Estatinas en enfermedad renal crónica / Statins in chronic kidney disease

La enfermedad renal crónica constituye una patología de prevalencia e impacto creciente en la población mundial por sus múltiples complicaciones, incluyendo un riesgo cardiovascular aumentado, que representa la principal causa de morbimortalidad en pacientes nefrópatas crónicos. Sin embargo, la relevancia de las dislipidemias, especialmente, la hipercolesterolemia LDL, en el deterioro de la función renal y desarrollo de ateroesclerosis en sujetos con daño renal crónico no ha sido claramente establecida. Esta situación ha generado controversia sobre el beneficio real del uso de hipolipemiantes en estos pacientes. En base a la evidencia disponible, incluyendo estudios clínicos recientes, la recomendación más apropiada sugiere que el uso de terapia hipolipemiante basada en estatinas (con o sin ezetimiba) es beneficioso desde un punto de vista cardiovascular en nefrópatas crónicos con insuficiencia renal leve a moderada antes de la diálisis. Por otro lado, no existe evidencia definitiva para apoyar el uso rutinario de este tipo de hipolipemiantes en el manejo del deterioro de la filtración glomerular y/o la proteinuria. Basándose en la evidencia analizada en esta revisión, las futuras guías clínicas para el manejo del daño renal crónico deberán incorporar el uso de estatinas y/o ezetimiba como un elemento más dentro del armamento terapéutico de este tipo de pacientes.(AU)

Chronic kidney disease is a condition of increasing prevalence and impact on the world population by its many complications, including increased cardiovascular risk that represents the leading cause of morbidity and mortality in chronic nephropathy patients. However, the relevance of dyslipidemia, especially high LDL cholesterol, in the impairment of renal function and development of atherosclerosis in subjects with chronic kidney disease has not been clearly established. This situation has generated controversy regarding the real benefit of use of lipid-lowering therapy in these patients. Based on available evidence, including recent clinical studies, the most appropriate recommendation suggests that the use of lipid-lowering therapy based on statins (with or without ezetimibe) is beneficial from a cardiovascular standpoint in chronic nephropathy with mild to moderate renal failure before dialysis. On the other hand, there is no definitive evidence to support the routine use of lipid lowering drugs in the management of impaired glomerular filtration and/or proteinuria. Based on the evidence discussed in this review, future clinical guidelines for management of chronic renal damage should incorporate the use of statins and/or ezetimibe as a key element in the therapeutic armamentarium to be applied in these patients.(AU)

La biblioteca actual en la educación médica: un rol en evolución / The current library in medical education: an evolving role

Las bibliotecas biomédicas han mostrado una evolución acelerada en las últimas décadas, aparejadas al desarrollo tecnológico por una parte y a la velocidad acelerada del desarrollo del conocimiento, por otra. Los niveles de organización de la información han superado los textos en formato de libro y artículo y se han generado bases de datos, que han permitido una organización y presentación del conocimiento en forma distinta. Por otra parte, la portabilidad de la información ha transformado a las bibliotecas en estructuras más parecidas a redes neurales que a extensiones del aula de clases. Estos avances determinan, y lo harán más aun en el futuro, cambios sustantivos en los procesos de enseñanza-aprendizaje en medicina, con alumnos que se encuentran en la práctica rodeados de un aura informática que les acompaña en su quehacer cotidiano, haciendo más eficientes las tomas de decisiones e idealmente, disminuyendo los errores.(AU)

Medical libraries have quickly evolved in the last decades associated with technological progress on one side and the continuing rapid advance in knowledge on the other. The levels of information management have moved beyond simple textbooks and papers into databases, which have allowed us to organize and communicate knowledge in different ways. On the other hand, data mobility have made libraries evolve into structures comparable to neural networks more than extensions of our old classrooms. All this improvements have produced ­and they will accomplish much more in the future- important changes within teaching-learning processes in Medicine. Medical students are now surrounded by digital fields that are constantly available during their daily tasks, improving their clinical decisions and hopefully reducing errors (AU)

[Rapid aspirin desensitization in patients with a history of aspirin hypersensitivity requiring coronary angioplasty. Report of four cases]. / Desensibilización rápida en pacientes con hipersensibilidad a aspirina sometidos a angioplastía coronaria. Reporte de cuatro casos.

Aspirin use is necessary after a coronary angioplasty. It should not be used in patients with a history of hypersensitivity. However, rapid desensitization protocols have been reported to allow its use in such patients. One of these protocols consists in the administration of progressive doses of aspirin, from 1 to 100 mg in a period of 5.5 hours, in a controlled environment. We report four male patients aged 45,49, 59 and 73 years with a history of aspirin hypersensitivity, who were subjected to a coronary angioplasty. In all, the rapid aspirin desensitization protocol was successfully applied, allowing the use of the drug after the intervention without problems.

Desensibilización rápida en pacientes con hipersensibilidad a aspirina sometidos a angioplastía coronaria: Reporte de cuatro casos / Rapid aspirin desensitization in patients with a history of aspirin hypersensitivity requiring coronary angioplasty: Report of four cases

Background: Aspirin use is necessary after a coronary angioplasty. It should not be used in patients with a history of hypersensitivity. However, rapid desensitization protocols have been reported to allow its use in such patients. One of these protocols consists in the administration of progressive doses of aspirin, from 1 to 100 mg in a period of 5.5 hours, in a controlled environment. We report four male patients aged 45,49, 59 and 73 years with a history of aspirin hypersensitivity, who were subjected to a coronary angioplasty. In all, the rapid aspirin desensitization protocol was successfully applied, allowing the use of the drug after the intervention without problems.

Utilidad de isosorbide sublingual en la reversibilidad de la hipertensión pulmonar reactiva, en pacientes candidatos a trasplante cardíaco / Usefulness of sublingual isosorbide to assess the reversibility of pulmonary hypertension in cardiac transplant candidates

Background: Continuous infusion of short life vasodilators are employed to test reversibility of pulmonary hypertension in cardiac transplant candidates. Sublingual isosorbide administration has not been described in the literature and it might be a simpler alternative. Aim: To evaluate sublingual isosorbide administration as a test of reversibility of pulmonary hypertension in heart failure. Patients and Methods: Prospective evaluation of patients referred for cardiac transplant evaluation. Patients underwent right catheterization for hemodynamic measurements at baseline and after repeated doses of 5 mg sublingual isosorbide every 5 minutes until observing a decrease in pulmonary vascular resistance decrease or symptomatic hypotension. Results: Twenty one patients, 18 men, age 49±15 years, were studied. Fourteen (66%) were transplanted. The mean sublingual isosorbide dose was 15±5 mg. After isosorbide administration, there was a significant decrease in mean arterial pressure (80±8.5 to 71±6.6 mmHg, p <0.0001), mean pulmonary artery pressure (38±11 to 26±7.8 mmHg, p <0.0001), systemic vascular resistance (1540±376 to 1277±332 dyn*s/cm5 p <0.001), pulmonary vascular resistance (3.5±2.2 to 2,5±1.6 Wood Units, p <0.05) and transpulmonary gradient (13±7 a 10±4 mmHg, p <0.004). The cardiac output increased from 3.96±0.7 to 4.38±0.9 L/min, p=0.05. The relation between pulmonary and systemic vascular resistance before and after isosorbide was 0.17 and 0.15, respectively (p=0.04). One transplanted patient with partial reversibility of pulmonary hypertension developed acute right heart failure. Conclusions: Sublingual isosorbide administration is useful and well tolerated to evaluate the reversibility of pulmonary hypertension prior cardiac transplant.

Respuesta cardiovascular al ejercicio a gran altura en trabajadores crónicamente expuestos a hipoxia hipobárica intermitente / Cardiovascular response to exercise at high altitude in chronically exposured workers to intermittent hypobaric hypoxia

The isottonic work perfomance was assessed in 34 workers aged 35 ñ 5.8 years old that had working of four days at 4500 m over the sea level and resting periods of other four days at the sea level during at least two years. Subjects were assessed in one occasion at the sea level, and at the first and fourth day of the working shift at 4500 m over the sea level. resting arterial oxygen saturation in theses three periods was 97 ñ 1.1, 88 ñ 18 and 91 ñ 1.1 percent respectively (p<0.01) and markedly decreased during maximal and submaximal exercise at 4500 m over sea level. Evercise duration in the three periods was 931 ñ 210, 775 ñ 105 and 778 ñ 105 seg respectively (p<0.001). Heart rate in the resting period was at least 10 percent higher and maximal and submaxilmal rates were lower at the high altitude. No differences in blood pressure or packed red cell volume were observed. Exercise duration correlated inversely with age (r=-0.49 p=0.03) and directly with maximal heart rate (r=0.44 p=0.009) at the sea level. No correlation between aerobic capacity and other measured parameters was observed. These results show no differences in the cardiovascular response to exercise between the first and fourth day of stay at high altitude in workers chronically exposed to intermittent hypobaric hypoxia

[Eosinophilia in pediatrics. Report of clinical cases]. / Eosinofilia en pediatría. Presentación de casos clínicos.

We present four clinical cases where eosinophilia was a prominent sign. Final Diagnoses were Toxocariasis, Ascaris Lumbricoides Infection, Acute Lymphocytic Leukaemia and Histiocytosis of Langerhans Cells.

[Bacterial infections of the skin. Impetigo: etiology and clinical aspects]. / Infecciones bacterianas de la piel. Impétigos: etiologia y clínica.

One hundred children with a clinical diagnosis of Impetigo are presented. Seventy of them were bacteriologically studied. The sign-symptomatology is that usually described in this type of affection. Streptococcus was the principal bacterium involved and predominated in the youngest patients. Males were more frequently affected. There were no complications which could be attributed to this pathology either by local extension or by immunological involvement.

Eosinofilia en pediatría. Presentación de casos clínicos. / [Eosinophilia in pediatrics. Report of clinical cases]

We present four clinical cases where eosinophilia was a prominent sign. Final Diagnoses were Toxocariasis, Ascaris Lumbricoides Infection, Acute Lymphocytic Leukaemia and Histiocytosis of Langerhans Cells.

Infecciones bacterianas de la piel. Impétigos: etiologia y clínica. / [Bacterial infections of the skin. Impetigo: etiology and clinical aspects]

One hundred children with a clinical diagnosis of Impetigo are presented. Seventy of them were bacteriologically studied. The sign-symptomatology is that usually described in this type of affection. Streptococcus was the principal bacterium involved and predominated in the youngest patients. Males were more frequently affected. There were no complications which could be attributed to this pathology either by local extension or by immunological involvement.

Mielodisplasias: experiencia clínica en 35 pacientes / Myelodysplasia: an analysis of 35 patients

Myelodysplasia, characterized by varied reductions of peripheral blood elements with normal or hypercellular bone marrow, is reltively frequent among older patients and may evolve to acute leukemia. We reviewed findings in 35 patients whon, according to the FAB classification were distributed as follows: simple refractory anemia (RA) 34%, sideroblastic refractory anemia (SRA) 14%, refractory anemia with excess blast forms (RAEB) 31%, chromic myelomonocytic leukemia (CMML) 12% and refractory anemia eith excess blast forms in transformation (RAEBT 9%). Cytogenetic studies performed in 16 patients were abnormal in 5(31%), al among patients with poor prognosis forms of the disorder. All patients had anemia; thrombopenia and neutropenia were more frequent in subtypes RAEB, CMML and RAEBT). Mean survival rate was 30 months, significantly greater in RA and SRA comapred to the other groups. Infections and development of acute leukemia were the causes of death

Taponamiento cardíaco hemorrágico sin rotura cardíaca en el curso de infarto del miocardio: caso clínico / Hemorrhagic cardiac tamponade without cardiac rupture during an evolving myocardial infarction: case report

Cardiac tamponade during acute myicardial infarction is a lif threatening complication that can be confounded with right ventricular infarction. The most frequent cause of this complication is cardiac rupture. We report here a patient with acute myocardial infarction that developed cardiac tamponade on day 7, after receiving late systemic thrombolysis. The diagnosis was suspected with echocardiography and confirmed with hemodynamic measurements. The tamponade was partially relieved with pericardiocentesis but afterwards required emergency surgery. No cardiac rupture was found but an hemorragic infarction. We conclude that in this case the hemorragic tamponade was probably related both to late thrombolysis and to post infarction pericarditis

Remodelamiento miocárdico post infarto del miocardio: desde los datos experimentales a la prevención de insuficiencia cardíaca / Myocardial remodeling post myocardial infarction: from experimental data to prevention of heart failure

Structural and biochemical modifications of the myocardium (remodeling) occur after acute myocardial infarction. An important part of this process of myocardial remodeling takes place in the intersticial compartment which is comjposed mainly of fibrillar collagen. These remodeling changes are associated with modifications in left ventricular geometry and function that could be deletereous and have significant clinical manifestations. Some salutatory effects of the treatment are related to modifications of the process of intersticial remodeling. Clinical studies with calcium channel antagonists, nitrtes and, specially converting enzyme inhibitors have shown significant in the degree of ventricular dilation, hemodynamics and exercise tolerance as a comapred to palcebo treated patients. Ongoing clinical studies will provide us with more definite information on the effects of converting enzyme inhibitors on long term prongnosis as vell as on myocardial remodeling after acute myocardial infarction

Comparación de los efectos clínicos y neurohumorales de Milrinona y Captopril en pacientes con insuficiencia cardíaca crónica / Clinical and neuroendocrine response of Milrinone vs. Captopril in heart failure

En el presente estudio hemos comparado los efectos de Milrinona (M), un nuevo fármaco inótropo, positivo con un inhibidor de enzima convertidora, Captopril (C), en la condición clínica y respuesta adrenérgica al esfuerzo físico leve en pacientes con insuficiencia cardíaca congestiva (ICC) en CF III. El estudio randomizado, cruzado y doble ciego evaluó los efectos de M, 10 mg c/6 hr. o C 50 mg c/8 hr. durante 9 semanas, comparados con placebo, en 16 pacientes con ICC (6 de causa isquéemica, 10 por miocardiopatíia dilatada), que recibían digital y diuréticos. Se determinó un score clínico (SC), que incluía síntomas, examen físico y Rx. tórax, (rango 0-14), la fracción de eyección radio isotópica (FE) y la actividad de renina plasmática (ARP). La noradrenalina plasmática (NAD) se midió en reposo (r) y a iguales niveles de esfuerzo físico leve (e) (6 min. Naughton, VO2 8-9 ml/kg/min.). El score clínico mejoró en forma significativa y similar por efectos de ambas drogas (5.2+-0.4 a 4.4+-0.5, 4.1+-0.4 respectivamente, p<0.01). Lo mismo ocurrió con la fracción de eyección de VI que aumentó de 23.6+-2.6% por efecto de milrinona y a 28.6+-3.2% por efecto de captopril, (p<0.01). La respuesta neurohumoral fue diferente ya que no hubo modificaciones de la ARP o NAD en reposo y esfuerzo por efecto de Milrinona. La ARP aumentó (1.6+-0.5 a 5.3+-1.5 ng/ml/hr y la NAD en esfuerzo disminuyó (1228+-158 a 820+-100 pg/ml) por efecto de Captopril (p<0.01). La elevación de ARP y la menor respuesta adrenégica al esfuerzo físico observada con C confirma un diferente efecto humoral con respecto de M e indican que favorece una mejor adaptación al esfuerzo físico en pts. con ICC