[Alport syndrome. Report of two cases]. / Repercusiones oculares del Síndrome de Alport: A propósito de dos casos.

Alport syndrome is an inherited progressive form of glomerular disease that is often associated with sensorineural hearing loss and ocular abnormalities. We report two men with Alport syndrome. Both had chronic kidney disease and consulted for long-term loss of visual acuity. One had auditory abnormalities. On the ophthalmological examination, both had anterior lenticonus and one had dot or fleck retinopathy. Those findings are described in up to 50% and 70% of men with X-linked Alport syndrome, respectively. Both patients had a family history of Alport syndrome or suggestive signs and symptoms.

Repercusiones oculares del Síndrome de Alport: A propósito de dos casos / Alport syndrome. Report of two cases

Alport syndrome is an inherited progressive form of glomerular disease that is often associated with sensorineural hearing loss and ocular abnormalities. We report two men with Alport syndrome. Both had chronic kidney disease and consulted for long-term loss of visual acuity. One had auditory abnormalities. On the ophthalmological examination, both had anterior lenticonus and one had dot or fleck retinopathy. Those findings are described in up to 50% and 70% of men with X-linked Alport syndrome, respectively. Both patients had a family history of Alport syndrome or suggestive signs and symptoms.

Latin American and Caribbean consensus on noninvasive central nervous system neuromodulation for chronic pain management (LAC2-NIN-CP).

INTRODUCTION: Chronic pain (CP) is highly prevalent and generally undertreated health condition. Noninvasive brain stimulation may contribute to decrease pain intensity and influence other aspects related to CP. OBJECTIVE: To provide consensus-based recommendations for the use of noninvasive brain stimulation in clinical practice. METHODS: Systematic review of the literature searching for randomized clinical trials followed by consensus panel. Recommendations also involved a cost-estimation study. RESULTS: The systematic review wielded 24 transcranial direct current stimulation (tDCS) and 22 repetitive transcranial magnetic stimulation (rTMS) studies. The following recommendations were provided: (1) Level A for anodal tDCS over the primary motor cortex (M1) in fibromyalgia, and level B for peripheral neuropathic pain, abdominal pain, and migraine; bifrontal (F3/F4) tDCS and M1 high-definition (HD)-tDCS for fibromyalgia; Oz/Cz tDCS for migraine and for secondary benefits such as improvement in quality of life, decrease in anxiety, and increase in pressure pain threshold; (2) level A recommendation for high-frequency (HF) rTMS over M1 for fibromyalgia and neuropathic pain, and level B for myofascial or musculoskeletal pain, complex regional pain syndrome, and migraine; (3) level A recommendation against the use of anodal M1 tDCS for low back pain; and (4) level B recommendation against the use of HF rTMS over the left dorsolateral prefrontal cortex in the control of pain. CONCLUSION: Transcranial DCS and rTMS are recommended techniques to be used in the control of CP conditions, with low to moderate analgesic effects, and no severe adverse events. These recommendations are based on a systematic review of the literature and a consensus made by experts in the field. Readers should use it as part of the resources available to decision-making.

[A model of ophthalmological network care including primary care centers and a tertiary care hospital]. / Experiencia de atención en red entre Hospital del Salvador y tres unidades de Atención Primaria Oftalmológica: Un modelo de salud pública para mejorar la atención oftalmológica.

BACKGROUND: Primary care units of ophtalmology (UAPO) were incorporated in 2003 into the healthcare system of the Ministry of Health, in response to the high demand for hospital care. Three of these primary care units were incorporated to provide a network care with the ophthalmology service of a tertiary care hospital. AIM: To report the public health impact of networking. MATERIAL AND METHODS: A descriptive-prospective study was carried out analyzing all the healthcare attentions carried out between June and August 2016. An epidemiological characterization of the sample was made. We recorded: clinical diagnoses, decisions, resolution of the clinical problem at the primary care or referral to the hospital. RESULTS: A total of 2,096 ophthalmologic attentions were carried out in the three UAPOs during the study period. The main diseases attended were disorders of refraction, cataracts, glaucoma and diabetic retinopathy. The resolution index was 84% of attentions. Only 16% of attentions required referral and consisted mainly of cataracts (covered by a special health care system), diabetic retinopathy, capsulotomies, iridotomies, uveitis, pterygium and lacrimal duct obstruction. CONCLUSIONS: This model of care allowed an efficient management of the high demand for hospital referral. This is expressed in the high-resolution index and low derivation, resulting in a decrease in waiting lists at the tertiary level. This system should be implemented by other tertiary centers of our country.

Experiencia de atención en red entre Hospital del Salvador y tres unidades de Atención Primaria Oftalmológica: Un modelo de salud pública para mejorar la atención oftalmológica / A model of ophthalmological network care including primary care centers and a tertiary care hospital

Background: Primary care units of ophtalmology (UAPO) were incorporated in 2003 into the healthcare system of the Ministry of Health, in response to the high demand for hospital care. Three of these primary care units were incorporated to provide a network care with the ophthalmology service of a tertiary care hospital. Aim: To report the public health impact of networking. Material and Methods: A descriptive-prospective study was carried out analyzing all the healthcare attentions carried out between June and August 2016. An epidemiological characterization of the sample was made. We recorded: clinical diagnoses, decisions, resolution of the clinical problem at the primary care or referral to the hospital. Results: A total of 2,096 ophthalmologic attentions were carried out in the three UAPOs during the study period. The main diseases attended were disorders of refraction, cataracts, glaucoma and diabetic retinopathy. The resolution index was 84% of attentions. Only 16% of attentions required referral and consisted mainly of cataracts (covered by a special health care system), diabetic retinopathy, capsulotomies, iridotomies, uveitis, pterygium and lacrimal duct obstruction. Conclusions: This model of care allowed an efficient management of the high demand for hospital referral. This is expressed in the high-resolution index and low derivation, resulting in a decrease in waiting lists at the tertiary level. This system should be implemented by other tertiary centers of our country.

Undertreatment of pain and low use of opioids in Latin America.

Pain is highly prevalent among the adult Latin American population. However, many patients with moderate to severe pain do not have access to effective pain management with opioids due to limited access to healthcare, overuse of nonopioid analgesics, regulatory barriers and lack of appropriate information about opioids. There is scarce training on use of opioids among physicians and other healthcare providers, which leads to misconceptions, mainly related to a fear of prescribing opioids. Although opioids are safe and effective drugs for the treatment of moderate to severe chronic pain, the use of opioids in Latin American nations is clearly below standards compared with developed countries.

Hábitos alimentarios y funcionalidad familiar en familias de la región metropolitana: un estudio descriptivo / Eating habits and family functionality in families in the metropolitan region: A descriptive study

Existen múltiples estudios acerca del funcionamiento familiar en la población chilena y sobre sus prácticas alimenticias, relacionándose ambas con morbilidades psicológicas o psiquiátricas. A pesar de esto, no logramos encontrar estudios que relacionen específicamente los hábitos alimenticios con el comportamiento a la hora de comer y el funcionamiento familiar en Chile. Definir los hábitos alimentarios no resulta sencillo, ya que existe una diversidad de conceptos, sin embargo, la mayoría converge en que se tratan de manifestaciones recurrentes de comportamiento individuales y colectivas respecto al qué, cuándo, dónde, cómo, con qué, para qué se come y quién consume los alimentos (1). El presente estudio es un estudio descriptivo tipo corte transversal, cuyo objetivo es explorar la relación entre el funcionamiento familiar y el hábito de comer en familia en padres y madres que acuden al policlínico de pediatría. El estudio se aplicó en 5 centros de salud de diferentes comunas de la región Metropolitana: Centro de Salud de San Bernardo (San Bernardo), Policlínico el Salto (Recoleta), Patronato Nacional de la Infancia (Estación central), CESFAM Juan Pablo II (La Reina) y CESFAM Aníbal Ariztía (Las Condes). Todos corresponden a campos clínicos universitarios de la Universidad de Los Andes en el área de pediatría. Todos centros caracterizados por recibir pacientes en su mayoría chilenos, de un nivel socioeconómico medio-bajo (2). Se consideraron como criterios de inclusión el ser padres y/o madres de pacientes que se atendían en los consultorios antes mencionados, mayores de 18 años y que firmaran el consentimiento informado. Los datos fueron obtenidos mediante la auto-aplicación de dos cuestionarios, uno de ellos, de fabricación propia, describe la práctica alimenticia de la familia, el otro, correspondiente al cuestionario APGAR familiar, validado en Chile, fue usado para medir el funcionamiento familiar según la percepción de los padres y/o madres. De un total de 53 encuestas realizadas, 90.6% presentó un APGAR de familia funcional, un 7.5% un APGAR con disfunción familiar moderada y un 1.88% con un APGAR de disfunción familiar severa. El análisis estadístico muestra que este nivel de funcionamiento se explica en un 53% por tres de las variables estudiadas; Comunicación y ambiente a la hora de comer, y si los padres viven juntos o no. Será necesario confirmar estos hallazgos en futuras investigaciones que cuenten con poblaciones de estudio más extensas y variadas en su morfología familiar, para extrapolar estos datos a nivel regional. Palabras clave: APGAR, funcionamiento familiar, comer en familia, hábito alimenticio, trastornos alimenticios

Abstract: There are multiple studies on family functioning in the Chilean population and on their dietary practices, both have been related to psychological or psychiatric morbidities. Despite this, we could not find studies that specifically relate eating habits to eating behaviors and family functioning in Chile. Defining eating habits is not easy, since there is a diversity of concepts, however, most converge in that they are recurrent manifestations of individual and collective behavior with respect to what, when, where, how, with what, and for what purpose we eat and who consumes the food (1). The present study is a descriptive cross-sectional study, whose objective is to explore the relationship between family functioning and the habit of eating as a family in parents who attend the pediatric polyclinic. The study was performed in 5 health centers in different communes of the Metropolitan Region: San Bernardo Health Center (San Bernardo), El Salto Polyclinic (Recoleta), National Children's Trust (Central Station), CESFAM Juan Pablo II (La Reina) and CESFAM Aníbal Ariztía (Las Condes). All correspond to pediatric university clinical campuses of the Universidad de Los Andes. All centers are characterized as receiving mostly Chilean patients, of a medium-low socioeconomic level (2). Inclusion criteria were: fathers and/or mothers of patients who attended the clinics, who were older than 18 years and who signed the informed consent. The data were obtained through the self-administration of two questionnaires, one of them of our own manufacture, describes the family's nutritional practice, the other, corresponding to the family APGAR questionnaire, validated in Chile, was used to measure family functioning according to the perception of fathers and/or mothers. Of a total of 53 surveys conducted, 90.6% presented an APGAR of functional family, 7.5% an APGAR with moderate family dysfunction and 1.88% with an APGAR of severe family dysfunction. The statistical analysis shows that this level of functioning is explained in 53% by three of the studied variables: communication and atmosphere at mealtime, and whether the parents live together or not. It will be necessary to confirm these findings in future investigations that have more extensive and varied study populations in their family morphology to extrapolate these data at a regional level.Key words: APGAR, family functionality, family meal, feeding behavior, eating disorders

Most Relevant Neuropathic Pain Treatment and Chronic Low Back Pain Management Guidelines: A Change Pain Latin America Advisory Panel Consensus.

Objective: Chronic pain conditions profoundly affect the daily living of a significant number of people and are a major economic and social burden, particularly in developing countries. The Change Pain Latin America (CPLA) advisory panel aimed to identify the most appropriate guidelines for the treatment of neuropathic pain (NP) and chronic low back pain (CLBP) for use across Latin America. Methods: Published systematic reviews or practice guidelines were identified by a systematic search of PubMed, the Guidelines Clearinghouse, and Google. Articles were screened by an independent reviewer, and potential candidate guidelines were selected for more in-depth review. A shortlist of suitable guidelines was selected and critically evaluated by the CPLA advisory panel. Results: Searches identified 674 and 604 guideline articles for NP and CLBP, respectively. Of these, 14 guidelines were shortlisted for consensus consideration, with the following final selections made: "Recommendations for the pharmacological management of neuropathic pain from the Neuropathic Pain Special Interest Group in 2015-pharmacotherapy for neuropathic pain in adults: A systematic review and meta-analysis.""Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society" (2007). Conclusions: The selected guidelines were endorsed by all members of the CPLA advisory board as the best fit for use across Latin America. In addition, regional considerations were discussed and recorded. We have included this expert local insight and advice to enhance the implementation of each guideline across all Latin American countries.

The role of tramadol in pain management in Latin America: a report by the Change Pain Latin America Advisory Panel.

OBJECTIVE: Change Pain Latin America (CPLA) was created to enhance chronic pain understanding and develop pain management improving strategies in this region. During its seventh meeting (August 2016), the main objective was to discuss tramadol's role in treating pain in Latin America. Furthermore, potential pain management consequences were considered, if tramadol was to become more stringently controlled. METHODS: Key topics discussed were: main indications for prescribing tramadol, its pharmacological characteristics, safety and tolerability, effects of restrictions on its availability and use, and consequent impact on pain care quality. RESULTS: The experts agreed that tramadol is used to treat a wide spectrum of non-oncological pain conditions (e.g. post-surgical, musculoskeletal, post-traumatic, neuropathic, fibromyalgia), as well as cancer pain. Its relevance when treating special patient groups (e.g. the elderly) is recognized. The main reasons for tramadol's high significance as a treatment option are: its broad efficacy, an inconspicuous safety profile and its availability, considering that access to strong analgesics - mainly controlled drugs (classical opioids) - is highly restricted in some countries. The CPLA also agreed that tramadol is well tolerated, without the safety issues associated with long-term nonsteroidal anti-inflammatory drug (NSAID) use, with fewer opioid-like side effects than classical opioids and lower abuse risk. CONCLUSIONS: In Latin America, tramadol is a valuable and frequently used medication for treating moderate to severe pain. More stringent regulations would have significant impact on its availability, especially for outpatients. This could cause regression to older and frequently inadequate pain management methods, resulting in unnecessary suffering for many Latin American patients.

Latin-American guidelines for opioid use in chronic nononcologic pain.

AIM: Latin-American experts in the use of opioids in patients with chronic nononcologic pain (CNOP) have updated existing recommendations to current Latin-American reality. METHODS: Several key opinion leaders from Latin America participated in a face-to-face meeting in Guatemala (April 2015) to discuss the use of opioids in CNOP. Subgroups of experts worked on specific topics, reviewed the literature and shaped the final manuscript. RESULTS: The expert panel developed guidelines taking into consideration the utility of both opioid and nonopioid analgesics and factors pertaining to their efficacy, safety, adherence, administration and risks for abuse/addiction. CONCLUSION: Latin-American guidelines for the use of opioids in CNOP should improve pain relief and patients' quality of life by increasing access to these effective agents.

Hipertermia maligna: a propósito de un caso / Malignant hyperthermia: a case report

Malignant hyperthermia (MH) is a rare neuromuscular hereditary disorder, triggered in susceptible individuals by exposure to inhalational agents or succinylcholine and manifested as a hypermetabolic state. We report the case of a 22 years old male patient anesthetized with Desflurane in whom MH was suspected because of unexplained increased levels of End-Tidal carbon dioxide. Dantrolene was administered with good response. Respiratory acidosis and hyperkalemia were also detected but could be easily controlled. The postoperative period was uneventful with the exception of a superficial venous thrombosis at the dantrolene’s injection site. The patient was discharged eight days after the episode without sequela. Successful management of a malignant hyperthemia episode must include: early suspicion, asking for help and early treatment with dantrolene.

La Hipertermia Maligna es un trastorno neuromuscular hereditario infrecuente, manifestado por un estado hipermetabólico desencadenado en individuos susceptibles por la exposición a anestésicos halogenados o Succinilcolina. Se reporta el caso de un hombre de 22 años anestesiado con Desflurano, en quien el diagnóstico de Hipertermia Maligna se sospechó por la presencia de elevación inexplicada del CO2 espirado, que respondió a la suspensión del Desflurano y administración de Dantroleno. Se observó además hiperkalemia y acidosis respiratoria, que fueron fácilmente compensadas. La evolución postoperatoria fue satisfactoria, a excepción de una trombosis venosa superficial en el sitio de inyección del Dantroleno. El paciente fue dado de alta al 8avo día postoperatorio, sin secuelas. Las claves del manejo exitoso de un episodio de hipertermia maligna están en: Sospecha precoz, solicitar ayuda e inició rápido del tratamiento con Dantroleno.

Use of Opioids in Latin America: The Need of an Evidence-Based Change.

OBJECTIVE: The subject of this publication has been focused on local considerations for facilitating regional best practice, including identifying and uniformly adopting the most relevant international guidelines on opioid use (OU) in chronic pain management. DESIGN AND SETTING: The Change Pain Latin America (CPLA) Advisory Panel conducted a comprehensive, robust, and critical analysis of published national and international reviews and guidelines of OU, considering those most appropriate for Latin America. METHODS: A PubMed search was conducted using the terms "opioid," "chronic," and "pain" and then refined using the filters "practice guidelines" and "within the last 5 years" (2007-2012). Once the publications were identified, they were selected using five key criteria: "Evidence based," "Comprehensive," "From a well-recognized source," "Current publications," and "Based on best practice" and then critically analyzed considering 10 key criteria for determining the most relevant guidelines to be applied in Latin America. RESULTS: The initial PubMed search identified 177 reviews and guidelines, which was reduced to 16 articles using the five preliminary criteria. After a secondary analysis according to the 10 key criteria specific to OU in Latin America, 10 publications were selected for critical review and discussion. CONCLUSIONS: The CPLA advisory panel considered the "Safe and effective use of opioids for chronic non-cancer pain" (published in 2010 by the NOUGG of Canada) to be valid, relevant to Latin America, practical, evidence-based, concise, unambiguous, and sufficiently educational to provide clear instruction on OU and pain management and, thus, recommended for uniform adoption across the Latin America region.

Conocimientos y prácticas sobre prevención de caries dental asociados a prevalencia de pérdida de primera molar permanente en tres municipios de El Salvador, 2013 / Knowledge and practices on the prevention of dental caries associated with the prevalence of loss of the first permanent molar in three municipalities of El Salvador, 2013

Objetivo: Determinar la asociación entre los conocimientos y prácticas de prevención de caries dental de padres y encargados y la prevalencia de pérdida de la primera molar permanente en menores de 7 a 17 años, en tres Unidades Comunitarias de Salud Familiar de la región Central y Paracentral en los meses de agosto a noviembre, 2013. Materiales y métodos: La muestra conformada fue de 183 padres o encargados y 183 menores; la información se obtuvo mediante una cédula de entrevista y una guía de observación. Las variables independientes fueron: 1) conocimientos sobre prevención de caries dental de padres y encargados, 2) prácticas de prevención de caries dental de padres y encargados y 3) frecuencia de ingesta de alimentos cariogénicos de menores de 7 a 17 años; la variable dependiente fue: 1) pérdida de la primera molar permanente en menores de 7 a 17 años. Con el estadístico Chi-Cuadrado se determinó la significancia entre las variables asociadas, y posteriormente se calculó el riesgo relativo. Resultados: 26.8% de encargados reveló conocimiento adecuado sobre prevención de caries dental, 41% de los encargados orientaron eficientemente en técnicas de higiene bucal. 83% de menores evidenció historia de caries en las primeras molares permanentes, 70.5% de los menores presentaron niveles de placa superiores al 50%; 4.1% de molares estaban perdidas, la prevalencia de pérdida de primeras molares permanentes fue mayor en el grupo de 13 a 17 años así como en el sexo femenino. Estadísticamente se determinó que "los conocimientos inadecuados sobre prevención de caries dental es un factor predisponente en la pérdida de la primera molar permanente‖ (p= 0.002), ­deficiente orientación sobre ejecución de prácticas en higiene bucal incide en la pérdida de la primera molar permanente‖ (p= 0.001) y que ­la alta frecuencia de ingesta de azúcar de los niños y adolescentes repercute en la pérdida de la primera molar permanente‖ (p= 0.001). Conclusiones: Conocimiento inadecuados y prácticas deficientes sobre prevención de caries dental de los padres o encargados inciden en la pérdida de la primera molar permanente con riesgos relativos de 1.4 y 1.6 respectivamente. También altas frecuencias de ingestas de azúcar repercute en la pérdida de la primera molar permanente.

Objective: To establish the relationship between parents or representative's tooth decay prevention and practices knowledge and 6-year-old molar loss prevalence in children from 7 to 17 years old in three Family Health Community Centers of Central and Paracentral areas during the months from august to november, 2013. Materials and methods: They were 183 parents or representatives and 183 children and teenagers who were comprised in this research. It was used an interview format document and an observation format document. Independent variables were: 1) parents or representative's tooth decay prevention knowledge, 2) parents or representative's tooth decay prevention and practices and 3) children's tooth decay producer food frequency consumption; dependent variable was: 1) minors' 6-year-old molar loss. Chi-squared test was applied to establish the level of significance between linked variables. After that, Risk Ratio was calculated. Results: 26.8% of parents revealed adequate tooth decay prevention knowledge, 41% oriented efficiently on oral hygiene techniques. 83% of minors revealed tooth decay history in 6-year-old molar. 70.5% of minors showed plaque levels above 50%. 4.1% of 6-year-old molar were missing. 6-year-old molar lost prevalence was higher on 13 to 17 years old group and also on girls group. Statistically it was determined that ­lack of parents or representatives' tooth decay knowledge plays an underlying role on 6-year-old molar loss in minors‖ (p=0.002), ­defective orientation on oral hygiene techniques influences 6-yearold molar loss‖ (p=0.001) and ­high sugar consumption falls upon 6-year-old molar loss‖ (p=0.001). Conclusions: inadequate knowledge and defective practices about tooth decay prevention of parents play upon 6-year-old molar loss with a risk of 1.4 and 1.6 respectively. Also, high sugar consumption influences 6-year-old molar loss.