The multidimensional comprehension of Chagas disease. Contributions, approaches, challenges and opportunities from and beyond the Information, Education and Communication field

Chagas is a complex, multidimensional phenomenon in which political, economic, environmental, biomedical, epidemiological, psychological, and sociocultural factors intersect. Nonetheless, the hegemonic conceptualisation has long envisioned Chagas as primarily a biomedical question, while ignoring or downplaying the other dimensions, and this limited view has reinforced the disease's long neglect. Integrating the multiple dimensions of the problem into a coherent approach adapted to field realities and needs represents an immense challenge, but the payoff is more effective and sustainable experiences, with higher social awareness, increased case detection and follow-up, improved adherence to care, and integrated participation of various actors from multiple action levels. Information, Education, and Communication (IEC) initiatives have great potential for impact in the implementation of multidimensional programs of prevention and control successfully customised to the diverse and complex contexts where Chagas disease persists.

How people affected by Chagas disease have struggled with their negligence: history, associative movement and World Chagas Disease Day

It is well documented that Chagas disease (CD) can pose a public health problem to countries. As one of the World Health Organization Neglected Tropical Diseases undoubtedly calls for comprehensive healthcare, transcending a restricted biomedical approach. After more than a century since their discovery, in 1909, people affected by CD are still frequently marginalised and/or neglected. The aim of this article is to tell the story of their activism, highlighting key historical experiences and successful initiatives, from 1909 to 2019. The first association was created in 1987, in the city of Recife, Brazil. So far, thirty associations have been reported on five continents. They were created as independent non-profit civil society organisations and run democratically by affected people. Among the common associations' objectives, we notably find: increase the visibility of the affected; make their voice heard; build bridges between patients, health system professionals, public health officials, policy makers and the academic and scientific communities. The International Federation of Associations of People Affected by CD - FINDECHAGAS, created in 2010 with the input of the Americas, Europe and the Western Pacific, counts as one of the main responses to the globalisation of CD. Despite all the obstacles and difficulties encountered, the Federation has thrived, grown, and matured. As a result of this mobilisation along with the support of many national and international partners, in May 2019 the 72nd World Health Assembly decided to establish World Chagas Disease Day, on 14 April. The associative movement has increased the understanding of the challenges related to the disease and breaks the silence around Chagas disease, improving surveillance, and sustaining engagement towards the United Nations 2030 agenda.

Actualidades en la higiene de manos quirúrgica. Revisión de la literatura / Current trends in hand hygiene for surgery. A literature review / Atualidades na higiene de mãos cirúrgica. Revisão da literatura

Resumen Introducción: La higiene de manos quirúrgica, procedimiento esencial en cirugía; es una técnica que ha evolucionado y se ha ido actualizando tras el surgimiento de evidencia científica. El manual de la Organización Mundial de la Salud (OMS) publicado hace diez años es uno de los documentos que plasman cambios de esta técnica, como dejar de usar el cepillo. Sin embargo, es necesario analizar la evidencia actual con la finalidad de reconocer las nuevas tendencias de acuerdo con los resultados de las investigaciones publicadas. Objetivo: Realizar una revisión actualizada de la literatura sobre la higiene de manos quirúrgica. Desarrollo: El lavado de manos quirúrgico con cepillo es un procedimiento que se realiza en la mayoría de las instituciones hospitalarias de México; pocas han incursionado en la técnica en la que se omite el uso de cepillo. Existen diversos estudios que sustentan que el uso de cepillos debe ser erradicado debido al daño tisular que estos ocasionan. La abrasión dérmica provocada por el uso de cepillos origina que el personal se cepille las superficies de las manos y brazos por menos tiempo que el recomendado y esto a su vez impide un efecto idóneo por parte de los antisépticos. Las sustancias más recomendadas son la clorhexidina y las soluciones a base de alcohol. Conclusiones: La higiene de manos quirúrgica sin cepillo debe ser considerada debido a que disminuye costos hospitalarios, garantiza la efectividad de la descontaminación de manos, ocasiona menos lesiones dérmicas y contribuye a la reducción de las infecciones relacionadas al sitio quirúrgico.

Abstract Introduction: Hand hygiene for surgery is an essential clinical procedure whose technique has been evolving as the result of new scientific evidence. The related WHO manuals reflect the changes in this procedure; for example, the now non-binding need of using a brush. Nevertheless, it is necessary to continue analyzing the current evidence in order to recognize the new guidelines which are being established as the result of new published research. Objective: To carry out an updated literature review on hand hygiene for surgery. Development: Hand washing for surgery using a brush has long been a regular practice in Mexican hospitals, however, there are diverse studies which support the omission of brushes due to the tissue damage which these utensils can cause - including dermal abrasions which can make the staff tend to brush their hands and arms for less time in comparison to the recommended standards, resulting in incomplete antiseptic effects. Conclusions: Having in mind that some of the most recommended antiseptic substances are chlorhexidine and alcohol-based gels, hand hygiene for surgery without using a brush should be considered because it can reduce costs, guarantee hands decontamination, generate less dermal lesions, and contribute to the reduction of related surgical site infections.

Resumo Introdução: A higiene de mãos cirúrgica é um procedimento essencial em cirurgia; é uma técnica que evoluiu e se tem ido atualizando trás o surgimento de evidência científica. O manual da OMS publicado faz dez anos é um dos documentos que traduzem as mudanças desta técnica, como é deixar de usar a escova. No entanto, é necessário analisar a evidência atual com a finalidade de reconhecer as novas tendências conforme os resultados das pesquisas publicadas. Objetivo: Realizar uma revisão atualizada da literatura sobre a higiene de mãos cirúrgica. Desenvolvimento: O lavado de mãos cirúrgico com escova é um procedimento que se realiza na maioria das instituições hospitalares do México; poucas incursionaram na técnica na qual se omite o uso de escova. Existem diversos estudos que sustentam que o uso de escovas deve ser erradicado devido ao dano tissular que estes ocasionam. A abrasão dérmica provocada pelo uso de escovas origina que o pessoal se escove as superfícies das mãos e braços por menos tempo que o recomendado e isto por sua vez impede um efeito idóneo por parte dos antissépticos. As sustâncias mais recomendadas são a clorexidina e as soluções a base de álcool. Conclusões: A higiene de mãos cirúrgica sem escova deve ser considerada devido a que diminui custos hospitalares, garante a efetividade da descontaminação de mãos, ocasiona menos lesões dérmicas e contribui à redução das infecções relacionadas ao sítio cirúrgico.

Community-based approaches for malaria case management in remote communities in the Brazilian Amazon

Abstract INTRODUCTION Malaria case management is a pivotal intervention in malaria elimination. However, many remote areas in Brazil still lack access to basic health services. This study describes a community-based approach (CBA) for malaria case management in the large remote area of the Jaú National Park (JNP), Amazonas, Brazil. METHODS In 2001, a general health CBA was initiated with a motor group (MG); a participative community health diagnosis (PCHD) was subsequently implemented between 2001 and 2005. In 2006, a CBA for malaria case management started with an expanded MG including all sectors with a stake in malaria control, from the local residents to the federal government. In 2008, community microscopists were selected and trained to diagnose hemoparasites. A full malaria strategy was implemented in 2009 with subsequent quality control follow-up. RESULTS Two educational materials were co-created with local communities. The MG identified malaria as a major health problem and the malaria MG planned the control activities. Ten communities selected a resident to become malaria microscopists, and ten solar-operated health centers were built. The number of slide readings increased from 923 in 2006 to 1,900 in 2009, while malaria infections decreased from 354 cases in 2005 to 20 cases in 2015. The excess time (≥ 48 hours) between first symptoms and diagnosis/treatment decreased from 68.9% of cases in 2005 to 14.3% in 2010. CONCLUSIONS While many factors were likely involved in the reduction of malaria transmission in the JNP, the CBA played an important role in the sustained success of the initiative.

Cáncer de metaplásico de mama: revisión de dos casos clínicos / Metaplastic breast cancer: review of two clinical cases

RESUMEN El carcinoma metaplásico de mama es un tipo de cáncer infiltrante que asemeja un carcinoma de alto grado histológico, pero cuya incidencia es muy baja (< 1%). Desde el punto de vista anatomopatológico presenta un componente mixto epitelial y mesenquimal; siendo lo más característico su comportamiento clínico altamente agresivo junto con unas características anatomopatológicas, inmunohistoquímicas concordantes, como son el HER2/neu negativo, los receptores hormonales negativos, el tamaño tumoral grande y el alto grado histológico. Por todo ello, resulta de especial interés conocer esta entidad, con la finalidad de realizar un diagnóstico preciso y llevar a cabo un tratamiento adecuado en estas pacientes. En el presente artículo se presenta la revisión de dos casos clínicos de cáncer de mama metaplásico, diagnosticados y tratados en nuestro Hospital durante el año 2015 y 2018.

ABSTRACT The metaplastic breast cancer is a subtype of an infiltranting breast cancer and it's usually high grade. However it is a rare subtype of cancer (incidence <1%). This cancer has an epithelial and connective tissues, which has an epithelial invasor ductal breast cancer with high grade and sarcomas breast. The main characteristic of the metaplastic breast cancer is their high agressive behavior as clinical as anatomopathological, which immunohistochemical expression is like a triple negative breast cancer. Because of this we consider that their knowledge is very important with the purpose of being diagnosed in women. In this paper it is showed a revision of two cases of metaplastic breast cancer, whose diagnostic and treatment were reported in our Centre.

Que no tengan miedo de nosotros:el Chagas según los propios protagonistas / Não tenham medo de nós: a doença de Chagas segundo os protagonistas / Do not be afraid of us: Chagas disease as explained by people affected by it

El artículo da cuenta de un estudio internacional realizado entre octubre de 2011 y enero de 2012, como fundamento para el diseño y elaboración de un material audiovisual (spot) con el objeto de sensibilizar y visibilizar la problemática del Chagas. La investigación, de carácter cualitativo, recogió los datos de 38 encuestas, respondidas por personas afectadas y especialistas en la temática. La información para cada grupo se ordenó según aspectos que las personas asociaban con la palabra Chagas, y dificultades, retos, desafíos y logros vinculados. Para cada punto se presenta un análisis de las respuestas, relatos y anécdotas relacionadas. Las conclusiones refuerzan la necesidad de conocer y dar a conocer las dificultades que viven las personas afectadas por el Chagas, considerando que se trata de una realidad que tiene diversas manifestaciones dependiendo del contexto...

O artigo apresenta um estudo internacional realizado entre outubro de 2011 e janeiro de 2012, no qual se baseou o desenho e elaboração de um vídeo (spot) que tinha como objetivo a sensibilização e promoção da visibilidade da problemática vinculada à doença de Chagas. A pesquisa, de caráter qualitativo, analisou a informação recolhida por meio de 38 questionários respondidos por pessoas afetadas e especialistas sobre a doença. A informação, para cada um dos dois grupos, foi classificada de acordo com os aspectos que as pessoas associavam com a palavra Chagas, e as dificuldades, adversidades, desafios e conquistas vinculadas com a doença. Para cada um dos referidos aspectos, apresenta-se uma análise das respostas, relatos e anedotas. As conclusões reforçam a necessidade de se conhecer e divulgar as dificuldades vividas pelas pessoas afetadas pela doença de Chagas, tendo em mente que se trata de uma realidade que se manifesta de forma diversa dependendo do contexto...

This paper presents an international study that was conducted between October 2011 and January 2012, in which a video (spot) to boost awareness and raise the profile of Chagas disease issues was designed and developed. This study was of qualitative nature and analyzed information that was gathered from 38 questionnaires that had been answered by individuals affected by the disease and by specialists on this disease. The information from each group was classified according to factors that they associated with the word Chagas, along with the difficulties, adversities, challenges, objectives and achievements relating to the disease. The responses, reports and anecdotes relating to each of these factors were analyzed. The conclusions emphasize the need to know and make known the difficulties that people affected by Chagas disease experience, bearing in mind that the realities are manifested differently depending on the context...

Percepción de los pacientes hospitalizados sobre la empatía y el respeto que manifiestan las enfermeras / Perception of hospitalized patients about the empathy and respect shown by nurses

La relación enfermera-paciente es un proceso de interacción basado en una serie de contactos donde se establece la comunicación. La empatía y el respeto son componentes de una relación terapéutica que se manifiestan por medio de la comunicación verbal y no verbal de los individuos. La transmisión de mensajes que establece el personal de enfermería al brindar cuidado puede ser terapéutica generando aspectos benéficos y cambios positivos en la salud de los individuos. El conocer la percepción de los pacientes sobre los comportamientos de las enfermeras que reflejan empatía y respeto, permite detectar fortalezas y aspectos a mejorar en la relación enfermera-paciente y contribuir al incremento en la satisfacción de los usuarios. Objetivo. Describir la percepción de los pacientes sobre la empatía y el respeto que manifiestan las enfermeras y contribuir a la validez de constructo del instrumento CECOP. Metodología. Observacional, descriptivo y transversal realizado en un hospital de tercer nivel de atención de la ciudad de México. La muestra probabilística fue integrada por 350 pacientes hospitalizados. Se empleó el instrumento CECOP-23 el cual cuenta con validez de contenido. Resultados. La percepción de los pacientes sobre el respeto que le manifiestan las enfermeras fueron altos (49.04/55±5.00), teniendo mayor puntaje que la empatía (44.35/60±8.84). Ambos resultados coinciden con las calificaciones otorgadas por los pacientes en una escala análoga: empatía (8.83) y respeto (9.31). La valoración global de la relación enfermera-paciente también obtuvo puntajes altos (93.39/115±12.18). Conclusiones. La empatía y el respeto que manifiestan las enfermeras es percibida por los pacientes dentro de estándares altos, lo anterior favorece la relación terapéutica. Los componentes que la conforman deben evaluarse constantemente para asegurar una atención de calidad, empática y respetuosa. Implicaciones para la práctica. Se propone desarrollar programas de educación continua dirigidos a las enfermeras para incrementar sus habilidades en la comunicación enfermera-paciente enfatizando los aspectos relacionados con la empatía para con ello desencadenar una relación terapéutica óptima que incremente la satisfacción del profesional de enfermería y de los pacientes.

The nurse-patient relationship is an interaction process based on a series of contacts where communication is established. Empathy and respect are components of a therapeutic relationship that are manifested through verbal and non-verbal communication of individuals. The transmission of messages established by the nursing staff when providing care can be therapeutic, generating beneficial aspects and positive changes in the health of individuals. Knowing the perception of patients on the behaviors of nurses that reflect empathy and respect, allows to detect strengths and aspects to improve in the nurse-patient relationship and contribute to the increase in user satisfaction. Objective. Describe the perception of patients about the empathy and respect shown by nurses and contribute to the construct validity of the CECOP instrument. Methodology. Observational, descriptive and cross-sectional carried out in a tertiary care hospital in Mexico City. The probabilistic sample consisted of 350 hospitalized patients. The CECOP-23 instrument was used, which has content validity. Results. The patients' perception of the respect shown by the nurses was high (49.04 / 55 ± 5.00), having a higher score than empathy (44.35 / 60 ± 8.84). Both results coincide with the scores given by the patients on an analogous scale: empathy (8.83) and respect (9.31). The global assessment of the nurse-patient relationship also obtained high scores (93.39 / 115 ± 12.18). Conclusions. The empathy and respect shown by the nurses is perceived by the patients within high standards, the above favors the therapeutic relationship. The components that comprise it must be constantly evaluated to ensure quality, empathetic and respectful care. Implications for practice. It is proposed to develop continuing education programs aimed at nurses to increase their skills in nurse-patient communication, emphasizing aspects related to empathy in order to trigger an optimal therapeutic relationship that increases the satisfaction of the nursing professional and the patients.

Intervención de Enfermería en una familia mexicana con factores de riesgo para enfermedades crónico-degenerativas / Nursing intervention on a Mexican family with risk factors for chronic and degenerative illnesses

Introducción: La familia como sociedad influye directamente en los hábitos y costumbres de cada uno de sus integrantes. A través del tiempo, la estructura y dinámica familiar han cambiado así como algunas prácticas, costumbres y conductas saludables: preparación y consumo de alimentos dentro del hogar, recreación y actividad física de los integrantes de la familia. La diabetes mellitus (DM) y la hipertensión arterial sistémica (HAS) son las principales enfermedades crónico-degenerativas asociadas al sedentarismo y consumo de alimentos poco saludable. Objetivo: Proporcionar educación para la salud a una familia que le permita mejorar sus conocimientos sobre alimentación, actividad física y prevención de enfermedades crónico-degenerativas, así como promover conductas de salud positivas, que faciliten su autocuidado. Métodos: Se valoró la estructura, el desarrollo y la dinámica familiar con base en el modelo de Calgary y Friedman. Tras la detección de problemas reales y potenciales, se desarrolló una intervención educativa enfocada a hábitos alimentarios saludables, aumento de la actividad física y conocimiento de factores de riesgo sobre enfermedades crónico-degenerativas. Resultados: La familia aprendió y replicó lo aprendido, comprometiéndose a modificar sus hábitos poco saludables. Discusión: La valoración familiar es útil para el profesional de Enfermería, ya que permite identificar información relevante sobre los patrones transgeneracionales de enfermedades y conductas no saludables. Conclusiones: Para poder apreciar los resultados como la modificación de hábitos y estilos de vida, es necesario dar seguimiento prolongado y constante tras realizar una intervención educativa.

Introduction: Family, as a society, has direct influences on the habits and customs of its members. Along the times, the familial structure and dynamics have been changing; for example, regarding to its practices and behaviors such as food preparation and consumption, recreation, and physical activities. Diabetes mellitus and blood hypertension are the main chronic and degenerative illnesses related to sedentary and unhealthy eating life styles. Objective: To provide health education to a specific family so that it can improve its self-care and health behaviors, as a result of its eating habits, physical activity, and chronic and degenerative illnesses prevention knowledge enhancement. Methods: The familial structure, development, and dynamics were assessed using the Calgary & Friedman model. After the detection of actual and potential problems, an education intervention focused on healthy eating habits, physical activity, and chronic and degenerative illnesses risk factors addressing, was developed. Results: This family acquired the corresponding knowledge, and engaged into an unhealthy habits modification. Discussion: Assessing families is useful for nursing professionals in order to identify unhealthy behaviors as well as trans-generational illness patterns. Conclusions: In order to obtain results such as habits and life style modifications, it is necessary to continue following the education intervention up.

Prostatectomía radical asistida por robot da Vinci: experiencia inicial en 50 casos consecutivos / Da Vinci robot-assisted radical prostatectomy: initial experience in 50 consecutive cases

Objective: To report our initial experience in 50 cases submitted to a Robotic Radical Prostatectomy (RRP), evaluating results and the learning curve. Material and Methods: From January to October 2010 we performed 50 consecutives cases of RRP with the da Vinci S-HD Surgical System®. The database was performed prospectively, and was analyzed retrospectively. We evaluate demographic data (age, body mass index) and perioperative data such as clinical stage, preoperative PSA (Prostate Specific Antigen), Gleason Score, ASA, operative times, estimated blood loss, morbidity, hospital stay, time of bladder catheterization and positive margins. A statistical analysis of exponential regression was performed to estimate the learning curve. Results: The mean age was 62 years and the most frequent clinical stage was T1c (84 percent). The mean PSA was 6.36 ng/mL and in 50 percent of the patients the Gleason Score was 7. The median surgical time was 199 minutes. The mean blood loss was 666 mL (50-4.000 mL). The hospital stay and the average bladder catheterization time were 2 and 6 days, respectively. There were 2 conversions to a laparoscopic approach, none to open surgery, and 8 percent of postoperative complication (all Clavien 1). Inmediat urinary continence and potency rates were 88.3 percent and 33.3 percent, respectively. When comparing the 25 initial cases versus the last 25, there was a decrease in surgical time and estimated blood loss (254 minutes vs 189 minutes and 876 mL vs 467 mL, respectively). We also found a lower rate of positive margins (20 percent vs 12 percent). The learning curve statistically estimated is 40 procedures. Conclusion: The surgeon's experience determine a decrease in surgical time, intraoperative bleeding and especially in the rate of positive margins.

Objetivo: Comunicar nuestra experiencia inicial en 50 casos de Prostatectomía Radical Robótica (PRR), evaluando resultados y curva de aprendizaje. Material y Métodos: Desde enero a octubre de 2010 se realizaron 50 PRR con el sistema da Vinci S-HD®. La base de datos fue confeccionada en forma prospectiva y se evaluaron en forma retrospectiva los datos demográficos (edad, índice de masa corporal), estadio clínico, valor de Antígeno Prostático Específico (APE), Score de Gleason, ASA, tiempos quirúrgicos, sangrado estimado, complicaciones, estadía hospitalaria, tiempo de sonda vesical y tasa de márgenes positivos. Se realizó un análisis estadístico de regresión exponencial para estimar la curva de aprendizaje del método. Resultados: La edad media fue de 62 años y el estadio clínico más frecuente fue el T1c (84 por ciento). El valor medio de APE fue de 6,36 ng/mL. El score de Gleason en un 50 por ciento correspondió al 7 y la media del ASA a 2. La mediana del tiempo quirúrgico fue de 199 minutos. El sangrado medio estimado fue de 666 mL (50-4.000 mL). La media de la estadía hospitalaria y el tiempo de sonda fueron de 2 y 6 días, respectivamente. Hubo 2 conversiones a cirugía laparoscópica, ninguna a cirugía abierta y un 8 por ciento de complicaciones postoperatorias (todas Clavien 1). La tasa de continencia y de potencia inmediata fue de 88,3 por ciento y 33,3 por ciento, respectivamente. Cuando comparamos los 25 casos iniciales versus los 25 finales hubo un descenso significativo en el tiempo quirúrgico y sangrado estimado (254 minutos vs 189 minutos y 876 mL vs 467 mL, respectivamente). También encontramos una menor tasa de márgenes positivos en el grupo 2 (12 por ciento vs 20 por ciento). El análisis estadístico determinó la curva de aprendizaje en 40 procedimientos. Conclusión: Una mayor experiencia del cirujano, determina una disminución en los tiempos quirúrgicos, sangrado intraoperatorio y sobre todo en la tasa de márgenes positivos.

Ureterectomía radical distal por cáncer urotelial y reconstrucción ureteral asistida por robot / Radical distal ureterectomy secondary to an urotelial cancer and ureteral reconstruction robot-assisted: case report

Objective: To report a case of distal ureterectomy with robotic-assisted laparoscopic reimplantation using a Boari flap technique. Material and Methods: We report a 55 year old man with a diagnosis of distal ureteral urothelial carcinoma without multifocality. Results: A radical distal ureterectomy and robotic-assisted laparoscopic vesicoureteral reimplantation using a Boari flap technique was performed with the da Vinci S-HD surgical system. The operative time was 210 minutes, the estimated blood loss was 200 mL. The hospital stay was 48 hours, without perioperative complications. The histopathological study showed a high grade non-muscle invasive urothelial carcinoma of the distal ureter (pT1NxMx) with negative margins. Conclusions: The distal radical ureterectomy with Boari replacement is feasible and more precise with robotic assistance. Its oncological role must be demostrated with a larger number of cases.

Objetivo: Comunicar un caso de tumor ureteral distal tratado con ureterectomía radical y neoimplante vesicoureteral con técnica de Flap Boari asistida por robot. Material y Métodos: Paciente hombre de 55 años, con diagnóstico de carcinoma urotelial de uréter distal sin compromiso multifocal. Resultados: Se realizó ureterectomía distal radical y neoimplante vesicoureteral con Flap Boari asistido por Robot da Vinci S-HD. El tiempo operatorio fue de 210 minutos, con un sangrado estimado de 200 ml. La estadía hospitalaria fue de 48 horas, sin complicaciones perioperatorias. El estudio histológico mostró un carcinoma urotelial de alto grado con infiltración de la lámina propia (pT1NxMx) y márgenes quirúrgicos negativos. Conclusiones: La ureterectomía radical distal con reconstrucción tipo Boari es técnicamente factible y más precisa con la asistencia robótica. Su rol oncológico requiere de validación con mayor número de casos.

Uso de mucosa bucal para reconstrucción uretral / Oral mucosa for uretral reconstruction

La reconstrucción de la estrechez uretral requiere la eliminación del tejido fibroso patológico y el aporte de tejido sano que reemplace la pared uretral dañada. En las últimas décadas, el uso de injertos de mucosa oral se ha consolidado como la técnica de primera elección en la mayoría de los casos. La mucosa oral está fácilmente disponible y es de sencillo procuramiento. Su textura es muy apropiada y los injertos “toman” con facilidad, prácticamente sin retracción. En este artículo se describe en detalle la técnica que usamos en nuestro hospital para el procuramiento de mucosa oral.

Urethral stricture reconstruction requires replacement of the pathologic fibrous urethral tissue with healthy, normal tissue. In the last decades, oral mucosa graft has become the preferred alternative inmost cases. Oral mucosa is readily available, simple to use and has a high success rate. In this communication we describe in detail the technique we use in our hospital for oral mucosa procurement.

Hacia un manejo racional de la estrechez de la uretra anterior: ¿Que dice la evidencia?: [revisión] / Evidence based rationale behind anterior urethra treatment: [review]

El manejo de las estenosis de la uretra anterior es controversial. Tradicionalmente se le ha tratado con métodos minimamente invasivos (dilataciones y uretrotomía interna). Sin embargo esos métodos no son capaces de curar a más del 30 por ciento a 35 por ciento de los pacientes. Por otro lado la cirugía de reconstrucción uretral (uretroplastia) es más compleja y requiere entrenamiento, pero puede curar a la vasta mayoría de los pacientes en un solo procedimiento quirúrgico. Debido a falta de experiencia y entrenamiento en uretroplastia, existe sobre-uso y abuso de los métodos no invasivos, en perjuicio de la calidad de vida de los pacientes. Existe amplia evidencia que la uretrotomía interna es un excelente método para estenosis de hasta 1cm de longitud, pero su efectividad disminuye dramáticamente por sobre 1,5 cm. Estenosis mas largas tienen indicación directa de uretroplastia, sobre todo si ya han fallado una uretrotomía previa. De este modo creemos que el manejo debe ser selectivo empleando el tratamiento apropiado orientado a curar y no solo paliar la enfermedad. Es necesario mejorar el entrenamiento de los urólogos en uretroplastia y/o establecer centros de referencia, de modo de ofrecer el tratamiento óptimo para cada caso.

Management of anterior urethral stricture disease is controversial. For centuries the primary management has been minimally invasive dilation or urethrotomy. However, there is ample evidence that these methods cannot cure more than one third of the patients. The rest are condemned to chronic repetitive non-curative instrumentation. Open reconstructive urethral surgery is the alternative. Although it requires training and experience, the majority of patients are cured in one surgical procedure. Unfortunately, due to lack of training in urethroplasty techniques, there is abuse of internal urethrotomy and dilation, severely compromising patient’s quality of life. Optical internal urethrotomy is an excellent choice in strictures up to 1 cm long, but dramatically loses effectiveness over 1.5 cm. Strictures >2.0 cm should be treated with urethroplasty, particularly if they have failed a previous urethrotomy. We believe that management should be selective, oriented to cure and not only to palliate of the disease. Urologists should improve their training in urethroplasty and we need to implement referral centers in order to offer the best treatment and the best results for each case.

Prehistoric tuberculosis in America: adding comments to a literature review

Tuberculosis is a prehistoric American human disease. This paper reviews the literature and discusses hypotheses for origins and epidemiological patterns of prehistoric tuberculosis. From the last decades, 24 papers about prehistoric tuberculosis were published and 133 cases were reviewed. In South America most are isolated case studies, contrary to North America where more skeletal series were analyzed. Disease was usually located at the deserts of Chile and Peru, Central Plains in USA, and Lake Ontario in Canada. Skeletal remains represent most of the cases, but 16 mummies have also been described. Thirty individuals had lung disease, 19 of them diagnosed by the ribs. More then 100 individuals had osseous tuberculosis and 26 also had it in other organs. As today, transmission of the infection and establishment of the disease were favored by cultural and life-style changes such as sedentarization, crowding, undernutrition, use of dark and insulated houses, and by the frequency of interpersonal contacts. The papers confirm that despite previous perceptions, tuberculosis seems to have occured in America for millennia. It only had epidemiological expression when special conditions favored its expansion. Occurring as epidemic bursts or low endemic disease, it had differential impact on groups or social segments in America for at least two millennia

Utilidad clínica de la ecoendoscopia digestiva en la evaluación de lesiones malignas gastrointestinales: reporte preliminar / Endoscopic ultrasound in gastrointestinal malignant lesions: report

La ecoendoscopia es un método importante en la estadificación tumoral de lesiones malignas del tracto gastrointestinal, sin embargo no hemos evaluado su utilidad clínica en nuestro departamento. Determinar la utilidad de ecoendoscopia en la evaluación de lesiones malignas del tracto gastrointestinal. Estudiamos retropectivamente 40 pacientes consecutivos entre mayo y octubre de 1998 a quienes se les practicó ecoendoscopia. Se excluyeron seis pacientes. Se analizaron 34 pacientes con información completa (18 hombres, 16 mujeres), edad promedio de 57 años. A 32 pacientes se les practicó un solo examen y a 2 pacientes dos exámenes. El diagnóstico final se obtuvo por cirugía convencional o endoscópica (n=15), PCRE con o sin esfinterotomía (n=7), histología (n=2) y seguimiento médico (n=10) promedio de tiempo 3,7 meses. Todos los pacientes tenían endoscopia digestiva superior y ultrasonido abdominal, 68 por ciento con TAC, 26 por ciento tenían PCRE y 6 por ciento colonoscopia. En 14 pacientes el diagnóstico inicial de cáncer era dudoso y en 20 se realizó estadiaje tumoral. La endoscopia en un buen método de estadiaje tumoral en lesiones malignas del tracto gastrointestinal en nuestra unidad. Algunas veces, la utilidad clínica final dependerá de la decisión del paciente y de recursos quirúrgicos disponible en le centro de referencia

The 1986 dengue and dengue hemorrhagic fever epidemic in Puerto Rico: epidemiologic and clinical observations

In 1986 Puerto Rico experienced its eleventh dengue outbreak of this century, but the first with simultaneous transmission of three dengue virus serotypes, and the first with significant numbers of severe and fatal hemorrhagic disease. Overall, 10,659 cases were reported; 1,257 cases were laboratory confirmed as having current or recent dengue infection. Dengue 4 (DEN-4) was the predominant serotype (160/363 isolates, 44 percent) followed by dengue 1 (DEN-1) with 134 isolates (37 percent) and dengue 2 (DEN-2), 69 isolates (19 percent). Transmission peaked during September, but large numbers of cases occurred through November. Seventy-one (91 percent) of Puerto Rico's 78 municipalities had laboratory-confirmed cases. Fifty-one percent of all confirmed cases occurred in metropolitan San Juan. Most cases presented clinically as classical dengue fever, but 37 percent of all confirmed cases were reported to have developed some type of hemorrhagic manifestation, and 6 percent reported hematemesis. In addition, 29 laboratory confirmed cases met the WHO case definition for dengue hemorrhagic fever, 3 of which were fatal. Among the 29 laboratory-confirmed cases of dengue hemorrhagic fever/ dengue shook syndrome, virus was isolated from 12; one DEN-1, three DEN-2, and eight DEN-4. Among laboratory confirmed cases, infants less than one year of age were at greater risk of developing dengue hemorrhagic fever/ dengue shook syndrome, hematemesis and any reported hemorrhage than were the other age groups evaluated

Asociación de lupus eritematoso sistémico y sindrome de Klinefelter / Systemic erythematosus lupus associated with Klinefelter's syndrome

Se presenta la asociación de lupus eritematoso sistémico y sindrome de Klinefelter en un hombre de 47 años con cromatina de Barr positiva y estudio genético con cariotipo 47, XXY. Los estudios homonales foliculoestimulante (FSH), prolactina, estradiol plasmático y testosterona; observándose bajos niveles de testosterona y estradiol, con una prolactinemia normal.Fue internado por úlcera crónica de miembro inferior izquierdo.En el estudio exhaustivo del paciente se demostró la presencia de criterios (ACR) para LES con leucopenia ,células LE positivas,FAn positivos,Anti-ADN 1:32, Anti-Sm positivo,Anti-Ro negativo, Anti-La positivo y afectación renal demostrada por biopsia, sin insuficiencia renal ni hipertensión arterial.El estudio histológico de las lesiones ulcerosas demostró vasculitis necrotizante de arteriolas de pequeño calibre.Una biopsia de riñón puso en evidencia una glomerulonefritis proliferativa difusa (clase IV-OMS).Se presenta el caso con el objetivo de aportar datos sobre una coexistencia de enfermedades que es raramente informada, tanto en la casuística individual como en importantes revisiones referidas a LES en hombres

Frecuencia de genes y haplotipos del sistema HLA en la poblacion Panameña / Gene frequency and haplotypes of the HLA system in the Panamanian population

The authors determined the frequency of genes and haplotypes of the HLA system in 965 panamanian men and women not related to each other, between 6 and 65 years of age. The HLA-A locus genes with the highest frequency (f) were A2, with f 0.1763; A24, f 0.1584; A30, f 0.1340; A23, f 0.1069; A3, f 0.0774. The other 20 genes each had less than 0.07. The genes with the highest frequency for locus HLA-B were B35, f 0.1946; B44, f 0.0904; B7, f 0.0774; B60 and B61, f 0.0582. For locus HLA-C, the most frequent genes were Cw3 with f 0.1549 and Cw4, f 0.1444. For locus HLA-DR, the most frequent genes were DR2 with f 0.1283; DR3, f 0.0620; DR7, f 0.0409. The most frequent haplotypes in the panamanian population were A2-B35 with f 0.0382; A3-B35, f 0.0191; A24-35, f 0.0287; A24-B61, f 0.0239; A29-B44, f 0.0287; A30-B42, f 0.0239; A23-B44, f 0.0191; A1-B8, f 0.0143. The authors conclude that the panamanian population exhibits a high degree of polymorphism for loci HLA-A, B and C, while for locu HLA-DR the frequency is the median when compared with that in caucasian, negro and oriental groups; and that, according to locus, predominant genes originating from these groups and found, corroborating the multiracial origen of the panamanian population

Inapparent lung involvement in patients with the subacute juvenile type of paracoccidioidomycosis

Se presentan las historias de 3 pacientes con el diagnóstico de paracoccidioidomciosis juvenil, en los cuales no se demonstraron signos ni síntomas de compromiso pulmonar al momento del diagnóstico. Tal diagnóstico fué inicialmente comprobado por la observación del P. brailiensis en biopsias obtenidas de lesiones ganglionares clinicamente aparentes. Aunque las radiografias de torax no revelaron cambios patológicos en nungún caso, fué posible observar y aislar el hongo de muestras de esputos obtenidas de los tres pacientes. Este hallazgo refuerza la hipótesis de la genesis pulmonar de la paracoccidioidomicosis y comprueba la existencia de una infección primária pulmonar aún en aquellos pacientes que presentan las manifestaciones de la forma juvenil y en quienes el componente pulmonar está disimulado por el gran compromiso de anglios y órganos linfáticos

Construcción de un reservorio urinario continente autocateterizable a través de ostomía abdominal en disfunción vesical neuropática / Construction of a autocatheterizable urinary continent diversion through abdominal ostomy in neuropathic vesical disfunction

Presentamos una técnica de derivación urinaria continente aplicada en un grupo de pacientes con disfunción vesical neurogénica, quienes fallaron a otros métodos de tratamiento. Se utilizó el segmento ileo-cecal o un segmento ileon terminal, construyendo una válvula continente basada en una intususcepción ileo-cecal, o ileo-ileal, estabilizada con sutura de ácido poliglicólico, escarificación de la serosa y una malla de Marlex o Acido poliglicólico. Hubo morbilidad importante que logró ser controlada y no fue responsable de mortalidad ni falla del reservorio urinario. El control alejado ha demostrado continencia total del mecanismo valvular, ausencia de daño renal funcional o anatómico, y una absoluta independencia física, social y psicológica de todos nuestros pacientes