Componentes ético-clínicos presentes en la indicación de tratamiento en mujeres con cáncer de mama según edad de diagnóstico

Objetivo: Evaluar si existen diferencias basadas en la edad en la aproximación diagnóstica y de tratamiento del cáncer de mama. Se analizan aspectos éticos, como justicia, beneficencia y autonomía, en relación a la toma de decisiones. Material y Método: Estudio descriptivo cuantitativo y corresponde a un análisis retrospectivo de la base de datos del Centro de la Mama de Clínica Alemana de Santiago, en la que se analiza información de las mujeres de 70 años o más en relación a motivo consulta, estadio de la enfermedad al momento del diagnóstico y tratamientos recibidos y se la compara con la obtenida del grupo de mujeres menores de 70 años. Resultados: No hay diferencia en la oportunidad de la consulta, en el acceso al diagnóstico ni en el tipo de cirugía entre los dos grupos. Existen diferencias significativas en relación a la indicación de tratamientos adyuvantes como quimioterapia, radioterapia y hormonoterapia. El grupo de mujeres mayores de 70 años reciben menos terapias que las mujeres de menor edad. No existe información respecto a los motivos que expliquen esta diferencia. Discusión: Actualmente, mujeres mayores se encuentran en buenas condiciones generales, con una expectativa de vida mayor a 75 años. Es importante tratar sus enfermedades sin limitar a priori el acceso a protocolos de tratamiento, evitando la discriminación por edad. Conclusión: Se propone incorporar una evaluación geriátrica protocolizada con el objetivo de mejorar la atención de este grupo etario, preservando de esta manera los principios de justicia, beneficencia y autonomía en pacientes mayores.

Objective: To evalúate if there are differences on the diagnostic approach and breast cancer treatment based on women age. We analyze ethical aspects like justice, beneficence and autonomy in regards of decision making. Material and Method: Descriptiva and quantitative study that correspond and analysis of the Data Base of the Breast Cancer Center in Clínica Alemana de Santiago, in which we gather the information of women 70 years or more in relation to consultation motive, illness stage and treatments received, compare with the obtain in the group of women under 70 years. Results: There are no differences in the opportunity to reach consultation, access to diagnosis neither the type of surgery. There are significant differences in considering adjuvant treatment like chemotherapy, radiotherapy and hormonal therapy. The group of women with 70 years or older, receive less treatments than the younger group. There is no information that explains this differences. Discussion: In current days, women of the third and fourth age are in good general conditions and their life expectancy is over 75 years old. It is important to treat their diseases without limiting access to them only because of their age, avoiding this type of discrimination. Conclusion: it is proposed to incorporate a geriatric evaluation to improve quality of clinical attention in this age group, aiming to preserve justice, beneficence and autonomy principles in older patients.

Bee sting envenomation severe cases in Manaus, Brazilian Amazon: clinical characteristics and immune markers of case reports

Abstract Bee venom is a natural toxin composed of several peptides. Massive envenoming causes severe local and systemic reactions. We report two cases of severe bee envenomation, of which one was fatal. We also describe clinical characteristics and immune markers. Both victims suffered from respiratory distress, renal failure, rhabdomyolysis, and shock. They required invasive mechanical ventilation, vasoactive drugs, and renal replacement therapy. Moreover, serum levels of chemokines, cytokines, and cell-free circulating nucleic acids demonstrated an intense inflammatory process. Massive envenoming produced systemic injury in the victims, with an uncontrolled inflammatory response, and a more significant chemotactic response in the fatal case.

Pathological findings and morphologic correlation of the lungs of autopsied patients with SARS-CoV-2 infection in the Brazilian Amazon using transmission electron microscopy

Abstract INTRODUCTION: Electron microscopy (EM) is a rapid and effective tool that can be used to create images of a whole spectrum of virus-host interactions and, as such, has long been used in the discovery and description of viral mechanisms. METHODS: Electron microscopy was used to evaluate the pulmonary pathologies of postmortem lung sections from three patients who died from infection with SARS-associated coronavirus 2 (SARS-CoV-2), a new member of the Coronaviridae family. RESULTS: Diffuse alveolar damage (DAD) was predominant in all three patients. The early exudative stage was characterized principally by edema and extravasation of red blood cells into the alveolar space with injury to the alveolar epithelial cells; this was followed by detachment, apoptosis, and necrosis of type I and II pneumocytes. The capillaries exhibited congestion, exposure of the basement membrane from denuded endothelial cells, platelet adhesion, fibrin thrombi, and rupture of the capillary walls. The proliferative stage was characterized by pronounced proliferation of type II alveolar pneumocytes and multinucleated giant cells. The cytopathic effect of SARS-CoV-2 was observed both in degenerated type II pneumocytes and freely circulating in the alveoli, with components from virions, macrophages, lymphocytes, and cellular debris. CONCLUSIONS: Viral particles consistent with the characteristics of SARS-CoV-2 were observed mainly in degenerated pneumocytes, in the endothelium, or freely circulating in the alveoli. In the final stage of illness, the alveolar spaces were replaced by fibrosis.

Increased prevalence of hypertension among people living with HIV: where to begin?

Abstract INTRODUCTION: Cardiovascular diseases (CDVs) have become increasingly important for progressively older people living with HIV (PLHIV). Identification of gaps requiring improvement in the care cascade for hypertension, a primary risk factor for CVDs, is of utmost importance. This study analyzed the prevalence of hypertensive status and described the care cascade for hypertension screening, diagnosis, treatment, treatment adherence, and management in PLHIV. METHODS: This cross-sectional study included 298 PLHIV (age >40 years) who visited a referral center in the western Brazilian Amazon. Data were collected through a structured questionnaire interview and medical examinations. Thus, information regarding sociodemographic and clinical aspects, blood pressure, weight, height, body mass index, and laboratory profile was obtained. Descriptive and analytical statistics were performed, and results were considered significant ifp <0.05. RESULTS: In total, 132 (44.3%) participants reported that their blood pressure was never measured. The prevalence of hypertension was found to be 35.9% (107/298). Of these 107 participants, only 36 (33.6%) had prior knowledge of their hypertensive status, and 19 of 36 (52.7%) participants had visited a physician or cardiologist to seek treatment. Adherence to the BP-lowering treatment was noted in 11 (10.2%) participants. CONCLUSIONS: An increased prevalence of hypertension was found, and most of the hypertensive participants were unaware of their hypertensive status. In addition, blood pressure control was poor in the study population. This indicated that public health professionals did not sufficiently consider the full spectrum of healthcare and disease management for PLHIV.

Confirmed Invasive Pulmonary Aspergillosis and COVID-19: the value of postmortem findings to support antemortem management

Abstract We present postmortem evidence of invasive pulmonary aspergillosis (IPA) in a patient with severe COVID-19. Autopsies of COVID-19 confirmed cases were performed. The patient died despite antimicrobials, mechanical ventilation, and vasopressor support. Histopathology and peripheral blood galactomannan antigen testing confirmed IPA. Aspergillus penicillioides infection was confirmed by nucleotide sequencing and BLAST analysis. Further reports are needed to assess the occurrence and frequency of IPA in SARS-CoV-2 infections, and how they interact clinically.

High-impact drop exercise alters mechanical properties in osteopenic bone / Exercício de queda altera as propriedades mecânicas em osso osteopênico / El ejercicio de caída altera las propiedades mecánicas en hueso osteopénico

ABSTRACT Introduction: Osteopenia is a reversible condition and precedes osteoporosis. Physical activity and mechanical loading appear to play an important role in the regulation of bone homeostasis, without the side effects of targeted drug therapy. However, there is controversy as to which type of stimulus promotes more effective adaptations with respect to mechanical properties of bones. Objective: To investigate the effects of high-impact drop training on bone structure after ovariectomy-induced osteopenia in 40 10-week-old female Wistar rats. Methods: Twenty female rats (prevention program) were randomly assigned into two groups (n=10): Ovariectomized sedentary (OVXs), and OVX trained (OVX+Dropt). OVX+Dropt animals began training 3 days after surgery. Another twenty female rats (treatment program) were randomly assigned to two other groups (n=10): Ovariectomized sedentary (OVXs), and OVX trained (OVX+Dropt). OVX+Dropt animals began training 60 days after surgery. The rats in the trained groups were dropped from 40 cm height 20 times/day, 5 days/week over a period of 12 weeks period. At the end, the biomechanical tests were analyzed. Results: The final load and stiffness of the left tibia in the trained groups were higher than in the sedentary groups (p<0.05). Conclusions: Dropping exercise induced favorable changes in bone mechanical properties. High-impact drop exercise is effective to prevent bone loss after ovariectomy even when osteopenia is already established.

RESUMO Introdução: A osteopenia é uma doença reversível e precede a osteoporose. A atividade física e a carga mecânica parecem desempenhar um papel importante na regulação da homeostase óssea, sem os efeitos colaterais da terapia medicamentosa direcionada. No entanto, é controverso qual tipo de estímulo promove adaptações mais eficazes com relação às propriedades mecânicas dos ossos. Objetivo: Investigar os efeitos do treinamento de queda com impacto sobre a estrutura óssea depois de osteopenia induzida por ovariectomia em 40 ratas Wistar com 10 semanas de idade. Métodos: Vinte ratas (programa de prevenção) foram distribuídas aleatoriamente em dois grupos (n = 10): Ovariectomizadas sedentárias (OVXs) e OVX treinadas (OVX + Dropt). Os animais OVX + Dropt começaram a treinar três dias após a cirurgia. Outras vinte ratas (programa de tratamento) foram alocadas aleatoriamente em outros dois grupos (n = 10): Ovariectomizadas sedentários (OVXs) e OVX exercitadas (OVX + Dropt). Os animais OVX + Dropt iniciaram o treinamento 60 dias após a cirurgia. As ratas nos grupos treinados foram deixadas cair 20 vezes/dia, 5 dias/semana, de altura de 40 cm durante um período de 12 semanas. Ao final, foram analisados os testes biomecânicos. Resultados: A carga final e a rigidez da tíbia esquerda nos grupos treinados foram maiores do que nos grupos sedentários (p < 0,05). Conclusões: O exercício de queda provocou alterações favoráveis nas propriedades mecânicas dos ossos. O exercício de queda com impacto é eficaz para prevenir a perda óssea após ovariectomia, mesmo quando a osteopenia já está estabelecida

RESUMEN Introducción: La osteopenia es una enfermedad reversible y precede a la osteoporosis. La actividad física y la carga mecánica parecen desempeñar un papel importante en la regulación de la homeostasis ósea, sin los efectos secundarios de la terapia farmacológica dirigida. Sin embargo, es controvertido qué tipo de estímulo promueve adaptaciones más eficaces con respecto a las propiedades mecánicas de los huesos. Objetivo: Investigar los efectos del entrenamiento de caída con alto impacto sobre la estructura ósea después de osteopenia inducida por ovariectomía en 40 ratas Wistar hembras de diez semanas de edad. Métodos: Se asignaron aleatoriamente veinte ratas (programa de prevención) en dos grupos (n = 10): Ovariectomizadas sedentarios (OVXs) y OVX entrenadas (OVX + Drope). Los animales OVX + Drope comenzaron a entrenar tres días después de la cirugía. Otras veinte ratas hembras (programa de tratamiento) fueron asignadas aleatoriamente a otros dos grupos (n = 10): Ovariectomizadas sedentarias (OVXs) y OVX entrenadas (OVX + Drope). Los animales OVX + Drope iniciaron el entrenamiento 60 días después de la cirugía. Las ratas en los grupos entrenados se dejaron caer de una altura de 40 cm 20 veces/día, 5 días/semana durante un período de 12 semanas. Al final, se analizaron las pruebas biomecánicas. Resultados: La carga y rigidez de la tibia izquierda en los grupos entrenados fueron mayores que en los grupos sedentarios (p < 0,05). Conclusiones: El ejercicio de caída provocó cambios favorables en las propiedades de los huesos. El ejercicio de caída con impacto es eficaz para prevenir la pérdida ósea después de la ovariectomía, incluso cuando la osteopenia ya está establecida.

G6PD deficiency in Latin America: systematic review on prevalence and variants

Plasmodium vivax radical cure requires the use of primaquine (PQ), a drug that induces haemolysis in glucose-6-phosphate dehydrogenase deficient (G6PDd) individuals, which further hampers malaria control efforts. The aim of this work was to study the G6PDd prevalence and variants in Latin America (LA) and the Caribbean region. A systematic search of the published literature was undertaken in August 2013. Bibliographies of manuscripts were also searched and additional references were identified. Low prevalence rates of G6PDd were documented in Argentina, Bolivia, Mexico, Peru and Uruguay, but studies from Curaçao, Ecuador, Jamaica, Saint Lucia, Suriname and Trinidad, as well as some surveys carried out in areas of Brazil, Colombia and Cuba, have shown a high prevalence (> 10%) of G6PDd. The G6PD A-202A mutation was the variant most broadly distributed across LA and was identified in 81.1% of the deficient individuals surveyed. G6PDd is a frequent phenomenon in LA, although certain Amerindian populations may not be affected, suggesting that PQ could be safely used in these specific populations. Population-wide use of PQ as part of malaria elimination strategies in LA cannot be supported unless a rapid, accurate and field-deployable G6PDd diagnostic test is made available.

Plasmodium vivax malaria elimination: should innovative ideas from the past be revisited?

In the 1950s, the strategy of adding chloroquine to food salt as a prophylaxis against malaria was considered to be a successful tool. However, with the development of Plasmodium resistance in the Brazilian Amazon, this control strategy was abandoned. More than 50 years later, asexual stage resistance can be avoided by screening for antimalarial drugs that have a selective action against gametocytes, thus old prophylactic measures can be revisited. The efficacy of the old methods should be tested as complementary tools for the elimination of malaria.

Efeito de regimes de treinamento físico de alto impacto nas propriedades mecânicas de ossos: estudo experimental em ratas wistar / Effects of high-impact exercise training on bone mechanical proprieties: an experimental study in female wistar rats

INTRODUÇÃO: A realização de atividade física garante benefícios ao tecido ósseo uma vez que o estresse provocado pelo carregamento promove adaptações positivas em suas propriedades mecânicas, sendo sua utilização uma estratégia não farmacológica para fortalecimento ósseo. OBJETIVO: investigar o efeito de protocolos de treinamento de alto impacto com frequências semanais e períodos diferentes nas propriedades mecânicas de ossos de ratas Wistar. MÉTODOS: Foram utilizadas 54 ratas Wistar, idade média de 10 semanas, divididas em seis grupos (n = 9): GCI (grupo controle, quatro semanas, sedentário), GTI3 (treinou três vezes por semana durante quatro semanas), GTI5 (treinou cinco vezes por semana, quatro semanas), GCII (grupo controle, oito semanas, sedentário), GTII3 (treinou três vezes por semana, oito semanas) e GTII5 (treinou cinco vezes por semana, oito semanas). O protocolo de alto impacto consistiu de 10 saltos verticais por sessão. RESULTADOS: Os ossos dos animais que receberam treinamento de alto impacto com frequência semanal elevada por um período maior de tempo mostraram valores superiores de suas propriedades mecânicas força máxima e rigidez relativa quando comparados aos demais grupos. CONCLUSÃO: Os resultados indicam que a realização de um protocolo de treinamento de alto impacto na forma de saltos verticais possui efeitos positivos sobre o tecido ósseo mesmo com frequência semanal reduzida, embora a realização de uma frequência semanal maior por um período mais elevado garanta melhores resultados.

INTRODUCTION: Physical activity has well established benefits on bone mechanical proprieties and is a non-pharmacological treatment strategy of bone weakening pathologies where given loading stress promotes adaptive responses that enhance bone strengthening. OBJECTIVE: to investigate the effect of high-impact exercise training protocols with different durations and weekly frequencies on bone mechanical proprieties of female Wistar rats. METHODS: fifty-four female Wistar rats, 10 weeks old, were divided into six groups (n=9 each): GCI (four week sedentary group, control), GTI3 (trained three times per week, four weeks), GTI5 (trained five times per week, four weeks), GCII (eight week sedentary group, control), GTII3 (trained three times per week, eight weeks) and GTII5 (trained five times per week, eight weeks). The high-impact training protocol was based on the completion of 10 vertical jumps by the animals per session. RESULTS: Bone mechanical proprieties in the groups that trained with higher weekly frequency for longer periods had greater maximum strength and stiffness when compared with the animals that trained less. CONCLUSIONS: the present results indicate that performance of high-impact training protocol has beneficial effects on bone mechanical proprieties, even with low weekly frequency, suggesting hence, that for bone gain, daily work volume is not necessary; however, for greater result, daily exercise does present better outcome.

Efecto de la esteatosis hepática en el resultado de reconstrucción de vía biliar por lesión iatrogénica / Effect of liver steatosis in outcome after bile duct reconstruction for iatrogenic injury

Introducción: La prevalencia de la esteatosis hepática no alcohólica en población general es de 30 %. Las lesiones iatrogénicas de la vía biliar durante colecistectomías tienen una frecuencia constante y algunos pacientes con estas lesiones padecen esteatosis hepática concomitante. No se ha determinado si la esteatosis hepática tiene una influencia negativa en la reconstrucción de vías biliares. Material y métodos: De una cohorte de pacientes sometidos a reparación de vías biliares seleccionamos a los que se les tomó biopsia hepática. Se dividieron en dos grupos: I, con esteatosis hepática y II, sin esteatosis hepática. Se compararon los resultados de la reconstrucción, complicaciones posoperatorias, pruebas de función hepática y la necesidad de reoperación. Resultados: en el grupo I, 18 casos; en el grupo II, 71. En 11 % del grupo con esteatosis y en 10 % del grupo sin esteatosis hubo disfunción de la anastomosis. En tres casos del grupo I (17 %) y en once del grupo II (15.5 %) fue necesaria la reintervención quirúrgica. Se rehabilitó completamente a 77 % de los casos del grupo I y a 66 % del grupo II. No se obtuvo ninguna diferencia estadísticamente significativa entre ambos grupos. Conclusiones: Los pacientes con esteatosis hepática tienen mayor incidencia de colelitiasis, por lo que su probabilidad de tener una lesión en la vía biliar es mayor. Los resultados de la reconstrucción de estas lesiones son similares entre pacientes con y sin esteatosis hepática. Los datos analizados no demostraron repercusión en los resultados de la cirugía al padecer esteatosis hepática.

BACKGROUND: The estimated prevalence of nonalcoholic fatty liver disease (NAFLD) in the overall population is 30%. Bile duct injuries associated with cholecystectomy have a constant frequency and some patients with these types of injuries have concomitant hepatic stenosis (HS). It has not been determined if HS has a negative outcome on the results of surgical bile duct repair. METHODS: Among a cohort of patients surgically repaired for bile duct injury, we selected those from whom a liver biopsy was obtained. Patients were divided into the following groups: group I--HS, group II--without HS. The groups were compared for long-term results of the reconstruction, postoperative complications, liver function test and need for reintervention. RESULTS: From group I we obtained 18 patients and from group II 71 patients. In 11% of the HS group and in 10% of the non-HS group anastomosis dysfunction was observed. Three cases in group I (17%) and 11 patients in group II (15.5%) needed further surgical reintervention. Complete rehabilitation was obtained in 77% of the cases in group I and 66% of patients in group II. No statistical differences were found in any features between groups. CONCLUSIONS: Patients with HS have a higher incidence of gallstone disease than the general population; hence, an increased probability of having a bile duct injury. The results of surgical reconstruction after these injuries are similar to those of patients without HS. Analyzed data showed no repercussion in outcome of patients with HS.

Revisión: Aborto recurrente / Review: Recurrent abortion

El aborto recurrente (AR) es una patología relativamente infrecuente, pero de difícil manejo tanto desde el punto de vista técnico como de la relación medico-paciente. Suele ser muy frustrante para las parejas que lo padecen, su estudio es dificultoso y presenta diversas etiologías: genéticas, anatómicas, endocrinas, autoinmunes, aloinmunes, infecciosas y ambientales, cuyo estudio a la fecha es insuficiente. Una vez establecido el diagnóstico de AR, el manejo debe ser de especialista en el área de la reproducción humana. La presente revisión tiene como objetivo actualizar las principales teorías y causas involucradas en el AR, contrastándolas con la evidencia científica disponible hasta el momento, así como también esbozar brevemente la aproximación diagnóstica y el enfoque terapéutico.

Evolución y medicina evolucionaria: una puesta al día / Evolution and evolutionary medicine: an update

La teoría de la evolución, enunciada en 1839, y la medicina evolucionaria, que data desde 1991, constituyen un cuerpo teórico ineludible y enriquecedor en la práctica médica actual, entregando importantes (más que urgentes) respuestas a los procesos patológicos humanos. El objetivo del presente trabajo es entregar a los médicos conceptos sobre evolución y medicina evolucionaria, sus principales métodos de estudio y las razones por las cuales estas disciplinas no deben soslayarse.

Consideraciones acerca de la anticoncepción hormonal de emergencia: "La pastilla o píldora del día después" / Emergency contraception is not the \"Abortion pill\" the twotherapies are entirely different and it is important not to confuse them

La anticoncepción hormonal de emergencia es aquella que actúa después de una relación sexual no protegida pero antes del embarazo. Frecuentemente se la denomina como el método de la "píldora del día después" o de "la mañana siguiente". La anticoncepción hormonal de emergencia debe realizarse dentro de las 72 horas que siguen a una relación sexual no protegida, es decir, antes de la fecundación y del inicio del embarazo. Existen varios métodos de anticoncepción hormonal de emergencias efectivos, entre los cuales los más utilizados con el de Yuzpe y el del levonorgestrel exclusivo. Estos implican solamente tomar una mayor dosis de anticonceptivos habituales por un día. Estos son verdaderos anticonceptivos que evitan el embarazo, sea inhibiendo o retrasando la ovulación. No provocan el aborto si la mujer ya está embarazada en el momento de tomar las píldoras.