Entre la magia y la sanación. Las primeras enfermeras de Montoro / Between magic and healing. Montoro's first nurses

Durante siglos las mujeres han sido las encargadas de sanar y cuidar de la salud de las comunidades. Ellas fueron las primeras médicas en la historia de Occidente. Se desempeñaron como enfermeras, farmacéuticas, comadronas, alquimistas, químicas y consejeras. Hacían abortos, cultivaban hierbas medicinales, transmitían sus conocimientos y experiencias de unas a otras y de generación en generación. Visitaban a los enfermos en sus casas y viajaban de pueblo en pueblo [Fragmetno de texto] (AU)

Fractura lumbar como presentación de un linfoma linfoblástico de células B / Lumbar fracture as presentation of B-cell lymphoblastic lymphoma

Introducción: El linfoma linfoblástico de precursores de células B (LLB) es responsable del 2% de los casos de los linfomas diagnosticados en la edad pediátrica. El retraso en su diagnóstico es habitual, debido a la poca especificidad de los síntomas asociados. Exponemos un caso clínico con una presentación clínica muy poco común. Caso clínico: Paciente de 14 años de edad que acudió a nuestra consulta por un dolor en la rodilla, la cadera y el muslo izquierdo de 40 días de evolución, que le provocó incapacidad para deambular 1 semana antes de su ingreso. En su abordaje inicial se indicó tratamiento con ketorolaco y piroxicam, lo que propició una mejoría transitoria del dolor. Se realizaron radiografías de la columna lumbar, la cadera y la extremidad inferior, una tomografía computarizada (TC) y una resonancia magnética (RM). Las radiografías detectaron lesiones líticas, que posteriormente fueron documentadas en la TC, en el trocánter y la cabeza del fémur izquierdo y en la primera vértebra lumbar. La RM demostró, además, la presencia de adenomegalias supraclaviculares y una masa paravertebral en la octava vértebra torácica. El aspirado de médula ósea fue negativo para la infiltración, y la biopsia de una de las adenomegalias supraclaviculares reveló un linfoma tipo B. Conclusión: El LLB es una variedad de linfoma unicelular poco común en pediatría, que generalmente se diagnostica en estadios avanzados por su rápido crecimiento (AU)

Introduction: B-cell lymphoblastic lymphoma contributes 2% of the diagnosed lymphomas in the pediatric age. The diagnosis is often delayed by the low specificity of presenting symptoms. We illustrate an uncommon B-cell lymphoblastic lymphoma presentation. Case report: A 14-year old female presented with a 40-day history of left knee, hip and thigh pain that produced intermittent limping, associated with one week history of limping. During her initial medical assistance ketorolac and piroxicam were prescribed, partially decreasing pain. She evolved walking disability, leading her to hospitalization were X-rays, CT scan and MRI were ordered. Osteolithic lesions were found and confirmed by CT scan in 1st lumbar vertebra and left femur head and trochanter. MRI found bilateral supraclavicular lymphadenopathies along a paravertebral tumor at T8 level. Marrow aspiration was negative and biopsy of the supraclavicular masses revealed a B-cell lymphoma, which was further characterized by immunohistochemistry in B-cell lymphoblastic lymphoma. Conclusion: B-cell lymphoblastic lymphoma is a rare tumor in children and is usually diagnosed in advanced stages due to their rapid growth and delay in the diagnosis. The most important diagnostic tool for the general pediatrician is to maintain clinical suspicion due to the low specificity of the clinical symptoms (AU)

BDNF in the Aged Brain: Translational Implications for Parkinson's Disease.

Brain Derived Neurotrophic Factor (BDNF) is a member of the neurotrophin family of secreted growth factors. BDNF signaling is known to exert both chronic, pro-survival effects related to gene expression and protein synthesis ("canonical signaling"), and acute effects as a modulator of neurotransmission ("non-canonical signaling"). BDNF has received a great deal of attention for its role in neurodegenerative diseases including Huntington's Disease (HD), Alzheimer's Disease (AD), and Parkinson's Disease (PD) and has been extensively reviewed elsewhere in this regard (e.g., [1-6]). However aging-related changes in BDNF function and expression have been studied only rarely, with the majority of studies characterizing changes in structures such as the hippocampus and neocortex. In this review, we attempt to briefly summarize the extent of the existing literature on age-related BDNF changes, and discuss the relevance of these changes as a factor potentially impacting therapeutics in aged parkinsonian subjects.

Urban transmission of Chagas disease in Cochabamba, Bolivia.

Chagas disease is a major public health problem in Bolivia. In the city of Cochabamba, 58% of the population lives in peripheral urban districts ("popular zones") where the infection prevalence is extremely high. From 1995 to 1999, we studied the demographics of Chagas infections in children from five to 13 years old (n = 2218) from the South zone (SZ) and North zone (NZ) districts, which differ in social, environmental, and agricultural conditions. Information gathered from these districts demonstrates qualitative and quantitative evidence for the active transmission of Trypanosoma cruzi in urban Cochabamba. Seropositivity was high in both zones (25% in SZ and 19% in NZ). We observed a high risk of infection in children from five to nine years old in SZ, but in NZ, a higher risk occurred in children aged 10-13, with odds ratio for infection three times higher in NZ than in SZ. This difference was not due to triatomine density, since more than 1,000 Triatoma infestans were captured in both zones, but was possibly secondary to the vector infection rate (79% in SZ and 37% in NZ). Electrocardiogram abnormalities were found to be prevalent in children and pre-adolescents (SZ = 40%, NZ = 17%), indicating that under continuous exposure to infection and re-infection, a severe form of the disease may develop early in life. This work demonstrates that T. cruzi infection should also be considered an urban health problem and is not restricted to the rural areas and small villages of Bolivia.

Urban transmission of Chagas disease in Cochabamba, Bolivia

Chagas disease is a major public health problem in Bolivia. In the city of Cochabamba, 58 percent of the population lives in peripheral urban districts ("popular zones") where the infection prevalence is extremely high. From 1995 to 1999, we studied the demographics of Chagas infections in children from five to 13 years old (n = 2218) from the South zone (SZ) and North zone (NZ) districts, which differ in social, environmental, and agricultural conditions. Information gathered from these districts demonstrates qualitative and quantitative evidence for the active transmission of Trypanosoma cruzi in urban Cochabamba. Seropositivity was high in both zones (25 percent in SZ and 19 percent in NZ). We observed a high risk of infection in children from five to nine years old in SZ, but in NZ, a higher risk occurred in children aged 10-13, with odds ratio for infection three times higher in NZ than in SZ. This difference was not due to triatomine density, since more than 1,000 Triatoma infestans were captured in both zones, but was possibly secondary to the vector infection rate (79 percent in SZ and 37 percent in NZ). Electrocardiogram abnormalities were found to be prevalent in children and pre-adolescents (SZ = 40 percent, NZ = 17 percent), indicating that under continuous exposure to infection and re-infection, a severe form of the disease may develop early in life. This work demonstrates that T. cruzi infection should also be considered an urban health problem and is not restricted to the rural areas and small villages of Bolivia.

Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization.

AIMS: The purpose of the Euro Heart Survey Programme of the European Society of Cardiology is to evaluate to which extent clinical practice endorses existing guidelines as well as to identify differences in population profiles, patient management, and outcome across Europe. The current survey focuses on the invasive diagnosis and treatment of patients with established coronary artery disease (CAD). METHODS AND RESULTS: Between November 2001 and March 2002, 7769 consecutive patients undergoing invasive evaluation at 130 hospitals (31 countries) were screened for the presence of one or more coronary stenosis >50% in diameter. Patient demographics and comorbidity, clinical presentation, invasive parameters, treatment options, and procedural techniques were prospectively entered in an electronic database (550 variables+29 per diseased coronary segment). Major adverse cardiac events (MACE) were evaluated at 30 days and 1 year. Out of 5619 patients with angiographically proven coronary stenosis (72% of screened population), 53% presented with stable angina while ST elevation myocardial infarction (STEMI) was the indication for coronary angiography in 16% and non-ST segment elevation myocardial infarction or unstable angina in 30%. Only medical therapy was continued in 21%, whereas mechanical revascularization was performed in the remainder [percutaneous coronary intervention (PCI) in 58% and coronary artery bypass grafting (CABG) in 21%]. Patients referred for PCI were younger, were more active, had a lower risk profile, and had less comorbid conditions. CABG was performed mostly in patients with left main lesions (21%), two- (25%), or three-vessel disease (67%) with 4.1 diseased segments, on average. Single-vessel PCI was performed in 82% of patients with either single- (45%), two- (33%), or three-vessel disease (21%). Stents were used in 75% of attempted lesions, with a large variation between sites. Direct PCI for STEMI was performed in 410 cases, representing 7% of the entire workload in the participating catheterization laboratories. Time delay was within 90 min in 76% of direct PCI cases. In keeping with the recommendations of practice guidelines, the survey identified under-use of adjunctive medication (GP IIb/IIIa receptor blockers, statins, and angiotensin-converting enzyme-inhibitors). Mortality rates at 30 days and 1 year were low in all subgroups. MACE primarily consisted of repeat PCI (12%). CONCLUSION: The current Euro Heart Survey on coronary revascularization was performed in the era of bare metal stenting and provides a global European picture of the invasive approach to patients with CAD. These data will serve as a benchmark for the future evaluation of the impact of drug-eluting stents on the practice of interventional cardiology and bypass surgery.

Phenotypic features of peripheral blood leucocytes during early stages of human infection with Trypanosoma cruzi.

We performed a cross-sectional flow cytometric analysis of peripheral blood mononuclear cells to evaluate human immunologic status during early stages of Trypanosoma cruzi infection in children. We identified major immunological features corresponding to three proposed phases of disease: early acute (EA) phase, late acute (LA) phase and recent chronic (RC) phase. EA phase was accompanied by expansion of conventional B cells, up-regulation of CD54 on monocytes and down-regulation of CD54 on T cells and not associated with monocyte-activation phenotypes or changes of natural killer (NK) population. LA phase was characterized by a selective increase in a distinct lineage of NK cells (CD16+CD56-), as well as a persistent expansion of B cells and down-regulation of CD54 on T cells. RC phase showed persistent low levels of CD54 molecule on T cells and an increase of B cells, mainly triggered by expansion of the B1-cell subset, as well as increased expression of human leucocyte antigen (HLA-DR) by monocytes. These findings reinforce the hypothesis that T. cruzi-derived antigens are able to activate NK cells before the development of T-cell-mediated immunity. Moreover, our data support previous findings of increased levels of B1 lymphocytes during human Chagas' disease and show that this event is already present during initial stages of chronic infection.

Clinical and angiographic outcome of patients with mild coronary lesions treated with balloon angioplasty or coronary stenting. Implications for mechanical plaque sealing.

AIMS: To investigate the clinical and angiographic outcome of patients with mild coronary lesions treated with balloon angioplasty or coronary stenting (coronary plaque sealing, i.e. dilatation of angiographically non-significant lesions) compared to moderate and severe stenoses. METHODS AND RESULTS: Patients with chronic stable angina and a single de novo lesion in a native coronary vessel scheduled to undergo percutaneous coronary intervention (PCI) were selected from 14 different studies. Off-line analysis of angiographic outcomes was assessed in all patients using identical and standardised methods of data acquisition, analysis and definitions. Clinical endpoints were adjudicated by independent clinical events committees. All quantitative coronary angiographic (QCA) analyses were performed in the same core laboratory. Stenosis severity prior to PCI was categorised into three groups: <50% diameter stenosis (DS), 50-99%DS and >99%DS pre. A total of 3812 patients were included in this study; 1484 patients (39%) were successfully treated with balloon angioplasty (BA) only and stented angioplasty was performed in 2328 patients (61%).One-year mortality and rate of non-fatal myocardial infarction (MI) (Kaplan-Meier) did not differ between BA and stented angioplasty for any of the stenosis severity categories. Following BA, the combined event rate (death and non-fatal MI) was 4.8, 4.6 and 0% in the <50, 50-99 and >99%DS categories, respectively. Following stented angioplasty, the combined event rate was 3.1, 4.4 and 4.8% in the same categories. The need for repeat revascularisation corrected for stenosis severity in the Cox proportional-hazards regression model was reduced by 20% after stented angioplasty (hazard ratio (HR) 0.80, 95%CI 0.69-0.93). CONCLUSION: The concept of plaque sealing is appealing from the theoretical point of view. However, with current technology, plaque sealing cannot prevent death and future non-fatal MIs in the long-term because 1-year event rates after PCI of non-significant stenoses remain unacceptably elevated when compared with the estimated 1-year probability of a non-fatal MI in lesions with a <50%DS. Moreover, major adverse cardiac events at 1-year after PCI are not directly related to the degree of pre-procedural stenosis severity.

Clinical and quantitative coronary angiographic predictors of coronary restenosis: a comparative analysis from the balloon-to-stent era.

OBJECTIVES: We sought to assess whether coronary stents have modified the predictive value of demographic, clinical and quantitative coronary angiographic (QCA) predictors of coronary restenosis. BACKGROUND: A systematic analysis in a large cohort of registries and randomized trials of the percutaneous transluminal coronary angioplasty (PTCA) and stent era has never been performed. METHODS: A total of 9,120 treated lesions in 8,156 patients included in nine randomized trials and 10 registries, with baseline, post-procedural and six-month follow-up QCA analyses, were included in this study. Predictors of restenosis were identified with univariate and multivariate logistic regression analyses. Interaction terms were introduced in the regression equation to evaluate whether the predictors of restenosis were common to both eras or specific for either one of the revascularization techniques. RESULTS: The restenosis rate was 35% after PTCA and 19% after angioplasty with additional stenting. In the univariate analysis, favorable predictors were previous coronary artery bypass graft surgery (CABG), stent use, stent length and a large pre-procedural minimal lumen diameter (pre-MLD); unfavorable predictors were weight, body mass index, diabetes mellitus, multi-vessel disease, lesion length and a high residual post-procedural diameter stenosis (post-DS). Predictors specific for the PTCA population were a large post-procedural MLD (post-MLD) as favorable and a severe pre-procedural DS (pre-DS) as unfavorable. Favorable predictors specific for the stent population were a large post-MLD and a large pre-procedural reference diameter (pre-RD). In the multivariate analysis, the best model included the following favorable predictors: stent use, a large post-MLD, previous CABG and the interaction term between stent use and a large post-MLD; unfavorable predictors were lesion length and diabetes mellitus. CONCLUSIONS: There are no major differences in demographic and clinical predictors of coronary restenosis between PTCA and stent populations. In the modern (stent) era, a severe pre-DS is no longer an unfavorable predictor of restenosis. Still important, but more so in the stent population, is a large post-MLD (optimal result). Finally, a larger pre-RD became a favorable predictor with the advent of stenting.

A reliable and specific enzyme-linked immunosorbent assay for the capture of IgM from human chagasic sera using fixed epimastigotes of Trypanosoma cruzi.

A rapid, sensitive, specific, and reliable enzyme-linked immunosorbent assay (ELISA) is proposed for determination of the levels of anti-Trypanosoma cruzi IgM in acute chagasic sera (ACD). The efficiency of this ELISA as a diagnostic method was compared with that of parasite DNA detection by polymerase chain reaction (PCR) and that of indirect immunofluorescence (iIF) anti-T. cruzi IgM detection. We tested whether this ELISA using fixed epimastigotes (epi) could detect anti-T. cruzi IgM in serum samples from two groups of children with acute Chagas' disease from a hyperendemic area in Bolivia. In a comparison of the ELISA method with other techniques, 95% and 71% of the results correlated with PCR and iIF findings, respectively. At the serum dilution applied (1:250), rheumatoid factor (RF) did not influence the results, and samples from patients carrying leishmaniasis or mixed Leishmania and T. cruzi infection could also be excluded from ACD. Highly specific and reliable results were obtained, a great number of the sera could be tested in only one assay, and a quantitative index of reactivity (IR) could be calculated without serial titration. Using test samples in triplicate, the method provides a useful tool for the detection of early acute-phase T. cruzi infection in humans.

T-cell repertoire analysis in acute and chronic human Chagas' disease: differential frequencies of Vbeta5 expressing T cells.

Here, we analysed the use of Vbeta-TCR regions by CD4+ and CD8+ T cells from acute and chronic chagasic patients using flow cytometry. We determined the Vbeta expression in cells freshly isolated from patients, as well as after in vitro stimulation with antigens derived from epimastigote (EPI) or trypomastigote (TRYPO) forms of Trypanosoma cruzi. Analysis of Vbeta-TCR expression of T cells freshly isolated from patients showed a decrease in Vbeta5 expression in the CD4+ T-cell population from acutely infected individuals, whereas CD4+Vbeta5+ T cells were found to be increased in chronic patients with the cardiac, but not indeterminate, clinical form. After culturing peripheral blood mononuclear cells (PBMC) from chronic patients with EPI or TRYPO, we found that both antigenic preparations led to a preferential expansion of CD4+Vbeta5+ T cells. EPI stimulation also led to the expansion of CD8+Vbeta5+ T cells, whereas TRYPO led to the expansion of this cell population only if PBMC were from cardiac and not indeterminate patients. We observed that TRYPO stimulation led to an increase in the frequency of CD4+Vbeta17+ T cells in cultures of PBMC from indeterminate patients, whereas an increase in the frequency of CD8+Vbeta17+ T cells was found upon TRYPO stimulation of PBMC from cardiac patients. Despite this increase in the frequency of Vbeta17+ T-cell populations upon TRYPO stimulation, the same antigenic preparation led to a much higher expansion of Vbeta5+ T cells. These results show a differential expression of Vbeta5-TCR in cells freshly isolated from chagasic patients in different stages of the disease and that parasite-specific antigens stimulate a portion of the T-cell repertoire with preferential usage of Vbeta5-TCR.

Early, intermediate, and late acute stages in Chagas' disease: a study combining anti-galactose IgG, specific serodiagnosis, and polymerase chain reaction analysis.

The acute phase of Chagas' disease was classified as early, intermediate, and late based on the levels of anti-Galalpha, 3Gal IgG (Gal) and specific IgM (M) and IgG (G) anti-T. cruzi reactivity. While the early phase was M+G-Gal-, the intermediate phase was M+G-Gal+, M+G+Gal-, or M+G+Gal+, and the late phase was M-G+Gal+. This sequence of stages was consistent with our previous studies on acute-phase proteins. Analysis by the polymerase chain reaction (PCR) of parasite DNA in 65 blood samples of children living in Cochabamba, Bolivia showed a significant correlation (90.8%) between ELISA and PCR positivity. A lower correlation was observed between indirect hemagglutination, PCR (58%), and ELISA. Electrocardiographic analysis of 43 children studied by the PCR did not show any alteration typical of acute chagasic myocarditis. The PCR positivity was observed in eight samples where only Gal was increased, suggesting a very early T. cruzi infection, when specific antibodies were not yet present. By associating anti-Gal IgG with specific serology, early T. cruzi infection can be detected with greater precision. We suggest the use of anti-Gal antibody reactivity as an aid for the detection of recent T. cruzi infections, at least in endemic areas where diseases caused by other trypanosomatids do not overlap.

Acute-phase proteins and serologic profiles of chagasic children from an endemic area in Bolivia.

Chagas' disease represents a major public health problem in Latin America. In endemic areas, it is important to detect acute and even asymptomatic infections in children so that specific therapy can be started immediately. We studied 203 sera from children from the region of Cochabamba, Bolivia. A high percentage of seropositive individuals was found in the three villages studies. Levels of alpha-2 macroglobulin (A2M) and C-reactive protein (CRP) increased in a significant number of children with acute Chagas' disease. The combined analysis of serologic and biochemical parameters can define the different stages of acute infection by Trypanosoma cruzi: 1) an early stage, with an increase only in specific immunoglobulin M (IgM) levels; 2) intermediate stages, with high specific IgM and IgG levels and/or high anti-galactose (anti-Gal) levels and increased A2M and/or CRP levels; and 3) a late acute stage, with low IgM levels but high A2M, CRP, anti-Gal, and specific IgG levels. The detection of high IgG levels alone is indicative of the chronic/indeterminate stage of Chagas' disease. We also show serologic differences between seropositive asymptomatic villagers and symptomatic patients undergoing medical care; asymptomatic cases presented higher levels of A2M and lower levels of specific antibodies.

Prevalence and characteristics of smoking among adolescents.

The purpose of this study was to determine the prevalence of smoking and factors associated to the use of cigarettes in the adolescent population of the Francisco Oller High School in Cataño, Puerto Rico. A survey was administered to 106 randomly chosen students, regarding previous use of cigarette, age of first exposure, source of cigarettes, and smoking among peers. The average age was 16 years old. Fifty six percent (56%) of the participants denied ever using cigarettes, 34.5% admitted having used cigarettes and 9.5% admitted to be smokers. A higher prevalence of cigarette experimentation was reported among females (43% versus 26% in males). Smoking was reported among 16% of males vs 3% of females. A 44% admitted having used cigarettes before 14 years of age. A 42.5% of the adolescents reported obtaining their knowledge of tobacco effect from the communication media. This data is similar to published information on adolescents smoking in the United States.