiva bio-psico-social desde la neurobiología de los trastornos del ánimo / From neurobiology to the bio-psycho-social perspective in mood disorders

Se revisan aspectos psicosociales vinculados a las bases neurobiológicas de la fisiopatología de los Trastornos del Ánimo, en especial el Trastorno Bipolar. Se analiza el rol de la transmisión familiar, el género y la edad en el Trastorno Bipolar. La vulnerabilidad a los Trastornos del Ánimo guarda relación tanto con la genética como con los estresores psicosociales, siendo las alteraciones en las vías de transmisión de señales en las cascadas intracelulares, las responsables de las anormalidades estructurales del Sistema Nervioso Central en los Trastornos del Ánimo, discutiéndose sus implicancias en la terapéutica.

Psychosocial issues are reviewed in accordance to neurobiological basis of Major Affective Disorders physiopathology, in particular in Bipolar Disorder. Familiar heritability, gender and age are related to bipolar onset. The links between stressful experiences and vulnerability for Affective Disorders and the intracellular mechanisms in signal transduction pathways that lead to structural abnormalities related with Affective Disorders are discussed as also the implications in therapeutic approaches.

Litio como aumentador y antirrecurrencial en trastornos del ánimo / Lihium as augmentator and mood stabilizer in affective disorders

El litio es actualmente considerado el tratamiento coadyudante más efectivo en la depresión refractaria, alcanzando tasas de respuesta cercanas al 50 por ciento, y en muchos de los pacientes una mejoría clínica dentro de la primera semana de administración, resultando eficaz tanto en la fase aguda como en la de continuación, postulándose su indicación por no menos de seis meses. Se revisa el lugar del litio en la profilaxis de nuevos episodios anímicos, destacando la disminución en la recurrencia de fases tanto maníacas como depresivas, mostrando una mayor eficacia en bipolares II que en bipolares I. Por último, por su utilidad clínica, se examinan los factores predictores de un pronóstico favorable en la profilaxis con carbonato de litio. Estos son: inicio precoz del tratamiento respuesta inicial positiva en los primeros 6 a 12 meses de tratamiento, fases puras como la manía grandiosa-eufórica y la depresión de comienzo agudo, curso episódico con períodos de eutimia, antecedentes familiares de enfermedad bipolar, ausencia de trastornos de personalidad, presencia de sintomatología melancólica durante el episodio depresivo, mayor severidad del episodio depresivo, niveles séricos elevados de T4 libre, secuencia depresión-manía-intervalo libre y niveles plasmáticos de litio entre 0.6 - 1.0 meq/L.

El conflicto de intereses en medicina: una preocupación de la Sociedad de Neurología, Psiquiatría y Neurocirugía (SONEPSYN) / Conflicts of Interest: A Concern of the Society of Neurology, Psychiatry and Neurosurgery (SONEPSYN)

La literatura médica está prestando creciente atención al conflicto de intereses, de modo principal aunque no exclusivo, desde la perspectiva de las relaciones entre los médicos y la industria farmacéutica. Cuando hay intereses en competencia muchas veces la posibilidad de la distorsión del juicio médico no es visible a primera vista. Deben considerarse el posible sesgo inconsciente y no intencionado de autoservicio, como los efectos de que el juicio profesional parezca influenciado, independiente de si lo está o no. El advenimiento de la Medicina basada en la Evidencia y de la Salud Administrada plantea tensiones entre el enfoque poblacional de la medicina y las obligaciones de los médicos hacia sus pacientes individuales. Al igual que en otros países, es necesario que las sociedades científicas nacionales impulsen el estudio, conocimiento y difusión de aquellos factores que pueden contribuir a sesgar el juicio médico, como asimismo instituir pautas éticas locales que guíen a los profesionales.

Retossigmoidoscopia: relaçao com os aspectos antropomorficos / Rectosigmoidoscopies: relation with anthropomorphic aspects

Foram realizadas no periodo de fevereiro a julho de 1985, no Serviço de Colo-Proctologia do Hospital Universitario de Santa Maria (HUSM) - RS, 100 retossigmoidoscopias, onde foram estudadas a altura da junçao retossigmoide (JRS) e o numero de valvulas de Houston relacionadas com os aspectos antropomorficos dos pacientes. O retossigmoidoscopio utilizado foi do tipo Welch Allen de 25 cm. Em sua maioria os pacientes examinados eram brancos, femininos e normolineos. Nos tres tipos antropomorficos, a altura da JRS se encontrava a 15 cm do anus; nos brevilineos e longilineos, o numero de valvulas mais encontrado foi de tres e nos normolineos de duas. Concluiu-se que a JRS nao variou de altura(15 cm) nos diferentes biotipos e que o numero de valvulas nos normolineos foi menor

Esfincterotomia lateral interna fechada no tratamento da fissura e contratura anais / Lateral internal sphincterotomy in the treatment of anal fissure

Foram estudados, de forma prospecticva, prontuarios de pacientes tratados no Serviço de Proctologia do Hospital Universitario de Santa maria - RS (HUSM), com diagnostico de fissura e contratura anais com indicaçao de tratamento cirurgico, no periodo de novembro de 1985 a outubro de 1986. Comparou-se a fissurectomia mais esficterotomia aberta e a esficterotomia lateral interna fechada, analisando-se os resultados de cada uma delas, concluindo-se sobre as indicaçoes e vantagens dessas formas terapeutica da fissura e contratura do anus

Condiloma acuminado gigante: relato de um caso / Giant condylomata acuminata: report of a case

Os autores relatam um caso de condiloma acuminado gigante em adulto refratário a diversos tipos de tratamento (cirúrgico, imunoterápico e radioterápico). Discutem a etiologia e a ineficácia dos diversos tratamentos instituidos. Concluem pela sua degeneraçäo maligna após 3§ exame histopatológico, o que tornou os tratamentos instituídos ineficazes