Mieloma múltiple en Chile. Uso de drogas noveles en dos centros nacionales

Background: The incorporation of novel drugs, such as proteasome inhibitors and immunomodulators, improved considerably the survival of patients with multiple myeloma. Aim: To evaluate the effect on survival of proteasome inhibitors and immunomodulators in patients with multiple myeloma in two national hospitals. Material and Methods: Review of clinical records from two hospitals of Santiago. Epidemiological, clinical, laboratory and therapeutic data was obtained from 144 patients with multiple myeloma diagnosed between 2002 and 2016. Results: Information was retrieved from 78 patients at one center and from 66 at the other center. The mean age at diagnosis was 58 and 62 years, the proportion of males was 53% and 52%, and presentation at stage III was 34% and 46%, respectively. The use of novel drugs, mainly bortezomib, was 90% in one of the centers and 3% in the other one. The use of autologous stem-cell transplantation was 47% and 3% respectively. The median overall survival of patients from the centers with and without access to novel drugs was 117 and 71 months respectively (p < 0.05). The five-year overall survival was 93 and 43% respectively (p < 0.05). Conclusions: The use of novel drugs, especially bortezomib, and autologous stem-cell transplantation significantly improved the survival of multiple myeloma patients treated in national hospitals. It is necessary to include them as a first line treatment.

Eficacia y seguridad del tratamiento anticoagulante oral con antagonistas de vitamina k en pacientes con prótesis valvulares cardíacas / Safety and efficacy of anticoagulation with vitamin k antagonists in patients with prosthetic heart valves

Introducción: Los pacientes con válvulas mecánicas cardíacas (VMC) representan una proporción significativa del total de pacientes que requieren anticoagulación. Sin embargo, hay pocos estudios que comparen la efectividad de la anticoagulación con distintos antagonistas de vitamina K (AVK). Objetivo: Comparar la efectividad y seguridad del tratamiento con warfarina y acenocumarol en pacientes con VMC. Métodos: Estudio observacional de pacientes en po-liclínico de anticoagulación UC sometidos a recambio valvular entre los años 2005 y 2013. Se estandarizó las dosis de AVK con software Isaza Hytwin Biostac 2.0. Se evaluaron registros de hemorragia mayor y menor (seguridad) y accidentes vasculares y embolías sistémicas (efectividad). La efectividad se analizó mediante el tiempo en rango terapéutico (TTR) con método de Ro-sendaal. Resultados: Se incluyó 365 pacientes con edad promedio de 64,1 +/- 13,2 años, 53,9 por ciento de sexo femenino. El seguimiento promedio fue de 33,3 +/- 18 meses; La mortalidad registrada fue 2,1 por ciento. El promedio de TTR fue 68 +/- 13,3 por ciento (recambio aórtico TTR 66,1 +/- 12,6 por ciento, recambio mitral TTR 65,8 +/- 13,8 por ciento y recambio mitro-aórtico TTR 61,2 +/- 12 por ciento). Acenocumarol presentó un TTR menor que warfarina (65,1 +/- 13,1 vs. 71,2 +/- 13,6, p = 0,001), sin aumento del riesgo de complicaciones. Conclusión: Aunque warfarina ofrece un mejor perfil de TTR, no existen diferencias significativas en la eficacia o seguridad al compararla con acenocumarol.

Background: Patients with cardiac mechanical valves (MHV) represent a significant proportion of all patients requiring anticoagulation. However, there are few studies comparing safety and efficacy of different vitamin K antagonists (VKA). Aim: To compare the efficacy and safety of warfarin and acenocoumarol in patients with MHV. Methods: Observational study of patients who had a mitral and /or aortic valve replacement between 2005 and 2013, followed at the Catholic University anticoagulation clinics. VKA dose adjustments were performed using the Isaza Hytwin Biostac 2.0 software. Major and minor bleeding (safety) and stroke and systemic embolism (effectiveness) were evaluated. The efficacy was estimated by the time in therapeutic range (TTR) with the Rosendaal method. Results: 365 patients were included with a mean age of 64.1 +/- 13.2 years, 53.9 percent of them were females. Mean follow-up was 33.3 +/- 18 months Overall mortality rate was 2.1 percent, which is similar to that of patients treated with VKA for other reasons. The average TTR was 68 +/- 13.3 percent (66,1 +/- 12,6 percent for aortic valves, 65,8 +/- 13,8 percent for mitral valves and 61,2 +/- 12 percent for aortic and mitral valves). TTR was lower with acenocoumarol compared to warfarin (65.1 +/- 13.1 vs. 71.2 +/- 13.6 , p = 0.001 ), However, the risk of complications was not different between groups. Conclusions: Although warfarin provides a better profile of TTR , there were no significant differences in efficacy or safety when compared with acenocoumarol.

Endocarditis infecciosa por Listeria monocytogenes: revisión de la literatura a partir de un caso clínico / Infective endocarditis caused by Listeria monocytogenes: review of the literature and a case report

Infective endocarditis caused by Listeria monocytogenesis an extremely rare but usually aggressive disease. We have seen in recent years an increase in age of onset of this disease and a predilection for patients with valvular disease, especially prosthetic valve. The treatment of choice is ampicillin, which is combined with gentamicin for synergy. It is known that even with treatment the mortality is very high and higher than in other types of bacterial endocarditis. With optimal therapy, that is medical-surgical, mortality has declined significantly in recent years. We presents a review of the literature and a clinical case of a patient with a febrile syndrome diagnosed as a infective endocarditis caused by L. monocytogenestreated medically with successful outcome to date.

La endocarditis infecciosa por Listeria monocytogenes es una enfermedad extremadamente infrecuente, pero usualmente agresiva. Se ha observado en los últimos años un aumento en la edad de presentación y una predilección por pacientes con enfermedad valvular, especialmente válvula protésica. El tratamiento de elección es ampicilina combinada con un aminoglucósido para obtener sinergismo. Aun con un tratamiento adecuado, la mortalidad es elevada y mayor que en otros tipos de endocarditis bacteriana. Con una terapia óptima, incluyendo la resolución quirúrgica, la mortalidad ha disminuido significativamente en los últimos años. Se presenta una revisión de la literatura científica a partir de un caso clínico de un paciente con un síndrome febril en el que se diagnosticó una endocarditis por L. monocytogenesque fue tratada en forma médica con un resultado exitoso.

Trombolisis mecánica de tronco basilar con Solitaire FR®: caso clínico / Mechanical thrombolysis of the basilar artery: Report of one case

We report a 40year-old male presenting in the emergeney room with headache, vértigo and left hemiparesis. A magnetic resonante imaging reporten a left cerebellar infarction with occlusion of the basilar artery ana dissection ofthe right vertebral artery. Thepatient experienced a clinical deterioration with the appearance ofa right hemiparesis. Therefore a brain angiography wasperformed alongwith a mechanical thrombolysis using a Solitaire FR® revascularization device. A thrombus located in the distal third ofthe artery was eliminated obtaining a complete perfusión ofthe artery. Thepatient had a satisfactory evolution.

Hipertensión arterial: el factor de riesgo más importante para grosor íntima-media carotídeo elevado y placa carotídea en adultos de Santiago / Risk factors for a high carotid intima media thickness among healthy adults

Background: Carotid intima media thickness (CIMT) is a marker of cardiovascular damage that can be modified by traditional risk factors. Aim: To determine attributable risk factors for a high CIMT among healthy adults. Material ana Methods: A sample of 1270 individuáis (636 males and 634 femóles) aged 44 ±11 years, was studied. Blood pressure, weight, height, lipidprofile and blood glucose were measured in all. CIMT and thepresence of atheroscleroticplaques were determined by carotid ultrasound. Standard criteria were used to define hypertension, dyslipidemia and diabetes. Results: Mean CIMT in the sample studied was 0.62 ± 0.01 mm and percentile 75 was 0.67. The most important risk factor for a CIMT over percentile 75 and thepresence of atherosclerotic plaques was hypertension with attributable risks of 54 and 57 percent, respectively. Conclusions: In this sample, the main risk factor for a high CIMT was hypertension.

Índice cintura estatura y agregación de componentes cardiometabólicos en niños y adolescentes de Santiago / Waist height ratio, ultrasensitive c reactive protein and metabolic syndrome in children

Background: Waist to height ratio and ultrasensitive C-reactive protein are predictors of the presence of the metabolic syndrome in children. Aim: To determine the proportional risk of metabolic syndrome component clustering in children, using waist to height ratio and ultrasensitive C-reactive protein. Material and Methods: Anthropometric measures, blood pressure, fasting serum lipid profle, blood glucose and ultrasensitive C-reactive protein were determined in 209 children aged 11.5 ± 2 years (50 percent females). The presence of the metabolic syndrome as a function of waist to height ratio and C-reactive protein was modeled using logistic regression equations. The risk of clustering one, two or more components of the metabolic syndrome was calculated. Results: Metabolic syndrome was present in 5 percent of all children and 18 percent of those that were obese. The cut off points for waist to hip ratio and ultrasensitive C-reactive protein were 0.55 and 0.61 mg/L, respectively. For each 0.01 increment in waist to height ratio, the odds ratio of increasing one component of the metabolic syndrome was 1.2 (1.15-1.25) or 15 to 25 percent. The odds ratio for log-transformed ultrasensitive C-reactive protein was 1.62 (1.26-2.09). Excluding waist circumference, the odds ratio of adding one or more components of the metabolic syndrome was 1.05 (1.01-1.09) per 0.01 increment in waist to height ratio, but the odds ratio for C-reactive protein was no longer significant. Conclusions: Waist to height ratio and ultrasensitive C-reactive protein predict the risk of clustering components of the metabolic syndrome in these children.

Validación de un puntaje de riesgo cardiovascular en niños españoles aplicado a una población de escolares de Santiago de Chile / Association between a cardiovascular risk score and early markers of atherosclerotic disease in Chilean children

Background: A cardiovascular risk score for children, that includes traditional risk factors, obesity, sedentary habits and a family history of cardiovascular disease, has been recently proposed by Spanish researchers. Aim: To apply this score in school age children in Santiago de Chile and correlate its results with markers of subclinical atherosclerotic disease. Material and Methods: Retrospective analysis of data obtained from 209 children, aged 11.5 ± 2 years, studied between 2005 and 2006. Weight, height, blood pressure, ultrasound measurement of carotid intimamedia thickness and fow mediated dilatation of brachial artery and ultrasensible C reactive protein (us PCR) were measured. The Spanish cardiovascular risk score was calculated and correlated with ultrasound parameters and C reactive protein. Results: According to the score, 173 children (83 percent) had a low cardiovascular risk, 28 (13 percent) an intermediate risk and 8 (4 percent) a high risk. There was no association between the cardiovascular risk score and carotid intima-media thickness, fow mediated arterial dilatation and us PCR. Conclusions: No significant association was observed between the proposed cardiovascular risk score and early markers of atherosclerotic disease in this group of children.

Panniculus carnosus, remanentes vestigiales en la región axilar / Panniculus carnosus, vestigial remanents in the axillary region

Las variaciones anatómicas de los elementos musculares de la región axilar son poco frecuentes y, generalmente, se encuentran olvidadas en los textos modernos de anatomía. Sin embargo, cuando existen, presentan un serio escollo para el cirujano, ya que alteran los hitos anatómicos de referencia para el abordaje de los importantes elementos vasculares y neurales de la región. Desde el siglo XIX algunos autores han descrito una variedad de pequeños fascículos musculares originados en el Panniculus carnosus, que se disponen en relación con los elementos neurovasculares de la axila. En esta ocasión presentamos un hallazgo efectuado en un cadáver, de sexo masculino, utilizado con fines docentes en el Departamento de Anatomía de la Escuela de Medicina de la Pontificia Universidad Católica de Chile. En la región axilar derecha, se observa un fascículo muscular que se extiende desde la apófisis coracoides, dispuesto por delante del músculo subescapular y pasando por detrás del paquete neurovascular de la axila. En su trayecto, este fascículo toma íntima relación con el nervio axilar y con la porción distal de la arteria subescapular. El músculo aberrante termina como una expansión aponeurótica, dispuesta ventral al tendón del latísimo del dorso, que se funde con la fascia axilar.

The anatomical variations of the muscular elements of the axillary region are infrequent and, generally, they are forgotten in modern texts of anatomy. Nevertheless, when they exist, they present a serious obstacle for the surgeon, since they alter the anatomical landmarks of reference for the approach to important neural and vascular elements of the region. Since the 19th century some authors have described a variety of small muscular fascicles originated in the "panniculus carnosus", that are arranged in relation to neurovasculares elements of the axila. In this occasion we present a finding performed in a corpse, male sex, dissected in the Department of Anatomy of the School of Medicine of the Pontificia Universidad Católica de Chile. In the right axillary region, a muscular fascicle is observed that extends from the coracoid process, arranged in front of the subscapularis muscle, and passing behind the neurovascular elements of the axila. In its course, this fascicle takes close relation with the axillary nerve and with the distal portion of the subscapular artery. This aberrant fascicle ends as an aponeurotic expansion, arranged ventral to the tendon of the latissimus dorsi muscle, which melts with the axillary fascia.