Hamartoma lipomatoso pancreático: Reporte de caso y revisión de la literatura

Los hamartomas pancreáticos (HP) son lesiones no neoplásicas extremadamente inusuales y representan < 1% de todos los hamartomas. Además, existe una variante distintiva denominada Hamartoma Lipomatoso Pancreático (HLP), que es aún más raro, con solo 5 casos, incluyendo el presente reporte, descritos en la literatura. HLP carecen de características específicas y clínicamente puede ser confundido con otras lesiones lipomatosas pancreáticas, como lipoma, lipomatosis pancreática, PEComa, liposarcoma y tumores malignos con componentes lipomatosos. El presente reporte describe un caso de HLP en un paciente varón de 70 años, que aquejaba de dolor y masa abdominal, preoperatoriamente diagnosticado como tumor neuroendocrino de bajo grado no funcionante pancreático. Subsecuentemente, fue sometido a enucleación laparoscópica del tumor. El reporte patológico postoperatorio y los estudios de inmunohistoquímica confirmaron el diagnóstico de HLP.

Pancreatic hamartomas (PH) are extremely unusual non-neoplastic tumor-like lesions and accounts for <1% of all hamartomas. Moreover, there is a distinct variant of PH denominated Pancreatic lipomatous hamartoma (PLH), that is even rarer, with only 5 cases, including the present case, reported in the literature. PLH lacks well-defined features and clinically can be mistaken with other lipomatous lesions of the pancreas, including lipoma, pancreatic lipomatosis, PEComa, liposarcoma, and malignant tumors with lipomatous components. Here, we describe a case of PLH in a 70-year-old male with abdominal pain and a lesion, which was preoperatively diagnosed as a pancreatic no functional low-grade neuroendocrine tumor, and subsequent underwent a laparoscopic enucleation of the tumor. The postoperative pathology and immunohistochemical analyses confirmed the diagnosis of PLH.

Brechas en telemedicina: caracterización de consultas ambulatorias a teledermatología en Chile entre 2018-2020 / Gaps in telemedicine: characterization of ambulatory teledermatology consultations in Chile, between 2018 and 2020

Introducción: La teledermatología (TD) se ha desarrollado de manera importante en los últimos años. Además de mejorar el acceso de la población a consultas médicas, permite el diagnóstico precoz de lesiones complejas. En Chile, la TD forma parte de la plataforma Hospital Digital del Ministerio de Salud desde el 2018, en modalidad asincrónica. El objetivo de este estudio es la caracterización epidemiológica de las consultas ambulatorias a TD en Chile entre los años 2018-2020. Materiales y Métodos: Estudio descriptivo retrospectivo. Se analizaron las consultas ambulatorias a TD y a dermatología en el período 2018-2020, a partir de los datos del Departamento de Estadísticas e Información de Salud, y los datos de población total a partir del Instituto Nacional de Estadísticas, por lo que no se requirió comité de ética. Resultados: Del total de teleconsultas realizadas entre 2018-2020, un 14,2% correspondió a TD. De ellas, el 86,1% corresponden a consultas nuevas, y el 13,9% a controles. Del total de pacientes, el 63,0% fueron mujeres, mientras que el 78,9% fueron mayores de 15 años. Se realizaron 20,35 consultas a TD por cada 10.000 habitantes a nivel nacional, y 17,21 consultas dermatológicas por cada consulta a TD. Discusión: La TD es una de las principales aplicaciones de la telemedicina en Chile. La variación entre las regiones con respecto al número de consultas a TD podría deberse a factores que requieren mayor estudio. Es probable que la TD mantenga un rol creciente debido al desarrollo tecnológico y los beneficios demostrados de esta herramienta.

Introduction: Teledermatology (TD) has greatly developed in recent years. Besides improving access to medical consultations, it also allows the early diagnosis of complex lesions. In Chile, TD forms part of the Digital Hospital platform of the Ministry of Health since 2018, in a store-and-forward form. The objective of this study is to characterize ambulatory consultations with TD in Chile between 2018 and 2020. Materials and Methods: A retrospective descriptive study was performed. Ambulatory consultations with TD and dermatology between 2018-2020 were analyzed from data obtained from the Department of Statistics and Health Information, and population data were obtained from the Statistics National Institute, which did not require ethical approval. Results: Of the total teleconsultations made in the 2018-2020 period, 14.2% belonged to TD. From that, 86.1% were new consultations, and 13.9% were controls. Women represented 63.0% of the patients, while 78.9% were older than 15 years old. For every 10,000 inhabitants, 20.35 total consultations were made with TD nationwide, and 17.21 dermatological consultations were made for each consultation with TD. Discussion: TD is one of the main applications of telemedicine in Chile. The variation in the number of consultations with TD between regions could be caused by factors that require further study. It is likely that TD will keep a growing role due to technological development and benefits shown by this tool.

Narcotraficantes en Chile. Análisis estadístico-descriptivo de sujetos detenidos por tráfico de drogas durante el periodo 2017-2021 / Drug traffickers in Chile. Statistical-descriptive analysis of subjects arrested for drug trafficking during the period 2017-2021 / Os traficantes de drogas no Chile. Análise estatística-descritiva dos sujeitos presos por tráfico de drogas durante o período 2017-2021

Desde tiempos remotos, la conducta delictiva ha sido una de las principales preocupaciones de la sociedad. En particular, el narcotráfico ha movilizado a las instituciones del Estado y también a investigadores provenientes de distintas áreas del saber; pese a ello ­en Chile­ esta manifestación del crimen organizado ha sido un fenómeno poco abordado y con escasa evidencia científica. Mediante el lenguaje de programación R se realizó un estudio estadístico descriptivo dirigido a caracterizar el perfil actual del narcotraficante en Chile, a partir de los factores sociocriminógenos presentes en una muestra de 28 397 sujetos, quienes fueron detenidos por tráfico de drogas durante el periodo 2017­2021. Los resultados obtenidos dan cuenta de la inexistencia de un perfil único, sin embargo, se estableció que se trata ­mayoritariamente­ de un hombre adulto, de estado civil soltero, que promedia los 32.5 años, sin un trabajo u oficio formal, con antecedentes policiales y una carrera delictiva caracterizada por la versatilidad criminal. También se discutió el rol de los extranjeros, las mujeres y los adolescentes dentro del narcotráfico, pues, aun cuando su frecuencia estadística es mayor que en otros delitos, su participación dentro de la estructura criminal sigue limitándose a los eslabones más bajos de la organización.

Since ancient times, criminal behavior has been one of society's main concerns. In particular, drug trafficking has mobilized state institutions and researchers from different areas of knowledge; however, in Chile, this manifestation of organized crime has been a phenomenon that has been little addressed and with little scientific evidence. Using the R programming language, a descriptive statistical study was conducted aimed at characterizing the current profile of the drug trafficker in Chile, based on the sociocriminogenic factors present in a sample of 28 397 subjects, who were arrested for drug trafficking during the period 2017-2021. The results obtained show the inexistence of a unique profile, however, it was established that it is -mostly- an adult male, of single marital status, averaging 32.5 years of age, without a formal job or trade, with a police record and a criminal career characterized by criminal versatility. The role of foreigners, women and adolescents in drug trafficking was also discussed, since, although their statistical frequency is higher than in other crimes, their participation in the criminal structure continues to be limited to the lowest links in the organization.

Desde os tempos antigos, o comportamento criminoso tem sido uma das principais preocupações da sociedade. Em particular, o tráfico de drogas mobilizou instituições estatais e pesquisadores de diferentes áreas do conhecimento; entretanto, no Chile, esta manifestação do crime organizado tem sido um fenômeno pouco abordado e com poucas evidências científicas. Usando a linguagem de programação R, foi realizado um estudo estatístico descritivo para caracterizar o perfil atual do traficante de drogas no Chile, baseado nos fatores sócio-criminógenos presentes em uma amostra de 28.397 indivíduos que foram presos por tráfico de drogas durante o período 2017-2021. Os resultados obtidos mostram que não existe um perfil único, no entanto, foi estabelecido que se trata principalmente de um homem adulto, solteiro, com idade média de 32,5 anos, sem um emprego ou ocupação formal, com antecedentes criminais e uma carreira criminosa caracterizada pela versatilidade criminal. O papel dos estrangeiros, mulheres e adolescentes no tráfico de drogas também foi discutido, pois, embora sua freqüência estatística seja maior do que em outros crimes, sua participação na estrutura criminal ainda está limitada aos elos mais baixos da organização.

Recuperación mejorada después de cirugía en cáncer colorrectal. Instituto Nacional de Enfermedades Neoplásicas / Enhanced recovery after surgery in colorectal cancer. Instituto Nacional de Enfermedades Neoplásicas

RESUMEN Objetivo : Describir y analizar la seguridad de la aplicación del programa de "Recuperación Mejorada Después de Cirugía" (ERAS) para cirugía electiva por cáncer colorrectal. Materiales y Métodos : Estudio observacional retrospectivo de 272 pacientes con cáncer colorrectal operados con cirugía electiva entre enero 2019 y setiembre 2020 en el Instituto Nacional de Enfermedades Neoplásicas, Perú. Se utilizó la Prueba U de Mann-Whitney, Chi-cuadrado de Pearson, y odds ratios (OR) para el análisis estadístico. Resultados : 90 pacientes ingresaron al programa ERAS con una mediana de estancia hospitalaria postoperatoria de 3 días (rango 3-19). La cirugía laparoscópica se realizó en el 53 % de los casos, con una estancia hospitalaria significativamente menor que los pacientes con cirugía convencional (p=0,035). El inicio de la tolerancia oral < 24 horas se realizó en el 91 % de casos y la deambulación temprana en 89 %. La incidencia de complicaciones postoperatorias fue de 29 %, mayor en los pacientes con resección de recto/ano que en el grupo con resección de colon (40 % vs 20 %, p=0,043) (OR=2,67, IC del 95 %: 1,02 - 7,01). Ocho pacientes presentaron complicación mayor, 4 con dehiscencia de anastomosis y 4 requirieron readmisión hospitalaria. Conclusiones : El manejo según ERAS para cirugía electiva por cáncer colorrectal es seguro y factible con un riesgo de morbimortalidad perioperatoria aceptable.

ABSTRACT Aim : Describe and analyze the safety of the "Enhanced Recovery After Surgery" (ERAS) protocol in elective procedures for colorectal cancer. Materials and Methods : Observational study of 272 patients with colorectal cancer who underwent elective surgery from January 2019 to September 2020 at the "Instituto Nacional de Enfermedades Neoplásicas", Peru, were retrospectively collected. U Mann-Whitney test, Pearson chi-square test and odds ratios (OR) were used for statistical analysis. Results : 90 patients were included in the ERAS program with a median postoperative hospital stay of 3 days (range 3-19). Laparoscopic surgery was performed in 53% of the patients with significantly shorter postoperative hospital stay in comparison with the patients who had open surgery (p=0,035). Oral food intake less than 24 hours postoperatively was 91%, and early mobilization in 89% of the cases. The postoperative complication rate was 29%, higher in rectal/anus resection than in colonic resections (40% vs 20%, p=0,043) (OR=2,67, CI 95%: 1,02 - 7,01). Eight patients had a major postoperative complication, four with anastomotic leakage and four required hospital readmission. Conclusions : The perioperative management of ERAS program for colorectal cancer in elective surgery is safe and feasible with acceptable morbimortality risk.

¿La periodontitis crónica modifica la morbilidad de la artritis reumatoide?: aspectos clínicos y moleculares. Una revisión sistemática / Association between chronic periodontitis and rheumatoid arthritis: a systematic review

Rheumatoid arthritis (RA) and chronic periodontitis (CP) may be related due to a bidirectional etiology. The evidence shows that CP could alter the clinical course of RA. We performed a systematic search to determine if CP alters the morbidity of RA, analyzing its clinical and molecular aspects. Of 552 initial articles found, 16 were selected for a thorough review. There is a greater prevalence of CP in patients with RA. Patients with RA have significantly higher values of periodontal clinical parameters than healthy controls. Arthritis activity is significantly greater in patients who suffer from CP and decreases with nonsurgical periodontal treatment. There is a significant relationship between the severity of CP and RA activity.

Valor pronóstico de la razón de ganglios metastásicos en pacientes con cáncer gástrico operados / Prognostic value of lymph node ratio (LNR) in patients who underwent radical gastrectomy

Objetivo: El objetivo del estudio fue evaluar el valor pronóstico de la razón de ganglios metastásicos (LNR) en los pacientes con cáncer gástrico operados de gastrectomía radical D2. Materiales y métodos: Se revisaron retrospectivamente las historias clínicas de 498 pacientes del Instituto Nacional de Enfermedades Neoplásicas (INEN) entre los años 2008 y 2011 que cumplían los criterios de inclusión y exclusión. Se dividieron en 4 grupos de acuerdo a su LNR; LNR0: 0, LNR1: 0-0,13, LNR2: 0,14-0,4 y LNR3: ≥ 0,4. Resultados: La mediana de ganglios resecados fue de 42 [rango 8-153] y 494 (99,2%) pacientes tuvieron más de 15 ganglios resecados. 340 (68,5%) pacientes presentaron compromiso ganglionar y 175 (35,1%) fueron clasificados como pN3, 94 (18,5%) pN2 y 72 (14,5%) como pN1. 285 (57,2%) pacientes tuvieron estadío III. Hubo diferencias significativas entre los grupos del LNR en las curvas de sobrevida global (SV) y de sobrevida libre de enfermedad (SVLE) (p <0,05). Según los grupos del LNR existen diferencias según la edad, el tamaño de la lesión, el nivel de compromiso ganglionar (pN), la clasificación Lauren, la invasión vascular y la invasión linfática (p <0,05). El LNR es un factor pronóstico importante para explicar el tiempo de muerte (LNR3: HR: 6,77, 95%CI: 3,346-13,706, p <0,05) y de recurrencia (LNR3: HR: 5,3, 95%CI: 2,104-13,439, p <0,05). Conclusión: El LNR es un factor pronóstico independiente importante en los pacientes operados de gastrectomía radical con linfadenectomia D2 por cáncer gástrico.

Objective: The study objective was to evaluate the prognostic value of lymph node ratio (LNR) in patients with gastric cancer who underwent radical gastrectomy D2. Materials and methods: We reviewed retrospectively 498 medical records of patients with gastric cancer who were attended at the National Institute of Neoplastic Diseases (INEN) between 2008 and 2011and met the inclusion and exclusion criteria. They were distributed into 4 groups according to their LNR, LNR0: 0, LNR1: 0-0.13, LNR2: 0.14-0.4 and LNR3: ≥ 0.4. Results: The median of resected lymph nodes was 42 [range; 8.153] and 494 (99.2%) patients had more than 15 lymph nodes retrieved. 340 (68.5%) patients had lymph node involvement and 175 (35.1%) cases (35.1%) were classified as pN3, 94 (18.5%) pN2 and 72 (14.5%) were pN1. 285 (57.2%) patients had stage III disease. There was a significant difference between groups of LNR in overall survival (OS) and disease-free survival (DFS) curves (p <0.05). According to the LNR groups there was significant differences according to age, lesion size, lymph node involvement (pN), Lauren classification, vascular invasion and lymphatic invasion (p <0.05). LNR is an important prognostic factor to explain the time of death (LNR3: HR: 6.77, 95% CI: 3.346-13.706, p <0.05) and recurrence time (LNR3: 95% CI: 2.104-13.439, p <0.05). Conclusion: LNR remains as an important independent prognostic factor in patients undergoing radical gastrectomy and D2 lymphadenectomy for gastric cancer.

Tumor sólido pseudopapilar de páncreas: Tumor de Frantz / Solid pseudopapillary tumor of the pancreas: Frantz´s tumor

El tumor pseudopapilar de páncreas, también conocido como tumor de Frantz, es una enfermedad muy rara en nuestro medio, comprende menos del 3 % de los tumores pancreáticos (1). Su etiología es desconocida, y su incidencia se observa en mujeres jóvenes con predominancia de la tercera década de la vida. Presentamos el caso de una mujer de 23 años que ingresa por epigastralgia urente desde hace 3 meses, además de llenura precoz. Al examen presenta dolor a la palpación profunda. Cuenta con perfil bioquímico, hepático, marcadores tumorales dentro de valores normales, la tomografía espiral multicorte (TEM) abdomino-pélvica reporta lesión neoformativa sólida quística de morfología redondeada de bordes bien definidos, la patología confirma tumor sólido pseudopapilar de páncreas. La paciente se somete a resección de tumor, con evolución favorable.

The solid pseudopapillary tumor of the pancreas, also known as Frantz's tumor, is a very rare disease in our country, comprising less than 3 % of pancreatic tumors (1). Its etiology is unknown and it is predominantly found in young women in their third decade of life. We present the case of a 23-year-old woman who was admitted due to a 3-month burning epigastralgia and early satiety. On examination, she had pain with deep palpation. Her biochemical profile, liver profile, and tumor markers were within normal values. An abdomen and pelvis multislice helical/spiral computed tomography (CT) scan showed a solid cystic neoformative lesion with rounded structure and well-defined borders. Pathology confirmed a solid pseudopapillary tumor of the pancreas. The patient underwent a tumor resection with favorable evolution.

Implementación de una unidad de artritis reumatoide temprana en pacientes chilenos derivados desde centros de atención primaria de salud / Implementation of an early rheumatoid athritis unit for the early recognition and treatment of the disease

Background: Early recognition of rheumatoid arthritis (RA) provides clinical benefits in terms of remission induction, reduced disease progression, and eventually treatment free remission. Aim: To describe the setting of a Unit devoted exclusively to the recognition and treatment of early RA in patients referred from primary healthcare centers (PHC) in Chile. Materials and Methods: Patients were referred from nine participating PHC from 2014 through 2016. PHC physicians received a formal training to enhance criteria recognition and program adherence. Mandatory referral criteria were an age above 17 years, and arthralgia of less than 1-year duration, plus at least one of the following: morning stiffness of more than 30 minutes, swelling involving more than 3 joints for more than 1 month, a positive squeeze test or abnormal inflammatory serum markers. Results: One hundred twenty patients aged 45 ± 12 years (90% women) were assessed at the early rheumatoid arthritis unit. Median time to referral from PHC to the Unit was 14.6 days. The median duration of symptoms for the overall sample of patients was 10.8 months. RA was identified in 43 patients (36%), with a delay between onset of symptoms and diagnosis of 8.3 months. Regarding the performance of referral criteria, the most sensitive was morning stiffness (80%, sensitivity 95% confidence intervals (CI) 64-89%) and synovitis was the most specific (specificity 83%, 95% CI 72-90%). The positive predictive value of the three clinical criteria altogether was 68.1% (95% CI 47-83%). Conclusions: Institution of an early RA unit was feasible within the Chilean healthcare system enabling the identification of early RA in one-third of patients.

Suicidio en las cárceles de Chile durante la década 2006-2015 / Suicide in Chilean prisons during the 2006-2015 decade / Suicídio nas cadeias do Chile durante a década de 2006-2015

Chile presenta un alarmante incremento de suicidios, tanto en població n general como intrapenitenciaria, lo que preocupa a las autoridades de justicia y salud. Objetivo: analizar los suicidios consumados por prisioneros en cárceles chilenas durante los años 2006-2015, para obtener el perfil de características sociocriminó genas del acto suicida y de los centros penitenciarios. Metodología: de un total de 162 suicidios, se analizaron los 132 casos examinados por la Policía de Investigaciones de Chile. Resultados: 97,7% de los suicidios ocurrieron en hombres de todas las edades (de 16 a 74 años); dos terceras partes (66,7%) sucedieron en personas con ingresos previos a prisió n, aunque la mayoría no tenían antecedentes penales ni condenas anteriores (97,7%). Una mayoría (65,1%) ocurrieron durante el primer año de ingreso. El 73,5% eran solteros, 47% solo tenían estudios básicos, 84,8% no poseían oficio estable. En 43,2% se reportó estado depresivo como desencadenante del suicidio, y el método más común fue ahorcamiento (97%). Se encontraron diferencias con estadísticas significativas de ciertas correlaciones, como entre nivel de estudios y motivo manifestado para el suicidio, y entre nivel de estudios e ingresos previos a prisió n; asimismo, una correlació n relevante que muestra que a menor edad, más ingresos a prisió n y menor nivel de estudios

Chile exhibits an alarming increase in the number of suicides among both the general population and the prison community, this being a matter of concern for justice and health authorities. Objective: the analysis of suicides committed by prisoners in Chilean jails during years 2006-2015 in order to obtain the profile of both the suicide acts and penitentiary socio-criminogenic features. Methodology: out of a total of 162 suicides, the 132 cases examined by the Criminal Investigation Police of Chile were analyzed. Results: 97.7% of suicides were committed by men of all ages from 16 through 74 years. Two thirds (66.7%) were individuals with previous admissions into prison; but most of them (97.7%) did neither have criminal backgrounds nor former convictions. A majority (65.1%) occurred during the first year in prison. 73.5% prisoners were single, only 47% had basic studies, and 84.8% had no specific jobs. A depressed mood was reported in 43.2% as a trigger factor of suicide, and hanging was the most common method used (97%). Differences were found with significant statistics in certain correlations like, for example, between the study level and the motive for suicide revealed, and between the study level and previous periods of incarceration; and likewise, there is a relevant correlation where the youngest individuals show the highest number of admissions into prison and the lower study level

Chile apresenta um aumento alarmante de suicides, tanto na população geral quanto penitenciária, que preocupa à s autoridades da justiça e a saúde. Objetivo: analisar os suicídios consumados por prisioneiros em cadeias chilenas durante os anos 2006-2015, para obter o perfil de características sociais e criminó genas do ato suicida e dos centros penitenciários. Metodologia: de um total de 162 suicidos, 132 dos casos examinados pela Polícia das Pesquisas do Chile foram analisados. Resultados: 97.7% dos suicidos aconteceram nos homens de todas as idades (de 16 a 74 anos); duas terceiras partes (66.7%) aconteceram em pessoas com renda prévia à prisão, embora a maioria não tivesse os registros criminalis nem as sentenças precedentes (97.7%). Uma maioria (65.1%) aconteceu durante o primeiro ano da entrada. 73.5% eram solteiros, 47% só tinham estudos básicos, 84.8% não possuíam um ofício estável. Em 43.2% o estado depressivo foi relatado como ativador do suicido, e o método o mais comum foi o enforcamento (97%). As diferenças com estatísticas significativas de determinadas correlações foram encontradas, como entre o nível de estudos e a razão para o suicido, e entre o nível de estudos e renda prévia à prisão; também, uma correlação relevante que amostra que à idade menor, mais renda à prisão e menor nível de estudos

Escenario actual y perspectivas de la terapia con células madre mesenquimales en medicina intensiva / Overview and perspectives of mesenchymal stem cell therapy in intensive care medicine

Development of innovative therapies in intensive care medicine is particularly important since diseases as sepsis, acute respiratory distress syndrome (ARDS) and acute renal injury (AKI) have an elevated morbidity and mortality in spite of current gold-standard approaches. Mesenchymal stem cells (MSC) may have a promising role due to their properties in immunomodulation, tissue reparation and microbial clearance. Preclinical data and results of a systematic review of PubMed, PMC and ClinicalTrials.gov have been included to review the role of MSC therapy in sepsis, ARDS and AKI. A description of MSC biology, sources and benefits in preclinical models was included. A phase I/II clinical trial (RCT) is recruiting neutropenic patients with septic shock. In ARDS, the START trial (Stem cells in ARDS Treatment) is a phase I/II study of bone marrow-derived human MSC (hMSC) that is currently recruiting patients. In AKI, a phase I study has demonstrated the safety of hMSCs infusion in patients undergoing cardiac surgery with high risk to develop AKI. A phase II study is still active. The results of these studies will determine the real feasibility of MSC therapy in critically ill patients.

Embarazos exitosos en hemodiálisis crónica: experiencia de un único centro / Pregnancy during dialysis: Experience in six patients

Background: The frequency of pregnancies during dialysis is increasing. This condition requires changes in the dialysis schedule and nutritional approach. Aim: To report the experience in six patients with terminal kidney disease who became pregnant. Material and Methods: Retrospective review of medical records of women with terminal kidney disease in dialysis who became pregnant in a period of 27 years. Results: We recorded six successful pregnancies among women in hemodialysis treatment aged 32 ± 4 years. The mean dialysis-time per week was 19.5 ± 2.7 hours and Kt/V was 1.55 ± 0.17. The mean systolic blood pressure was 130 ± 13.3 mmHg. The mean packed cell volume of the group increased from 22.7% during pre-gestational stage to 30.2% during third trimester of pregnancy. All patients received an intensive treatment for anemia. The most common symptom of pregnancy was hyperemesis. The mean gestational age (GA) at diagnosis was 13.4 ± 4.7 weeks. All patients had preterm deliveries at a GA of 33 ± 1.7 weeks, and 66% of offspring were appropriate for gestational age. Conclusions: A multidisciplinary approach allows high rate of successful pregnancies during hemodialysis.

Daño arterial asociado a la enfermedad renal crónica: evaluación mediante técnicas de laboratorio no invasivo en pacientes hemodializados / Assesment of arterial damage by noninvasive peripheral arterial tonometry in non-diabetic hemodialysis patients

Background: Hemodialysis patients (HD) display high rates of cardiac disease and mortality. The cardiovascular morbidity and mortality of HD patients is attributable in a significant proportion to endothelial dysfunction, arterial stiffness, and vascular calcifications. Aim: To measure vascular reactivity in HD subjects and compare them with healthy volunteers. Material and Methods: Forty eight non diabetic patients aged 58 ± 4.6 years (29 males) on hemodialysis for a mean lapse of 4.8 years were studied. Arterial stiffness was measured in the radial artery. Pulse wave velocity was measured by noninvasive peripheral arterial tonometry in carotid and femoral arteries. Endothelial function was assessed, measuring reactive hyperemia response after a 5 min period of ischemia. As a control, all values were also measured in age and gender-matched healthy volunteers. Results: Arterial stiffness was significantly higher in HD patients than controls (23.9 ± 3.3 and 18.4 ± 3.4% respectively, p < 0.05). HD subjects had an increased pulse wave velocity (10.0 ± 0.8 and 7.6 ± 0.9 m/s respectively, p < 0.05). A reduction in the change in pulse amplitude pressure, as a measure of arterial dysfunction, was only observed in male patients (1.7± 0.4 and2.7 ± 0.4 respectively p < 0.01). Conclusions: Noninvasive assessment of peripheral vascular function may be useful for the identification of patients at risk for late cardiac events.

Tormenta simpática paroxística como manifestación de daño axonal difuso postraumatismo encefalocraneano / Paroxysmal sympathetic storm as a manifestation of diffuse axonal damage

Presentamos el caso de un hombre de 24 años que, secundario a un accidente de tránsito, presentó un traumatismo encefalocraneano grave con daño axonal difuso. Luego de un mes de evolución en la unidad de cuidados intensivos comenzó a presentar episodios súbitos de hipertensión, taquicardia, diaforesis, hipertermia, descerebración y dilatación pupilar, todo lo anterior con resolución espontánea en el curso de minutos. Estas crisis se repetían varias veces en el día. Se llegó al diagnóstico de un cuadro denominado Tormenta Simpática Paroxística que puede presentarse muy ocasionalmente como consecuencia de una lesión cerebral grave, especialmente el daño axonal postraumático. En este trastorno prima un desbalance simpático/parasimpático, lo que podría deberse a una pérdida del control cortical. El paciente fue tratado con opiáceos y betabloqueo con una respuesta satisfactoria, logrando disminuir significativamente sus episodios de tormentas simpáticas paroxísticas. En suma, nos parece importante comunicar esta experiencia dado la alta prevalencia de pacientes con trauma cerebral en nuestras Unidades de Pacientes Críticos. A pesar de que ni su diagnóstico ni tratamiento mejoran el pronóstico, su reconocimiento ahorra estudios innecesarios y permite iniciar una terapia sencilla que lleva al control precoz de la sintomatología.

A 24-year-old man suffered a traumatic brain injury due to a car accident. After one month of hospitalization in intensive care unit, he experimented episodic crisis of hypertension, tachycardia, hyperhidrosis, hypertermia, extensor posturing and pupil dilatation. This events presented in average 10 times per day. We reached to the diagnosis of Paroxysmal Sympathetic Storm. This is a subtype of dysautonomy which is present occasionally after a brain traumatic injury. The main mechanism of this brain dysfunction is a disassociation between the sympathetic and parasympathetic nervous systems due to cortical control loss. The patient was treated with morphine and labetalol and he experimented an excellent response, reducing his episodes of paroxysmal sympathetic storm by 80 percent. The aim of this review is to communicate this entity because a prompt and accurate diagnosis could minimize unnecessary studies and treatments.

Lipoma pancreático: presentación de un caso y revisión de la literatura / Pancreatic lipoma: presentation of a case and review of literature

El diagnóstico de lipoma pancreático, es muy poco frecuente. Presentamos el caso de una mujer de 51 años con una lesión de 9 por 8 cm. A nivel de la cabeza y cuello del páncreas, a quien se le realizó una pancreatoduodenectomia proximal. Se discute la decisión terapéutica.

Diagnosis of pancreatic lipoma, is very rare. We presented the case of a 51 years woman who show a tumour of 9x8 cm. at the head and neck of the pancreas. A pancreatoduodenectomy was performed with favourable evolution. We discuss the therapeutic decision.

Púrpura trombocitopénico trombótico con respuesta exitosa a vincristina / Successful treatment of thrombotic thrombocytopenic purpura with vincristine report of one case

Thrombotic thrombocytopenic purpura presents as a multisystemic disease with thrombocytopenia, microangiopathic hemolytic anemia, fever, neurological and renal involvement. We report a 24 years-old male presenting with purpura and a generalized seizure. His blood tests showed an hemolytic anemia, unconjungated hyperbilirubinemia, increased lactated dehydrogenase, thrombocytopenia and impairment of renal function. He was initially treated with daily plasmapheresis and steroids without improvement. Due to persistence of the disease, he was treated with two doses of intravenous vincristine in four days, with clinical and laboratory improvement. He was discharged 40 days after the last dose of vincristine, in good conditions.

Resultados a corto y largo plazo de la resección hepática por hepatocarcinoma: análisis de 232 resecciones consecutivas / Short and long-term results of liver resection for hepatocarcinoma in peru: a peruvian single center experience on 232 cases

ANTECEDENTES: Para evaluar la morbilidad, mortalidad post operatoria sobrevida yrecurrencia luego de las resecciones hepáticas por carcinoma hepatocelular (HCC) se realizóun análisis en 232 pacientes consecutivos con HCC resecados entre enero de 1990 y Diciembredel 2006 en el departamento de abdomen del Instituto de Enfermedades Neoplasicas (INEN).METODOS:La sobrevida global y libre de enfermedad fue calculada por el metodo deKaplan-Meier, los factores pronósticos fueron evaluados utilizando análisis univariadoy multivariado (Cox).RESULTADOS.- La media de edad fue 36 años, 44.2 tuvieron infección por virus de lahepatitis, solo el 16.3 por ciento tuvo cirrosis. La media de AFP fue de 5,467 ng/ml. la medianadel tamaño del HCC fue 15 cms.La mayoría de pacientes tuvo una resección hepática mayor (74.2 por ciento tuvo 4 o mássegmentos resecados).La morbilidad y mortalidad post operatoria fue de 13.7 ciento y 5.3 por ciento respectivamente. Despuésde una media de seguimiento de 40 meses el 53.3% de los pacientes presentó recurrencia.La sobrevida global a 1, 3 y 5 años fue de 66.5 por ciento , 38.7 por ciento y 26.7 por ciento respectivamente. Lasobrevida libre de enfermedad a 1, 3 y 5 años fue de 53.7 por ciento , 27.6 por ciento y 19.9 por ciento .En análisis multivariado, la presencia de múltiples nódulos (p<0.000), la cirrosis (p<0.001)y la invasión vascular macroscopica (p<0.001) fueron factores independientes asociadosa una pobre sobrevida.CONCLUSION: La resección quirúrgica es el tratamiento de elección para elhepatocarcinoma y puede realizarse en el Departamento de Abdomen del INEN con bajamorbi-mortalidad y adecuada sobrevida.

BACKGROUND: To evaluate the short and long term outcome of liver resections for hepatocellular carcinoma a retrospective analysis was performed on 232 consecutive patients with hepatocellular carcinoma resected between January 1990 and December 2006 at the Department of Abdomen of the Instituto de Enfermedades Neoplasicas of Lima Peru. METHODS: Disease-free survival (DFS) and overall survival (OS) were determined by Kaplan- Meier method, Prognostic factors were evaluated using univariate and multivariate analysis RESULTS: The median age was 36 years. 44.2% were associated with hepatitis B, only16.3% had cirrhosis. The median size of the tumors was 15 cm. The median value of AFP was 5,467 ng/ml. The majority of patients underwent a major hepatectomy (74.2 % hadfour or more segments resected)Overall morbidity and mortality were 13.7% and 5.3% respectively. After a median followup of 40 months, tumour recurrence appeared in 53.3% of the patients. The 1, 3, and 5 year overall survival rates were 66.5%, 38.7% and 26.7%respectively. The 1, 3, and 5year disease-free survival rates were 53.7%, 27.6%, and 19.9%. On multivariate analysis, presence of multiple nodules (p<0.000), cirrhosis (p=0.001), and macroscopic vascularinvasion (p=0.001) were found to be independent prognostic factors related to a worse long-term survival.CONCLUSIONS: Surgical resection is the optimal therapy for large HCC and can be safely performed with a reasonable long-term survival.

Localización de insulinoma pancreático con ultrasonografía laparoscópica / Location of insulinoma pancreatic with laparoscopic ultrasonography

Se presenta el caso de una paciente de 51 años con cuadro clínico de hipoglicemia por un probable insulinoma pancreático. Los exámenes de laboratorio confirmaron la sospecha de insulinoma, pero los estudios por imágenes no pudieron demostrar el tumor. Bajo estas circunstancias, la paciente tuvo abordaje laparoscópico y con la ayuda del ultrasonido intraoperatorio se localizó el tumor en el proceso uncinado del páncreas y, finalmente, se procedió a la enucleación laparoscópica.

The case of a 51-year-old woman with a clinical history of hipoglicemia causedby a presumed pancreatic insulinoma is reported. Laboratory tests pointed outfor a insulinoma, but imaginologic studies could not locate the tumor. Under this circumstances, the patient was laparoscopically approached. By means of the ultrasononography device the tumor was located at the uncinate process of the pancreas and, eventually treated by laparoscopic enucleation.

Tratamiento laparoscópico del insulinoma pancreático: técnica quirúrgica y resultados perioperatorios / Laparoscopic treatment of insulinoma pancreatic: surgical technique and perisurgical results

Objetivo: Reportar nuestra experiencia en el tratamiento de insulinoma pancreático vía laparoscópica. Pacientes y métodos: Entre Enero del 2000 a Setiembre del 2005, acudieron a nuestra institución cuatro pacientes con diagnóstico clínico y radiológico de insulinoma. Resultados: Todos fueron abordados vía laparoscópica con la intención de enuclear el tumor. En tres de ellos se pudo realizar la enucleación laparoscópica completa, y en el paciente restante se convirtió a laparotomía para realizar una resección de la porción central de páncreas. Una paciente presentó una fístula pancreática que cerró espontáneamente. El estudio anatomopatológico reveló en todos los casos un tumor benigno de los islotes del páncreas. La glicemia retornó a valores normales en todos los casos. Conclusión: La enucleación laparoscópica del insulinoma pancreático es factible y segura.

Aim.- Our experience with the laparoscopic treatment of pancreatic insulinomas is reported. Patients and Methods.- Four patients with clinical and radiological diagnosis of insulinoma were treated between January 2000 and September 2005. Results.- All the patients were laparoscopically approached to attempt the tumor enucleation. In three cases complete enucleation was possible; the remaining case was converted to perform the resection of the middle portion of the pancreas. One patient developed a pancreatic fistula that closed spontaneously. In all cases histological evaluation of the tumor showed benign islet cell tumor. Blood glucose levels returned to normality. Conclusion.- Laparoscopic enucleation of pancreatic insulinoma is a feasible and safe technique.

Pancreatectomia central: indicaciones y resultados perioperatorios de una técnica de conservación de tejido pancreático / Central Pancreatectomy: indications and perisurgical results of a pancreatic tissue conservation technique

Introducción: La pancreatectomía proximal o distal constituye el tratamiento estándar de los tumores benignos del páncreas que no pueden ser resecados. Estos procedimientos implican una resección radical así como una importante pérdida de tejido pancreático normal que puede resultar en insuficiencia pancreática endocrina y/o exocrina. Objetivo: Reportar nuestra experiencia institucional con la pancreatectomía central para el tratamiento de tumores benignos y de bajo potencial maligno del cuello y cuerpo del páncreas enfatizando en las indicaciones y los resultados periperatorios. Métodos: Serie prospectiva a pacientes con sospecha de tumores benignos del cuerpo del páncreas. Técnica quirúrgica: Resección del páncreas central con anastomosis pancreatoyeyunal en Y de Roux. Resultados: Entre Marzo de 1997 y Mayo de 2005, 12 pacientes tuvieron pancreatectomía central con anastomosis pancreatoyeyunal. Hubo 6 tumores benignos de los islotes, 3 cistadenoma microquístico, un cistadenoma mucinoso, un tumor sólido pseudopapilar y un cistadenoma seroso. La morbilidad fue de 33.3 por ciento sin muertes post operatoria. Durante el seguimiento ningún paciente desarrolló insuficiencia pancreática. Conclusión: Algunos casos seleccionados de tumores benignos y de bajo potencial de malignidad pueden tratarse con pancreatectomía central y anastomosis pancreatoyeyunal con una morbilidad aceptable y mínima mortalidad. El beneficio de conservar la mayor cantidad de tejido pancreático sano se traduce en la conservación de la función exocrina y endocrina del páncreas.

Introduction: Proximal or distal pancreatectomy is the standard treatment for nonresectable benign pancreatic tumors. These procedures imply a radical resection as well as a significant loss of distal normal pancreatic tissue for the standard resection, which may cause an endocrine and/or exocrine pancreatic failure. Purpose: Report our experience in central pancreatectomy for the treatment of benign/low malignancy potential tumors in the body and neck of the pancreas by emphasizing the indications and perisurgical results. Methods: Prospective study of patients with suspected benign tumors in the body of pancreas. Surgical technique: Resection of central pancreas through a Roux-en-Y pancreatojejunal anastomosis. Results: From March 1997 to May 2005, 12 patients underwent central pancreatectomy through pancreatojejunal anastomosis. 6 benign tumors were found in the islets of Langerhans: 3 microcystic cystadenomas, 1 mucinous cystadenoma, 1 pseudopapillary solid tumor, and 1 serous cystadenoma. Morbidity rate was 33.3 per cent with no post-surgery deaths. Pancreatic failure was not reported during follow up. Conclusion: Some selected cases of benign/low malignancy potential tumors may be treated with central pancreatectomy and pancreatojejunal anastomosis with acceptable morbidity levels and minimum mortality levels. The benefit from preserving the greatest extension of healthy pancreatic tissue as possible is translated into a preservation of the endocrine and exocrine functions of the pancreas.

Asociación de resincronizador biventricular y desfibrilador cardioverter automático implantable / Association of biventricular resynchronizer and implantable cardioverter defibrillator

La insuficiencia cardíaca avanzada es un problema de salud mundial a pesar de la terapéutica actual. Los pacientes con miocardiopatía dilatada (MCD) presentan muerte súbita por arritmias ventriculares en el 30% al 60%. Tanto el desflbrilador cardioverter automático implantable (DCAI) como la resincronización biventricular (RBV) en forma independiente han demostrado ser efectivos y seguros para lo que fueron destinados. Actualmente están en proceso varios estudios asociando estos dispositivos y los resultados son alentadores. El propósito del presente trabajo es reportar los primeros tres casos en México con ambos dispositivos, en uno se asoció un marcapaso con un DCAI y los otros dos con dispositivos que tienen ambas funciones. Se incluyeron tres hombres con edades de 63, 65 y 54 años, dos de ellos con historia de infarto, en clase funcional de la NYHA de II a IV, fracción de expulsión del ventrículo izquierdo (FEVI) de 25, 35 y 25%. Los tres mejoraron su clase funcional y la FEVI y dos han presentado descargas del DCAI.

Congestive heart failure (HF) remains a major and growing public health problem despite recent therapeutical developments. Thirty to sixty percent of patients with dilated cardiomyopathy (DCM) die suddenly from cardiac arrhythmias. Cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillator (ICD) therapy are effective treatments for HF with a wide QRS and for ventricular arrhythmias respectively. Several trials are currently being performer to evaluate the cardiac resynchronization and implantable cardioverter defibrillator therapy with good results. The objective of this paper is to report the first three patients, in Mexico, that have received this combined therapy. In one patient, a three cameral pacemaker was associated with a unicameral ICD and the other two received a device with both functions. Patients were men, aged 63, 65, and 54 years, two of them with previous myocardial infarct and functional class II to IV of the NYHA. Left ventricular ejection fraction was of 25% in two patients and of 35% in the other. All patients improved their functional class and LVFE, two patients presented discharges of the ICD.