Impacto del cambio climático en la salud / The impact of climate change on health

Climate changes evidenced by an increase in our planet's mean temperature, changes in rainfall, increased sea level and extreme weather conditions, favor air and soil contamination, ocean acidification, droughts, floods, heat waves and forest fires, which affect the health and wellbeing of exposed populations. These changes will exert negative effects on respiratory and cardiovascular systems, nutritional status, burden of infectious diseases, especially vector-borne infections, and human mental health. Moreover, environmental damages, such as loss of biodiversity, ecological collapse and deterioration of socioeconomic factors such as agricultural and fishery production, and the loss of habitable land, will impulse massive migrations. This article summarizes the impact that climate change is expected to have on respiratory, cardiovascular and infectious diseases and its repercussions on people of extreme ages. It is imperative to achieve the immediate commitment of worldwide national governments to control green-house gas emissions. The appropriate technology does exist, but political will is urgently needed to accomplish this goal.

Evaluación de la infección por VIH en Chile: pronunciamiento del Comité VIH de la Academia Chilena de Medicina / Evaluation of HIV epidemic in Chile: a statement of the Chilean Academy of Medicine

The Chilean Academy of Medicine convened a commission to evaluate the status of HIV epidemic and the national response to it, regarding its achievements, gaps and challenges, aiming to recommend actions to optimize assessment quality and national response. This publication summarizes the agreed upon opinion of its members. The epidemic is overwhelmingly sexually transmitted, predominant in homo/bisexual men. Vertical transmission is very low. An increasing number of new diagnoses is occurring, with relative over representation of foreign people lately. There is a legal guarantee of confidentiality, nondiscrimination and treatment for those affected, both in the private and public sector. All public health services have active HIV care units. Modern antiviral drugs and monitoring tests are also available. Despite these clear achievements, insufficient, occasionally inadequate public policies and certain rigid regulations thwart optimal effectivity and efficiency of the programs, contributing to the slow and incomplete compliance with international commitments. Shortcomings worth highlighting are: suboptimal educational and preventive programs directed to youngsters, vulnerable and general population; persistent underdiagnosis of infected population; cumbersome requirements to request and inform diagnostic tests, thus discouraging testing; excessive centralization and long latency of diagnosis confirmation and monitoring tests; incomplete epidemiologic analysis and public reporting of findings; non flexibility and slow updating of therapeutic guidelines; insufficient adaptation of care and drug delivery modalities to patients' needs; excessive administrative requirements at care centers and restrictive legislation for outcome and interventional clinical research. Recommendations to deal with these issues were proposed.

Evolución de mortalidad, abandono, traslado y retención a corto, mediano y largo plazo en pacientes con infección por VIH: Fundación Arriarán 1990-2015 / Evolution of mortality, retention and loss to follow up of HIV infected subjects followed in a special clinic

Background: The HIV epidemic reached Chile in late 1980s and as an early response, AIDS care centers were organized. Fundación Arriarán (FA) was the first center. Free antiretroviral therapy (ART) was later provided with progressive coverage and complexity over the years. Aim: To quantify evolution of mortality, retention and loss to follow up (LTFU) over 25 years according to different periods of access to ART, from no availability to full coverage with current drugs at FA center. Material and Methods: Retrospective analysis of FA database of 5,080 adults admitted between 1990 and 2014. The sample was distributed in 7 groups: A: no ART (1990-92), B: monotherapy, C: dual therapy, D: dual/triple ART, E: early triple therapy with incomplete coverage, F same as E but with complete coverage and G: contemporary ART (2008-14). Mortality, retention and LTFU were evaluated at 1, 3, 5, 7 and 10 years and at 31/12/2015. Results: Mortality varied from 40% to 2%, and 62% to 7% at 1 and 5 years, for groups A and G respectively; from 71% to 16% at 10 years for groups A and E, respectively. Retention at 5 years were 28%, 23%, 39%, 62%, 75%, 75% and 77% for groups A to G, respectively. LTFU was 10%, 19%, 15%, 17%, 9% 12% and 10% at 5 years for same groups, respectively. At 12/31/2015 22% of patients had died, 11% were LTFU, 60% were retained in care and 6% had been transferred. Conclusions: There is a marked reduction in mortality and increase in retention of HIV patients' concomitant to expanded access to modern therapy, although LTFU remains a problem.

Actinomicosis torácica por actinomyces odontolyticus / Pulmonary actinomycosis by actinomyces odontolyticus. A case report and review of the literature

Introduction: Actinomycosis is an infrequent infection caused by bacteria from Actinomyces genus that manifests as a chronic, suppurative and progressive disease. Thoracic actinomycosis occurs in 18 percent of the cases, and infection by Actinomyces odontolyticus is even less frequent. The clinical presentation mimics tuberculosis or neoplastic processes. Clinical case: We report the case of a 75 years old man with COPD and Diabetes Mellitus type 2. He was referred to our clinic presenting a history of chronic cough, progressive dyspnea, fever and occasional bouts of haemoptysis. Chest radiograph showed a peripherally-located parenchymal opacity in the upper right lobe with over a year of evolution that later became a cavitary mass mimicking bronchogenic neoplasm or tuberculosis. The patient underwent bronchoscopic and CT- guided biopsy that showed necrosis and inflammatory cells. In the culture of cavitary fluids grew Actinomyces odontolyticus. We concluded that it was a thoracic actinomycosis. Penicillin 20 million units per day for six weeks was given, followed by oral amoxicillin for 6 months with good clinical and radiological response. Comments: To our knowledge this is the first report in Chile of lung infection caused by Actinomyces odontolyticus. Actinomycosis is a great masquerader, in this case we made the diagnosis with a fluid culture. This microorganism must be considered in the differential diagnostic in cavitary lung diseases.

Introducción: La actinomicosis pulmonar es una infección infrecuente causada por una bacteria del género Actinomyces, se manifiesta como un proceso crónico, supurativo de curso progresivo, el compromiso torácico ocurre aproximadamente en el 18 por ciento de los casos y la infección por Actinomyces odontolyticus es aun menos frecuente. Caso clínico: Se presenta el caso de un paciente hombre de 75 años de edad con antecedentes de EPOC y Diabetes Mellitus tipo 2, que fue derivado a nuestra clínica por cursar con una reagudización infecciosa persistente caracterizada por tos productiva, disnea progresiva,fiebre y episodios reiterados de hemoptisis de escasa cuantía. En la radiografía de tórax y tomografia computada, se detectaron opacidades mal definidas en lóbulo superior derecho de un año de evolución, que posteriormente se transforman en una masa cavitada adyacente a la pared toráxica simulando una neoplasia broncogénica o tuberculosis. El paciente fue sometido a fibrobroncoscopía realizándose biopsia y punción transbronquial. Posteriormente se efectuó biopsia por punción trans-toráxica guiada radiológicamente y en una muestra de tejido de aspecto necrótico y en líquido de la cavidad enviado a cultivo se pudo aislar Actinomyces odontolyticus. Concluyéndose que se trataba de una actinomicosis tóraco-pulmonar, se procedió a tratar con penicilina sódica 20 10(6) UI/dia por seis semanas y después se programó tratamiento por seis meses con amoxicilina vía oral, con buena respuesta clínica y radiológica. Comentarios: En nuestro conocimiento esta sería la primera comunicación en Chile de una lesión pulmonar producida por Actinomyces odontolyticus. La Actinomicosis, es un gran imitador, en este caso realizamos el diagnóstico con cultivo de líquido por punción. Este microorganismo debe ser considerado en el diagnóstico diferencial de lesiones cavitarias pulmonares.

Diagnóstico bacteriológico de tuberculosis pulmonar mediante fibrobroncoscopía en pacientes con VIH / Bacteriological diagnosis of lung tuberculosis through bronchoscopy in HIV-infected patients

Tuberculosis can be lethal in HIV infected people. Lung is the organ most frequently involved, but clinical and radiological features are not typical of the disease. Diagnostic certification demands acid-fast bacillus microscopy and mycobacterial cultures on sputum. Some patients need bronchoscopy to obtain samples due to insufficient sputum. We reported a 9.1 percent diagnostic yield using bronchoscopy. Clinical suspicion before bronchoscopy had low positive predictive value of tuberculosis (10.8 percent). 47.8 percent of tuberculosis cases were not suspected before this procedure. Tuberculosis patients showed CD4 < 200 cells/mL (48.8 in average) and less use of ART (antiretroviral therapy). Cultures contributed to the diagnosis of 35 percent of tuberculosis cases but with a delay of 30 days. Induced sputum is a less costly alternative to bronchoscopy with a similar diagnostic yield.

La tuberculosis puede ser letal en pacientes infectados por VIH. El compromiso pulmonar es más frecuente en ellos y su cuadro clínico-radiológico no es típico de la enfermedad. El diagnóstico se confirma con baciloscopía y cultivo de Koch en esputo. Los pacientes sin esputo pueden requerir broncoscopía. Encontramos un rendimiento de 9,1 por ciento en diagnóstico de tuberculosis pulmonar por broncoscopía. La sospecha clínica de tuberculosis previa a broncoscopía tuvo bajo valor predictivo positivo (10,8 por ciento). 47,8 por ciento de los pacientes con Tuberculosis no fueron sospechados antes de la broncoscopía por lo que recomendamos este procedimiento en pacientes VIH con alteraciones radiológicas y síntomas respiratorios. Los casos de tuberculosis tenían CD4 < 200 células/mL (promedio 48,8) y menos uso de TAR: terapia antiretroviral. El 35 por ciento de los casos de tuberculosis se diagnosticó por cultivo (demora mínima de 30 días). El esputo inducido es una alternativa a la broncoscopía menos costosa y de similar rendimiento.

Prevalencia, factores de riesgo y manejo de la depresión en pacientes con infección por VIH: Revisión de la literatura / Depression in HIV infection: Prevalence, risk factors and management

Depression is one of the main psychiatric co-morbidities in HIV infection, presenting with a significantly higher prevalence than in the general population (around 35 percent). Its presence has been associated with poor quality of life, HIV disease progression and poor adherence to antiretroviral therapy. Although antidepressive treatment has demonstrated effectiveness on the management of depressive symptoms, improvement of clinical and laboratory parameters, and enhancement of antiretroviral adherence, depression is frequently under diagnosed and under treated in these patients. We analyzed the main international findings on depression prevalence, risk factors, con-sequences and management in people with HIV disease.

La depresión es una de las principales co-morbilidades psiquiátricas en el curso de la infección por VIH, presentándose con una prevalencia significativamente mayor que en población general (alrededor de 35 por ciento). Su presencia se ha asociado a deterioro de la calidad de vida, progresión de la enfermedad por VIH y disminución en la adherencia a la terapia anti-retroviral. El adecuado tratamiento antidepresivo ha demostrado ser efectivo en el manejo de la sintomatología depresiva, en la mejoría de parámetros clínicos y de laboratorio, y en reforzar la adherencia a la terapia anti-retroviral. A pesar de su importancia, la depresión suele ser sub-diagnosticada y sub-tratada en estos pacientes. En este trabajo se revisan los principales hallazgos internacionales sobre prevalencia, factores de riesgo, consecuencias y abordaje de la depresión en personas infectadas por VIH.

Resistencia a la terapia antirretroviral en pacientes infectados con el virus VIH-1 en Chile 2002-2005 / Resistance to anti-retroviral therapy in Chilean patients with HIV-1 from 2002 to 2005

Background: Resistance limits the effectiveness of anti-retroviral therapy. In Chile, there is free access to highly active anti-retroviral therapy since 2001, but there is no information about the frequency of mutations associated to drug resistance. Aim: To determine the most common mutations associated to anti-retroviral drug resistance in Chile. Materials and Methods: Retrospective study of 710 genotype analysis coming from 568 patients aged 22 to 70 years (85 percent males) with virological failure. The analysis was performed using a commercially available sequencing kit (Trugene HIV-1 genotypic assay from Bayer S.A). Results: Mean CD4+ cell count and viral load were 154 cells/fil and 228784 RNA copies/ml, respectively. The frequency of resistance to nucleoside RT inhibitors (NRTI), non nucleoside RT inhibitors (NNRTI) and protease inhibitors (PI) was 71 percent, 62 percent and 22 percent, respectively. The most common mutations found were T215Y (46 percent), L10F (44 percent), Ml84V (3896), K103N (35 percent) and M41L (32 percent). Fifty five percent of mutations corresponded to the TAM (thymidine analogue mutations) group. Multiresistance was 47 percent to NNRTI, 7 percent to NRTI, 4 percent to PI and 0.7 percent to all groups. During the four years of the study, there was a significant increase in NNRTI resistance. Conclusions: These data provides important information about the epidemiology of drug resistance mutations and should help to design newHAARTstrategies.

Evolución de mortalidad y estado actual de una población infectada por VIH controlada en un centro multiprofesional / Evolution of mortality and current status of an HIV-infected population cared for at a comprehensive HIV/AIDS center in Chile

Background: Chile, a middle-income country with an HIV epidemic of moderate proportions (global infection rate 0.2%) began a government sponsored, free, highly active antiretroviral therapy (HAART) for patients from the public health system in 2001 reaching in 2004 a 100% coverage. Arriaran Foundation (AF) is the largest public AIDS care center for adults in the country. Aim: To show the present status of the AF population and the evolution of mortality. Material and Methods: Review of AF database from 1991-2004 that at 12/31/2004 had a total cumulative population of 2,259 adult patients; an active census of 1,065 patients and admitting rate 160-190 patients per years. Results: The global mortality registered was 33.4%, with decreasing annual mortality from 15.7% of its active population in 1995 to 1.9% in 2004. As of 12/31/2004, 817 patients (76.7%) were receiving antiretroviral therapy (ART); and 19.3% either did not require nor accept it. Thirty one percent received Combivir® and nevirapine, with undetectable viral load (<400 copies per ml) in 78%. Thirty percent received Combivir® and efavirenz with undetectable viral load in 80% at last count. Both regimens were used mainly as first therapy. Lopinavir/ritonavir was received by 6.3% of patients, mainly for post failure therapy and 58% had undetectable viral load. A baseline CD4 count <200 x mm3 was present in 70% of patients, 45.3% had a count below 100 and 47.8% had clinical AIDS. At the last follow up assessment, CD4 count was <200 in 36.8%, <100 in 10.6% and 200-350 in 44.9%. Conclusion: The expanded access program to ART in a public, comprehensive AIDS care center in Chile has been highly successful in reaching high undetectability (75%), reducing mortality and improving immune status despite very advanced baseline disease.

Tratamiento de la neumonía del adulto adquirida en la comunidad / Treatment of community-acquired pneumonia in adults

Appropriate antibiotic treatment reduces the duration of symptoms associated to pneumonia, the risk of complications and mortality. In most cases, it is not possible to identify the etiologic agent so antibiotic treatment is empirically prescribed. In Chile, one third of Streptococcus pneumoniae strain isolates has diminished susceptibility to penicillin; in-vitro erythromycin resistance is about 10-15% and cefotaxime resistance 2-10%. It is recommended to classify patients with community acquired pneumonia in four risk categories: Group 1: patients under 65 years without co-morbidities, in ambulatory attendance. Treatment: oral amoxicillin 1 g TID, 7 days. Group 2: patients over 65 years and / or co-morbidities, in ambulatory attendance. Treatment: oral amoxicillin/clavulanate 500/125 mg TID or 875/125 mg BID, or cefuroxime 500 mg BID, 7 days. Group 3: patients admitted to general wards with criteria of moderate severity. Treatment: ceftriaxone 1-2 g once a day or cefotaxime 1 g TID, IV, 7-10 days. Group 4: patients with severe CAP that must be interned into ICU. Treatment: ceftriaxone 2 g once a day or cefotaxime 1 g TID, IV, associated to erythromycin 500 QID, levofloxacin 500-1.000 mg once a day, or moxifloxacin 400 mg/once a day, IV, 10-14 days. In the presence of allergy to or treatment failure with betalactam drugs and/or positive serology for Mycoplasma, Chlamydia or Legionella sp it is recommended to add: erythromycin 500 mg QID, IV or oral, oral clarithromycin 500 mg BID, or oral azythromycin 500 mg once a day.

El tratamiento antimicrobiano apropiado reduce la duración de la sintomatología asociada a la neumonía, el riesgo de complicaciones y la mortalidad. En la mayoría de los casos, no es posible identificar el agente microbiológico que ocasiona la infección y por esto el tratamiento antibacteriano se prescribe en forma empírica. En Chile, un tercio de las cepas de Streptococcus pneumoniae muestra susceptibilidad disminuida a penicilina; mientras que la resistencia a eritromicina fluctúa entre 10-15% y a cefotaxima entre 2-10%. Se recomienda clasificar a los pacientes con neumonía comunitaria en cuatro categorías de riesgo: Grupo 1: pacientes bajo 65 años de edad, sin comorbilidad de manejo ambulatorio. Tratamiento: amoxicilina 1 gramo cada 8 horas vía oral durante 7 días. Grupo 2: pacientes sobre 65 años de edad y/o con comorbilidad de manejo ambulatorio. Tratamiento: amoxicilina/ácido clavulánico 500/125 mg cada 8 horas ó 875/125 mg cada 12 horas, o cefuroxima 500 mg cada 12 horas vía oral durante 7 días. Grupo 3: pacientes hospitalizados en sala de cuidados generales que tienen criterios de gravedad moderada. Tratamiento: ceftriaxona 1-2 g/día o cefotaxima 1 g cada 8 horas EV durante 7-10 días. Grupo 4: pacientes con neumonía comunitaria grave que deben ser manejados en la UCI. Tratamiento: ceftriaxona 2 g/día o cefotaxima 1 g cada 8 horas EV asociado a eritromicina 500 mg cada 6 h, levofloxacina 500-1.000 mg/día, o moxifloxacina 400 mg/día EV durante 10-14 días. En presencia de alergia o fracaso de tratamiento con agentes b-lactámicos y/o serología positiva para Mycoplasma, Chlamydia o Legionella sp se recomienda agregar: eritromicina 500 mg cada 6 h EV o VO, claritromicina 500 mg cada 12 h VO, o azitromicina 500 mg/día VO.

Uso y abuso de antibióticos: momento de su evaluación, más allá del ser humano / Use and misuse of antibiotics: time to evaluate it beyond humans

Antibiotics, once called the ®wonder drugs¼ might be loosing their magic through development and dissemination of bacterial resistance. We are very responsible for that by way of inappropriate and excessive use of them. Although we have not created the problem we have promoted, accelerated and amplified it. So we used to think. Now we can share the blame: massive use in animal feed, seems to be contributing a great deal to the same effect, and they are not even used to treat infections, but to promote growth and weight gain. Dubious purpose, since same effects can be achieved with better and more hygienic feeding practices. Equal or larger amounts of antibiotics are thought to be used for this purpose than for human health. Resistance in animal flora and transmission to humans has been inevitable. In this issue, F Cabello reports this practice in Chilean aquaculture: greater amounts than in other countries and a wider range of antimicrobials are used here, some sharing chemical and spectrum properties with those for human use, some slowly biodegradable. This situation may have a great impact in bacterial resistance locally, along with other untoward consequences of exposing unnecessarily salmons, humans and the environment to bioactive products. The time to openly discuss the practice, probably quite unknown to the general public, and perhaps to some authorities, has come (Rev Méd Chile 2004, 132: 909-10).

Consideraciones clínico-epidemiológicas en relación a la etiología de las endocarditis infecciosas / Clinic-epidemiologycal considerations related with the infectious endocarditis etiology

La endocarditis infecciosa (EI) persiste como patología frecuente y trascendente. Ha cambiado en relación a la endocarditis subaguda tradicional de antaño: otros tipos de huéspedes, otros factores de riesgo y patologías subyacentes y modificaciones en la distribución etiológica y resistencia de sus agentes causales. Siguen predominando largamente los agentes bacterianos clásicos, aunque se están reconociendo agentes atípicos dados los progresos del diagnóstico microbiológico, serológico y molecular. Desde un punto de vista práctico es útil diferenciar 4 tipos de endocarditis, con distintas manifestaciones, criterios diagnósticos comunes y, en particular, diferente distribución etiológica, que ayuda a buscar con dedicación preferencial los agentes más característicos o, en caso de fallar en el diagnóstico etiológico orientar y dirigir la terapia empírica. Se distingue la clásica EI de paciente valvulópata previo de adquisición extrahospitalaria en donde predomina Streptococcus spp largamente seguido de S aureus y Enterococcus sp. Está luego la EI del paciente con drogadicción endovenosa, excepcional en Chile, cuya etiología mayoritaria es S aureus y en menos grado bacilos Gram negativos (BGN) y menos aún hongos. EI en valvula protésica con etiología variable de acuerdo al momento de ocurrencia, primando S aureus, S coagulasa negativo (SCN), BGN y hongo en la fase precoz, y una distribución más clásica en los casos tardíos sin nunca perder importancia S aureus y SCN. Finalmente están las EI nosocomiales de pacientes con múltiples patologías de base, no siempre cardíacas que hacen EI como consecuencia de bacteremias nosocomiales cuya etiología representa la distribución de éstas, pero predominando S aureus, SCN y BGN.

Características clínicas e historia natural de la infección por virus de inmunodeficiencia humana: estudio de una población chilena atendida en un centro piloto multiprofesional / Clinical characteristics and natural history of human immunodeficiency virus infection: study of a chilean population from a pilot multi-professional center

Four hundred and eighty six infected adults (90,7 percent men) were prospectively followed from 1988 to 1993 at a multi-professional center in Santiago, Chile. 87,8 percent of male patients (pts), 84 percent of them homo/bisexual, and 64,4 percent of women acquired the infection sexually. At the beginning of the follow up (F/U) 51 percent of men and 71 percent of women were asymptomatic and 30 percent of the total group had AIDS. (AIDS definition: CDC 1993, excluded CD4 lymphocyte count <200 x mm3). 240/486 (49,4 percent) had developed AIDS at the end of the study (12/31/93). AIDS defining events (ADE) were: interstitial pneumonia (confirmed or suggestive as caused by P. carinii [PCP]), 25 percent; tuberculosis (all forms), 22.1 percent; wasting, 13.8 percent; Kaposi Sarcoma, 9.2 percent; esophageal candidiasis, 6.7 percent; isosporiasis, 5,4 percent. Of all PCP cases, 72 percent were ADE, the rest, post AIDS'. As expected, AIDS pts continued having major complications (mainly bacterial pneumonias, PCPs, esophagitis, tuberculosis and diarrhea due to I. belli and Cryptosporidium. Less frequently, but also observed, were toxoplasmic encephalitis and cryptococcal meningitis). Known mortality (excluded abandonment of F/U) was 27 percent for the whole group and varied from 5.8 percent, 51,6 percent to 69.2 percent for the first, 4th and 6th yaer of F/U respectively. For II-III CDC pts the mortality was 5 percent and 57 percent and for IV CDC pts it was 38 percent and 100 percent during the first and 6th year of F/U respectively. 36 percent, 53 percent, 74 percent and 85 percent of the pts followed for 1, 3, 5 and 6 years respectively had developed AIDS by the end of 1993. Multifactorial causes with either diarrhea, wasting or both were responsible for the death in half the pts in whom this was known, 15 percent died of respiratory complications and 5,7 percent of cryptococcal meningitis. 80 percent of AIDS pts survived their ADE. This study has provided information about the clinical profile of the HIV infection and natural history of the disease in Chile

Infecciones intra-hospitalarias / Intra-hospitalary infections

Se evaluó la existencia de subnotificación de infecciones intrahospitalarias (IIH) con el método de notificación voluntaria a través de un estudio comparativo entre incidencia notificada (IN) y prevalencia encontrada (PE) en 6 servicios de un hospital general. La menor IN fue en Obstetricia (1.3 por ciento) y la mayor fue en Cirugía y Pediatría (10 por ciento). la PE varió entre 15.3 por ciento (Pediatría>) y 25 por ciento (Cirugía y Obstetricia). El promedio de IN fue de 3.5 por ciento y de PE de 20.2 por ciento (1:5,8). El 62.4 por ciento (IN) y 63.7 por ciento (PE) de los pacientes con IIH habían recibido antibioterapia previa. El 58.2 por ciento de las IIH (IN) eran causadas por bacilos gram negativos (BGN). En el 75 por ciento de estos pacientes había antibioterapia previa y el 50.2 por ciento de los BGN eran resistentes a gentamicina a diferencia de un 32 por ciento de resistencia del total de cepas gram negativas de pacientes hospitalizados (P<0.001). El 32.8 por ciento de las IIH (PE) eran causadas por BGN, en el 91 por ciento de los casos hubo antibioterapia previa, el 50 por ciento de las cepas eran resistentes a gentamicina. Se concluye que el método actual de notificación voluntaria de IIH aporta datos insuficientes cuantitativamente y cualitativamente. Estudios de prevalencia periódica parecen más aconsejables