Mal de Pott en paciente con insuficiencia hepática: presentación de un caso de probable tuberculosis espinal y revisión de literatura / Pott's disease on a patient with hepatic insufficiency: case presentation of probable spinal tuberculosis and literature review

Introducción: La Tuberculosis Espinal corresponde a una infección causada por Mycobacteriun tuberculosis localizada en la región vertebral. El tratamiento farmacológico de esta patología no está exento de complicaciones, principalmente dado por la toxicidad hepática. El caso clínico a presentar se centra en el tratamiento farmacológico en un paciente con Insuficiencia Hepática. Presentación del caso: Paciente de 58 años con antecedentes de Insuficiencia Hepática, inició cuadro de 3 meses de evolución caracterizado por dolor lumbar progresivo con escasa a nula respuesta a tratamiento analgésico. Al examen físico destacó dolor axial de columna lumbar, paresia M4 en L5, Lasegue y Tepe (-). Se solicitaron exámenes de imagenología y laboratorio, confirmándose probable diagnóstico de Tuberculosis Espinal. Se inició tratamiento antituberculoso alternativo. Discusión: El tratamiento universalmente aceptado es la asociación de Isoniazida, Rifampicina, Pirazinamida, Etambutol. En relación al caso clínico y a la Insuficiencia Hepática se recomienda no utilizar Pirazinamida y ante riesgo alto reemplazar el uso de Isoniazida por Fluoroquinolona. Además se recomienda medir enzimas hepáticas al inicio del tratamiento y durante su mantención. En caso de encontrarse elevadas, se recomienda iniciar un esquema con mínimo riesgo de toxicidad hepática, asociando Estreptomicina - Etambutol, mientras se normalizan las alteraciones. En el caso clínico presentado el esquema antibiótico considera la asociación de Estreptomicina, Etambutol y Fluoroquinolona. Es importante reconocer la clínica de la Tuberculosis Espinal, con el fin de proporcionar un tratamiento oportuno y eficaz, considerando el riesgo de hepatoxicidad de éste y su indicación en pacientes con diagnóstico de Insuficiencia Hepática.

Introduction: Spinal Tuberculosis corresponds to an infection caused by Mycobacterium tuberculosis located in the vertebral region. The pharmacological treatment of this pathology is not free of complications, mainly due to liver toxicity. The clinical case to be presented focuses on the pharmacological treatment in a patient with Hepatic Insufficiency. Case report: A 58-year-old patient with a history of Hepatic Insufficiency, started a 3-month evolution characterized by progressive lumbar pain with little to no response to analgesic treatment. Physical examination revealed lumbar spine axial pain, M4 paresis in L5, Lasegue and Tepe (-). Imaging and laboratory tests were requested, confirming the probable diagnosis of Spinal Tuberculosis. Alternative antituberculous treatment was started. Discussion: The universally accepted treatment is the association of Isoniazide, Rifampin, Pyrazinamide, Ethambutol. In relation to the clinical case and Hepatic Insufficiency, it is recommended not to use Pyrazinamide and at high risk to replace the use of Isoniazide with Fluoroquinolone. It is also recommended to measure liver enzymes at the start of treatment and during maintenance. In case of being elevated, it is recommended initiate a scheme with minimal risk of liver toxicity, associating Streptomycin - Ethambutol, while the alterations are normalized. In the clinical case presented, the antibiotic scheme considers the association of Streptomycin, Etambutol and Fluoroquinolone. It is important to recognize the clinic of Spinal Tuberculosis, in order to provide timely and effective treatment, considering the risk of hepatoxicity thereof and its indication in patients diagnosed with Hepatic Insufficiency

Cirugía bariátrica: Cambios fisiológicos en el tratamiento del síndrome metabólico / Bariatric Surgery: Physiological changes in the treatment of metabolic syndrome

La cirugía bariátrica (CB) consiste en una serie de procedimientos quirúrgicos que actúan restringiendo la capacidad gástrica y/o produciendo malabsorción parcial de los alimentos debido a diversas alteraciones fisiológicas de los péptidos incretinas, los ácidos biliares y del sistema autónomo; cuyo objetivo principal es generar pérdidas significativas de peso a corto y largo plazo, logrando reducir las morbilidades asociadas al Sindrome Metabólico (SM), el cual se asocia a mayor riesgo de enfermedad cardiovascular, Diabetes Mellitus tipo 2 (DM2), Hipertensión Arterial (HTA), lesiones tempranas en órganos blanco, entre otros. La persistencia de dichos beneficios a largo plazo ha permitido realizar estudios longitudinales observando la disminución del riesgo de aparición de enfermedades metabólicas, reducción del riesgo cardiovascular y la mortalidad general de obesos mórbidos. En este artículo de revisión se realiza una puesta al día de las evidencias que sustentan los beneficios de la CB como terapéutica en estos pacientes dado que ninguna otra intervención médica trata simultáneamente tantas comorbilidades.

Bariatric surgery consists in a series of surgical procedures that act through the restriction of gastric capacity or partial food malabsortion due to various physiological modifications of incretin hormones, bile acids and autonomous system; whose main objective is to generate short and long term significant weight loss, achieving to reduce morbidities associated with Metabolic Syndrome (SM) and the increased risk of cardiovascular disease, type 2 Diabetes Mellitus (DM2), Hypertension (HTA), early lesions in target organs and others. Most of the benefits of bariatric surgery persist long term, this feature has allowed longitudinal studies looking at the decreased risk of metabolic diseases, cardiovascular risk reduction and overall mortality in morbidly obese. This review is an update of the supporting the benefits of CB as therapy in these patients because no other medical intervention is simultaneously performed many comorbidities.

Metabolic Effects of Growth Hormones in Children

Ever since recombinant human growth hormones (GH) were produced in the 1980s, many studies on their metabolic effects have been performed. GH has been shown to have a diabetogenic action resulting in glucose intolerance. Even though there is no evidence that GH increases the risk of diabetes, HbA1c, glucose, insulin tests should be carried out during GH treatment. GH increases free fatty acids and glycerol, and inhibits fat formation. Moreover, GH degrades abdominal fat and redistributes it to peripheral areas. GH increases amino acid intake via IGF1, increases protein synthesis by directly enhancing the translation of the transcription mRNA, and inhibits protein degradation to form a positive nitrogen balance. GH produces sodium and water retention effects through the activation of Na+ K+ ATPase in distal nephron and renin-angiotensin-aldosterone axes and ANP receptor down-regulation. Metabolic side-effects with clinical significance due to GH treatment do not occur, however such side-effects of long-acting or high-dose GH treatment should be investigated. GH treatment can be used safely in children, yet it requires continuous and vigilant monitoring.

An evaluation of the metabolic effects of antipsychotic medications in patients suffering from psychiatric illness.

Present study evaluates the effects of antipsychotic medications on metabolic parameters in patients suffering from psychiatric illness. The study was carried out at tertiary care teaching hospital, department of psychiatry after obtaining written informed consent from the patients. They were randomized into three groups - Group I (n=31) (haloperidol 10 mg/day, orally), Group II (n=34) (risperidone 4-6 mg/day, orally) and Group III (n=38) (olanzapine 10 mg/day, orally). Metabolic parameters [fasting blood sugar (FBS), post prandial blood sugar (PP2BS), glycosylated haemoglobin (HbA1c), serum cholesterol, triglyceride, low density lipoprotein (S.LDL) and high density lipoprotein (S.HDL)] were measured at the end of 3 and 6 months. Data was analysed using a suitable statistical tests. In group II significant changes (p<0.05) were observed in FBS, HBA1C, cholesterol, S.LDL and S.HDL while in group III significant changes (p<0.05) were observed in all the metabolic parameters at the end of 6 months. In group III, FBS, PP2BS, HbA1C, Serum cholesterol, triglyceride and S.LDL levels were increased 9.41%, 7.09%, 8%, 6.25%, 7.68% and 9.92% respectively, at the end of 6 months. Patients treated with haloperidol showed minimum changes in metabolic parameters at the end of 6 months. Olanzapine is associated with more disturbances in metabolic parameters as compared to risperidone and haloperidol.

01-2 Special effects and mechanism of Ibusuki hot spring sand bath / 日本温泉気候物理医学会雑誌

  Ibusuki hot spring sand bath (SB) (Sunamushi) has traditionally been used for the relief of musculoskeletal pain. It is specified by piling up heavy (40-60 kg) and hot (50°C) sands on the lied body heated by the hot spring water gushed at the seashore of Ibusuki. In this study, remarkable circulatory activation and metabolic improvements probably due to thermal vasodilation and higher hydrostatic pressure is examined. Subjects: The subjects examined were 20 healthy males (34.3±10.5 yrs) who accepted informed consents. Methods: The subjects were thin bathrobe and kept rest for 30 min in the supine position. BP, HR and sublingual temperature measurements and venous blood sampling from the indwelling catheter was done. Blood counts, blood gas pressure and plasma chemistry were examined. Then sand bath carried out for 10 min and 30 min rest under keeping sufficient warmth by blankets. Results: Systolic blood pressure was significantly increased though diastolic blood pressure was significantly reduced. HR and sublingual temperature were significantly increased by +22 bpm and +1.1°C, respectively, just after 10 min SB. Venous blood pO2 and pH were significantly increased by +18.3 mm Torr and +0.03pH, and pCO2 was significantly reduced by -5.8 mm Torr. Lactate and pyruvate were significantly reduced after 10 min and 30 min after sand bath suggesting the improved peripheral oxidative metabolism. Conclusion: Increase in blood pressure and heart rate indicating cardiac acceleration was considered to be induced by hydrostatic pressure with heavy sands and thermal vasodilation. Improved peripheral circulation and oxidative metabolism were also suggested by increased pO2, decreased pCO2 and decreased lactate and pyruvate level. Sufficient O2 supply and removal of wasted substances due to activated circulation was considered to be the basic mechanism of the effects of sand bath.

SL1 Cardiovascular and metabolic effects of Ibusuki Hotspring sand bath (Sunamushi) / 日本温泉気候物理医学会雑誌

  Ibusuki hotspring sand bath (SB)(Sunamushi) is a special thermal therapy using heated sands by natural hotspring gushed at the seashore of Ibusuki city. Heated heavy sands (50°C, 40-60kg) was piled on the lied body. It has traditionally been used here for 250 years to relieve muculoskeletal and neuralgic pain, and still accepts 260 thousands visitors a year. In the present study, cardiovascular and metabolic effects by SB was studied from the viewpoint of accelerated circulation. Subjects and Methods: General physical parameters (BP, HR, sublingual temperature) and plasma chemistry were examined in 20 healthy males(36 ± 10yrs). The subjects wore thin bathrobe and a venous catheter for blood sampling were set in the forearm. They kept rest in the supine position for 30min and subjected 10min SB at the municipal SB institute with hotspring piping under the sands. In another 28 healthy subjects (44.3 ± 2.4yrs), cardiac outputs and plasma catecholamines (CA) and renin activity (PRA) were measured. In 6 subjects intracardiac study by Swan-Ganz catheterization were performed. Results: Diastolic pressure were significantly decreased by 6mmHg, and heart rate and sublingual temperature were significantly increased by +20bpm and +1.1°C, respectively, after 10min SB. Venous blood pO2 and pH was significantly increased by 20mm Torr and 0.03pH, and pCO2 was significantly reduced by 5mm Torr. Lactate, pyruvate and L/P ratio were significantly reduced suggesting improved oxidative metabolism of peripheral tissues. Plasma CAs and PRA were elevated after SB. All of these results gradually returned to the resting level after 30min. Cardiac output (CO) measured by dye dilution or thermo-dilution method was significantly increased from 5.6l/min to 10.5 l/min after 10min SB, and reduced to 8.1 l/min by removing piled heavy sands. Calculated total peripheral resistance (TPR) was significantly decreaased suggesting thermal vasodilation. Although mean right atrial pressure and pulmonary arterial pressure were increased during SB, they were immediately decreased by removing piled sands. Discussion: All of these results indicate that the basic effects of SB are derived from strong hydrostatic pressure of piled heavy sands and thermal vasodilation. Increased CO due to accelerated venous return and reduced afterload (TPR) will induce sufficient oxygen supply and increased discharge of wasted matters from peripheral tissues. These data seem to be compatible with the clinical effects of SB to relieve musculoskeletal pain and fatigue. Conclusion: Significant clinical effects is induced by increased CO due to the increased hydrostatic pressure of piled sands and thermal vasodilation.

SL1Cardiovascular and metabolic effects of Ibusuki Hotspring sand bath (Sunamushi) / 日本温泉気候物理医学会雑誌

  Ibusuki hotspring sand bath (SB)(Sunamushi) is a special thermal therapy using heated sands by natural hotspring gushed at the seashore of Ibusuki city. Heated heavy sands (50°C, 40-60kg) was piled on the lied body. It has traditionally been used here for 250 years to relieve muculoskeletal and neuralgic pain, and still accepts 260 thousands visitors a year. In the present study, cardiovascular and metabolic effects by SB was studied from the viewpoint of accelerated circulation.<BR><b>Subjects and Methods: </b>General physical parameters (BP, HR, sublingual temperature) and plasma chemistry were examined in 20 healthy males(36 ± 10yrs). The subjects wore thin bathrobe and a venous catheter for blood sampling were set in the forearm. They kept rest in the supine position for 30min and subjected 10min SB at the municipal SB institute with hotspring piping under the sands. In another 28 healthy subjects (44.3 ± 2.4yrs), cardiac outputs and plasma catecholamines (CA) and renin activity (PRA) were measured. In 6 subjects intracardiac study by Swan-Ganz catheterization were performed. <BR><b>Results: </b>Diastolic pressure were significantly decreased by 6mmHg, and heart rate and sublingual temperature were significantly increased by +20bpm and +1.1°C, respectively, after 10min SB. Venous blood pO₂ and pH was significantly increased by 20mm Torr and 0.03pH, and pCO₂ was significantly reduced by 5mm Torr. Lactate, pyruvate and L/P ratio were significantly reduced suggesting improved oxidative metabolism of peripheral tissues. Plasma CAs and PRA were elevated after SB. All of these results gradually returned to the resting level after 30min. Cardiac output (CO) measured by dye dilution or thermo-dilution method was significantly increased from 5.6l/min to 10.5 l/min after 10min SB, and reduced to 8.1 l/min by removing piled heavy sands. Calculated total peripheral resistance (TPR) was significantly decreaased suggesting thermal vasodilation. Although mean right atrial pressure and pulmonary arterial pressure were increased during SB, they were immediately decreased by removing piled sands.<BR><b>Discussion: </b>All of these results indicate that the basic effects of SB are derived from strong hydrostatic pressure of piled heavy sands and thermal vasodilation. Increased CO due to accelerated venous return and reduced afterload (TPR) will induce sufficient oxygen supply and increased discharge of wasted matters from peripheral tissues. These data seem to be compatible with the clinical effects of SB to relieve musculoskeletal pain and fatigue.<BR><b>Conclusion: </b>Significant clinical effects is induced by increased CO due to the increased hydrostatic pressure of piled sands and thermal vasodilation.

01-2Special effects and mechanism of Ibusuki hot spring sand bath / 日本温泉気候物理医学会雑誌

  Ibusuki hot spring sand bath (SB) (Sunamushi) has traditionally been used for the relief of musculoskeletal pain. It is specified by piling up heavy (40-60 kg) and hot (50°C) sands on the lied body heated by the hot spring water gushed at the seashore of Ibusuki. In this study, remarkable circulatory activation and metabolic improvements probably due to thermal vasodilation and higher hydrostatic pressure is examined.<BR><b>Subjects:</b> The subjects examined were 20 healthy males (34.3±10.5 yrs) who accepted informed consents. <BR><b>Methods:</b> The subjects were thin bathrobe and kept rest for 30 min in the supine position. BP, HR and sublingual temperature measurements and venous blood sampling from the indwelling catheter was done. Blood counts, blood gas pressure and plasma chemistry were examined. Then sand bath carried out for 10 min and 30 min rest under keeping sufficient warmth by blankets.<BR><b>Results:</b> Systolic blood pressure was significantly increased though diastolic blood pressure was significantly reduced. HR and sublingual temperature were significantly increased by +22 bpm and +1.1°C, respectively, just after 10 min SB. Venous blood pO₂ and pH were significantly increased by +18.3 mm Torr and +0.03pH, and pCO₂ was significantly reduced by -5.8 mm Torr. Lactate and pyruvate were significantly reduced after 10 min and 30 min after sand bath suggesting the improved peripheral oxidative metabolism. <BR><b>Conclusion:</b> Increase in blood pressure and heart rate indicating cardiac acceleration was considered to be induced by hydrostatic pressure with heavy sands and thermal vasodilation.Improved peripheral circulation and oxidative metabolism were also suggested by increased pO₂, decreased pCO₂ and decreased lactate and pyruvate level. Sufficient O₂ supply and removal of wasted substances due to activated circulation was considered to be the basic mechanism of the effects of sand bath.

Endocrine and metabolic consequences of being born small- or large-for-gestational age: a review

In this review article, the genetics of size at birth, prenatal metabolic programming and the endocrine and metabolic consequences of abnormal size at birth are discussed. In addition, the relevance of fetal origin of adult disease in developing countries and the public health implication as well as future perspectives are also discussed. Being born either small- or large-for-gestational age affects such children and adults in several ways. These include increased risk of type 2 diabetes mellitus, metabolic syndrome, oxidative stress, persistent reduction in growth, cardiovascular disease, osteoporosis and premature pubarche as well as adrenarche. Individuals with abnormal size at birth who experienced rapid growth in the first three years of life have the greatest risk for future metabolic abnormalities. The mechanisms involved in prenatal (fetal) metabolic programming in infants with abnormal size at birth are just beginning to be explored. Both the “thrifty genes” and the “thrifty phenotype” could result in adverse health consequences later in life on exposure to plentiful nutrition. The most important epigenetic reactions affecting genetic transcription are acetylation and methylation. However, the major challenge at this point in time is to link such alterations with modifications in gene expression and ultimately, with metabolic abnormalities encountered in adult life. Thus, developmental origins of health and disease (DOHaD) represent a relatively new frontier of research and with time, some of the discrepancies may be resolved.

El café y sus efectos en la salud cardiovascular y en la salud materna / Coffee, caffeine and its effects on cardiovascular health and maternal health

Caffeine is the principal active component of coffee and the effects of coffee consumption are mainly associated to this component. Caffeine is a methylxanthine, which acts as antagonist of adenine receptors at the nervous system. A great number of health effects, both beneficial and detrimental, have been associated to caffeine consumption: such as cardiovascular disease, type 2 diabetes, glucose tolerance and insulin sensitivity, hepatic cirrhosis, hepatocellular carcinoma, are included as the main targets. The present work reviews two of the main concerns about coffee and caffeine consumption: cardiovascular disease and maternal health (perinatal period). The general conclusion is that caffeine consumption up to 300 mg/day does not constitute a risk of myocardial infarction, hypertension, or modification of cardiovascular risk markers such as reactive C protein or homocysteine plasmatic levels. Similar conclusions are reached about the maternal health. Moderate caffeine consumption (300 mg/day or less) does not constitute a major risk of less conception, increased gestational diabetes, decrease fetal growth, or congenital defects. However, absence frisk may not be interpreted as a signal to stimulate coffee consumption during pregnancy. Future mothers, which are moderated coffee consumers, may be suggested to continue this consumption during pregnancy, but under medical supervision.

La cafeína es el principal componente activo del café y los efectos del consumo de café se asocian mayoritariamente a la cafeína, una metilxantina que actúa como antagonista de los receptores de adenina en el sistema nervioso. Son numerosos los efectos en la salud atribuidos a la cafeína, siendo algunos benéficos y otros deletéreos: en la salud cardiovascular, diabetes tipo 2, tolerancia a la glucosa y sensibilidad a la insulina, en la cinosis hepática y el carcinoma hepatocelular, entre otros efectos. Este artículo realiza una revisión de dos aspectos de preocupación en la salud pública relacionados con el consumo de café y la cafeína: su efecto en la salud cardiovascular y en la salud maternal (período perinatal). La conclusión general es que el consumo de cafeína, hasta 300 mg/día, no constituye un mayor riesgo de infarto al miocardio, de hipertensión, o de modificación de los niveles plasmáticos de indicadores de riesgo cardiovascular, como la proteína C reactiva y la homocisteína. En relación a la salud maternal, las conclusiones son similares, un consumo moderado de cafeína (300 mg/día o menos) no constituye un riesgo de menor concepción, de diabetes gestacional, de menor crecimiento fetal, o de defectos congénitos. La ausencia de riesgo, sin embargo, no constituye un estímulo al consumo de café durante el embarazo. Si el consumo de café por parte de la futura madre es moderado, puede considerarse la continuación del consumo durante el embarazo bajo supervisión médica.

Metabolic effects associated to the highly active antiretroviral therapy (HAART) in AIDS patients

The aim of this study was to evaluate the metabolic abnormalities (dyslipidaemia and insulin resistance) associated with highly active antiretroviral therapy (HAART) in AIDS patients, treated in Campo Grande, Mato Grosso do Sul, Brazil. The patients were distributed in five different groups: Group 1, HIV-infected without antiretroviral therapy; Group 2, with Zidovudine, Lamivudine and Efavirenz or Nevirapine; Group 3, with Zidovudine, Lamivudine and Protease Inhibitor; Group 4, with Stavudine, Lamivudine and Efavirenz or Nevirapine; and Group 5, with Stavudine, Lamivudine and Protease Inhibitor. The lipid and glucose profile were determined and statistics comparison was made. The findings of this study showed significant statistics elevations of total cholesterol and triglycerides levels in patients of Groups 3, 4 and 5, when comparing to patients of Groups 1 and 2. Significant differences were not observed between the groups in the others parameters evaluated: Glucose, HDL cholesterol and LDL cholesterol. Comparing two drugs of same class (NNRTI) through the subgroups II-efavirenz and II-nevirapine, significant differences in the serum levels of total cholesterol, triglycerides and glucose favorable to the subgroup II-NVP were observed. These findings suggest that combinations including Protease Inhibitors and/or Stavudine could cause more adverse metabolic effects, and if possible, should be avoided in patients with others cardiovascular risk factors to prevent the precocious atherosclerosis in AIDS patients receiving HAART.

Body Weight Gain and Metabolic Changes in Patients with Schizophrenia during 12-Week Randomized Treatment of Ziprasidone and Risperidone / 대한정신약물학회지

OBJECTIVE: Body weight gain and metabolic syndrome are frequent adverse side effects of atypical antipsychotics. However, ziprasidone has been reported to have less effect on body weight and other metabolic parameters of patients, such as blood glucose and cholesterol. In this study, changes in the body weight and metabolic parameters were compared between the treatment groups of ziprasidone and risperidone in the patients with schizophrenia or schizoaffective disorder. METHODS: Patients shown acute exacerbation of schizophrenia or schizoaffective disorder diagnosed by DSM-IV diagnostic criteria were randomly assigned to ziprasidone 40-80 mg b.i.d. (N=56) or risperidone 1-4 mg b.i.d. (N=56) for 12 weeks. Body weight was measured before treatment and at 1st, 2nd, 4th, 6th, 12th week after treatment. The serum levels of glucose and cholesterol were checked before treatment and 12th week after treatment, and serum levels of prolactin before treatment and at 4th and 12th week after treatment. RESULTS: Less gain of body weight was shown in the patients treated with ziprasidone compared to those treated with risperidone. Mean body weight gain for 12 weeks were 0.8 kg and 3.5 kg in the ziprasidone and risperidone group, respectively. There was significant difference in weight gain between these two groups from 4th week. Serum prolactin elevation was higher in the risperidone group than in the ziprasidone group. However, there were no significant differences in the effects on the level of blood glucose and cholesterol between two treatment groups. CONCLUSION: This study shows that ziprasidone had less effect on body weight and prolactin compared to risperidone in the patients with schizophrenia or schizoaffective disorder in Korea. Although further studies are necessary to investigate the long-term effects, the less effect of ziprasidone on body weight and serum prolactin in schizophrenia and schizoaffective patients in Korea may help to enhance treatment compliance and lessen the cardiovascular risks.