Coronary heart disease and tuberculosis: an unnoticed syndemia. Review of literature and management proposal.

Tuberculosis is an increasing disease that affects about one-third of the global population. In line with the rise of tuberculosis, cardiovascular disease has shown a similar trend, with ischemic coronary heart disease becoming the leading cause of death worldwide. Based on the literature, a relationship can be drawn between tuberculosis and ischemic coronary heart disease through their shared multiple risk factors and a possible pathophysiological substrate linking them. The presentation of these two conditions reported so far is varied: it has been found as the onset of acute coronary syndrome in patients with active tuberculosis, the progressive development of coronary atherosclerosis in patients with latent tuberculosis, among others. Given this possible link and the progressive increase in their incidence rates, we can assert that we are facing an unnoticed syndemic, with their concurrent management posing a challenge due to significant pharmacological interactions. The purpose of this review is to clarify this possible link, propose an approach for diagnosis, and provide a treatment algorithm for the entire spectrum of coronary disease coexisting with tuberculosis according to the current available literature.

La tuberculosis es una enfermedad que viene en aumento y que afecta cerca de un tercio de la población mundial. En consonancia con el aumento de la tuberculosis, la enfermedad cardiovascular ha tenido un comportamiento similar, de este grupo, la cardiopatía coronaria isquémica se ha convertido en la principal causa de muerte en todo el mundo. Se podría extraer, en base a la literatura, una relación entre la tuberculosis y la cardiopatía coronaria isquémica a través de que comparten múltiples factores de riesgo en común y desde un posible sustrato fisiopatológico que las vincula. La forma conjunta de presentación de estas dos entidades reportada hasta el momento es variada: se ha encontrado como debut de un síndrome coronario agudo en pacientes con tuberculosis activa, el desarrollo progresivo de aterosclerosis coronaria en pacientes con tuberculosis latente, entre otras. Dado este posible vínculo y el aumento progresivo de sus tasas de incidencia podemos afirmar que estamos ante una sindemia inadvertida, siendo su manejo conjunto un desafío por las grandes interacciones farmacológicas. El propósito de esta revisión es esclarecer este posible vínculo, plantear un enfoque para el diagnóstico, así como suministrar un algoritmo de tratamiento de todo el espectro de la enfermedad coronaria que coexiste con la tuberculosis de acuerdo con la literatura actual disponible.

Miedo a la muerte y a su proceso en personal de Pediatría durante la pandemia por COVID-19

Introducción: La evidencia obtenida en estudios previos señala que existe mayor ansiedad por el proceso de morir que, por la muerte misma, aunque falta mayor investigación. Objetivo: Analizar el miedo a la muerte y al proceso de morir propio y de otros en el servicio de Pediatría del Hospital Pablo Tobón Uribe. Metodología: Se realizó un estudio analítico transversal con la Escala de Miedo a la Muerte de Collett-Lester en 143 personas: 25,2 % pediatras generales y subespecialistas, 70,6 % profesionales de Enfermería y auxiliares, y 4,2 % terapeutas respiratorios. El análisis incluyó estadística descriptiva, pruebas de Chi2, U de Mann-Whitney, Fisher, T de Student, ANOVA y el Alfa de Cronbach. Resultados: los hallazgos del estudio sugieren que es menor el miedo a la propia muerte que el miedo a la muerte de otros, y no hay diferencia entre el miedo al proceso de morir propio y de otros. Es mayor el miedo a la muerte en enfermeras profesionales y menor en pediatras subespecialistas. Existe mayor miedo a la muerte en el servicio de UCI-UCE (media: 3,53 DS: 0,88) comparado con Urgencias (media: 2,66 DS: 0,59). Hay asociación entre el miedo a la muerte con: el sexo femenino (p = 0,000), tener una creencia religiosa (p = 0,048), y el cargo (p = 0,007). La escala tuvo muy alta fiabilidad (Alfa de Cronbach: 0,95). Discusión: es de aclarar que este estudio fue realizado durante el segundo año de la pandemia del COVID-19, cuando había menor temor, mayor conocimiento y vacunas, cuyos resultados se corresponden con otros estudios. Conclusión: en el presente estudio el mayor miedo a la muerte se asoció con ser mujer, tener creencia religiosa y laborar en UCI-UCE comparado con Urgencias.

Introduction: The evidence obtained from previous research suggests that there is more anxiety related to dying compared with death. Nevertheless, more research is needed. Objective: To analyze the fear of death and dying, oneself and others, in the pediatric service personnel at Pablo Tobón Uribe Hospital in Medellín. Methodology: This was a transversal analytic study to apply the Collett-Lester Fear of Death Scale on 143 people: 25,2 % were general pediatricians and subspecialists, 70,6 % were professional nurses and medical assistants, and 4,2 % were respiratory therapists. The analysis included descriptive statistics, Chi2 test, Mann-Whitney U test, Fisher, StudentsT, ANOVA and Cronbach's Alpha. Results: Here we report the mean of one's fear of death is lower than the fear of others' death. There is no difference when comparing the fear of one's process of dying mean, rather than when it's others. Fear of death is higher in professional nurses and lower in pediatric subspecialists. The study shows higher fear of death in the ICU-IMC services (mean: 3,53 SD: 0,88) compared with the emergency room (mean:2,66 SD: 0,59). There is a statistical association between fear of death and being a woman (p=0,000), having a religious belief (p=0,048) and job position (p=0,007). The scale has a high internal consistency (Cronbach's Alpha: 0,95). Discussion: It is important to mention that this research was conducted during the second year of the COVID-19 pandemic, when the fear had decreased, and with more knowledge and the vaccines were ready, the results are coherent with other papers. Conclusion: In this study the higher fear of death was associated with being a woman, having a religious belief and working in ICU-IMC compared to the emergency room.

Maintenance of chronicity signatures in fibroblasts isolated from recessive dystrophic epidermolysis bullosa chronic wound dressings under culture conditions.

BACKGROUND: Recessive Dystrophic Epidermolysis Bullosa (RDEB) is a rare inherited skin disease caused by variants in the COL7A1 gene, coding for type VII collagen (C7), an important component of anchoring fibrils in the basement membrane of the epidermis. RDEB patients suffer from skin fragility starting with blister formation and evolving into chronic wounds, inflammation and skin fibrosis, with a high risk of developing aggressive skin carcinomas. Restricted therapeutic options are limited by the lack of in vitro models of defective wound healing in RDEB patients. RESULTS: In order to explore a more efficient, non-invasive in vitro model for RDEB studies, we obtained patient fibroblasts derived from discarded dressings) and examined their phenotypic features compared with fibroblasts derived from non-injured skin of RDEB and healthy-donor skin biopsies. Our results demonstrate that fibroblasts derived from RDEB chronic wounds (RDEB-CW) displayed characteristics of senescent cells, increased myofibroblast differentiation, and augmented levels of TGF-ß1 signaling components compared to fibroblasts derived from RDEB acute wounds and unaffected RDEB skin as well as skin from healthy-donors. Furthermore, RDEB-CW fibroblasts exhibited an increased pattern of inflammatory cytokine secretion (IL-1ß and IL-6) when compared with RDEB and control fibroblasts. Interestingly, these aberrant patterns were found specifically in RDEB-CW fibroblasts independent of the culturing method, since fibroblasts obtained from dressing of acute wounds displayed a phenotype more similar to fibroblasts obtained from RDEB normal skin biopsies. CONCLUSIONS: Our results show that in vitro cultured RDEB-CW fibroblasts maintain distinctive cellular and molecular characteristics resembling the inflammatory and fibrotic microenvironment observed in RDEB patients' chronic wounds. This work describes a novel, non-invasive and painless strategy to obtain human fibroblasts chronically subjected to an inflammatory and fibrotic environment, supporting their use as an accessible model for in vitro studies of RDEB wound healing pathogenesis. As such, this approach is well suited to testing new therapeutic strategies under controlled laboratory conditions.

Maintenance of chronicity signatures in fibroblasts isolated from recessive dystrophic epidermolysis bullosa chronic wound dressings under culture conditions

BACKGROUND: Recessive Dystrophic Epidermolysis Bullosa (RDEB) is a rare inherited skin disease caused by variants in the COL7A1 gene, coding for type VII collagen (C7), an important component of anchoring fibrils in the basement membrane of the epidermis. RDEB patients suffer from skin fragility starting with blister formation and evolving into chronic wounds, inflammation and skin fibrosis, with a high risk of developing aggressive skin carcinomas. Restricted therapeutic options are limited by the lack of in vitro models of defective wound healing in RDEB patients. RESULTS: In order to explore a more efficient, non-invasive in vitro model for RDEB studies, we obtained patient fibroblasts derived from discarded dressings) and examined their phenotypic features compared with fibroblasts derived from non-injured skin of RDEB and healthy-donor skin biopsies. Our results demonstrate that fibroblasts derived from RDEB chronic wounds (RDEB-CW) displayed characteristics of senescent cells, increased myofibroblast differentiation, and augmented levels of TGF-ß1 signaling components compared to fibroblasts derived from RDEB acute wounds and unaffected RDEB skin as well as skin from healthy-donors. Furthermore, RDEB-CW fibroblasts exhibited an increased pattern of inflammatory cytokine secretion (IL-1ß and IL-6) when compared with RDEB and control fibroblasts. Interestingly, these aberrant patterns were found specifically in RDEB-CW fibroblasts independent of the culturing method, since fibroblasts obtained from dressing of acute wounds displayed a phenotype more similar to fibroblasts obtained from RDEB normal skin biopsies. CONCLUSIONS: Our results show that in vitro cultured RDEB-CW fibroblasts maintain distinctive cellular and molecular characteristics resembling the inflammatory and fibrotic microenvironment observed in RDEB patients' chronic wounds. This work describes a novel, non-invasive and painless strategy to obtain human fibroblasts chronically subjected to an inflammatory and fibrotic environment, supporting their use as an accessible model for in vitro studies of RDEB wound healing pathogenesis. As such, this approach is well suited to testing new therapeutic strategies under controlled laboratory conditions.

Posición social y obesidad en población chilena: mediadores y moderadores psicológicos / Social position and obesity in Chilean population: Psychological mediators and moderators

Resumen Introducción: la obesidad es un problema de salud mundial que ha sido vinculada con la posición social de las personas. Si bien la evidencia que relaciona estas variables es clara, se ha puesto menos atención a los mecanismos por medio de los cuales estas variables pueden asociarse. El objetivo de este estudio fue determinar si la posición social se relacionaba directamente con obesidad abdominal e indirectamente vía percepción de discriminación, afectividad negativa y calidad de la dieta, y el rol moderador del apoyo social. Método: 420 funcionarios de una universidad chilena. Se midió el perímetro de cintura como proxy de obesidad, se utilizaron instrumentos de autorreporte para variables psicológicas y conductuales. Resultados: análisis de ecuaciones estructurales revelaron que la posición social no se asoció directamente con obesidad abdominal, pero sí a través de una secuencia de mediación que incluyó la percepción de discriminación, afectividad negativa y calidad de la dieta. El apoyo social no moderó estas relaciones. Conclusión: se identifican mecanismos que median el nexo entre posición social y obesidad abdominal. Se destaca la relevancia de considerar variables psicológicas y conductuales subyacentes en esta relación.

Abstract Introduction: Obesity is a health problem worldwide that has been linked to social position. Although the evidence linking these variables is sound, little attention has been paid to the mechanisms by which these variables can be associated. We sought to determine whether social position is directly related to abdominal obesity and indirectly via perceived discrimination, negative affectivity and diet quality, and the moderating role of social support. Method: Four hundred and twenty participants from a Chilean University were selected. Obesity was measured through waist circumference and self-reported measures were used to asses psychological and behavioral variables. Results: Structural equation modeling allowed us to estimate that social position was not directly related to abdominal obesity, but indirectly via a sequenced mechanism that included perceived discrimination, negative affectivity and diet quality. Social support did not moderate these associations. Conclusion: We identified underlying mechanisms that mediate the association between social position and abdominal obesity. We highlight the relevance that psychological and behavioral variables has in obesity.

Síndrome coronario agudo en el paciente joven / Acute coronary syndrome in the young patient

Resumen Las enfermedades del sistema circulatorio constituyen la primera causa de muerte en el mundo. En Colombia, la enfermedad cardíaca isquémica se ubica como la principal causa de muerte, tanto en hombres como en mujeres. En la población femenina es la causa de más de la mitad de las muertes, cercana al 53%. La enfermedad isquémica en jóvenes, definidos como aquellos menores de 45 años, se ha descrito en cohortes en hasta un 11,6%, con una menor tasa de mortalidad. La dificultad para el abordaje de estos pacientes es mayor, dado que, al consultar al servicio de urgencias, pocas veces se sospecha enfermedad cardíaca isquémica.

Abstract The diseases of the circulatory system constitute the leading cause of death in the world. In Colombia, ischemic heart disease is the main cause of death, both in men and women, being within the group of women the cause of more than half of the deaths, close to 53%. Ischemic disease in young people, defined as those under 45 years old, has been described in cohorts around to 11.6%, with a lower mortality rate. The difficulty in addressing these patients is higher, given that, when consulting the emergency department, ischemic heart disease is rarely suspected.

Neuro-Muscular Dentistry: the "diamond" concept of electro-stimulation potential for stomato-gnathic and oro-dental conditions.

Oro-Pharyngeal Dysphagia - or simply dysphagia - is the difficulty (persistent) in swallowing/passing food and/or liquid from the mouth to the pharynx into the esophagus and finally the stomach; a deglutition disorder (a symptom, by definition, often due to neuro-degenerative/-muscular, drug-induced or localized structural pathologies such as head and neck tumors, lesions and associated surgical and/or radiation injuries) linked to severe consequences on Quality of Life (QoL), including malnutrition, dehydration, and even sudden death. Likewise, Temporo-Mandibular Jaw and Joint disorder(s) - or simply TMD - is a multifactorial etiological condition, regularly encountered in the dental office. Whether due to malocclusion, bruxism, stress and/or trauma, TMD destabilizes the whole cranio-mandibular system structurally and functionally, via affecting mastication, teeth, supporting structures, comfort and aesthetics, and thus, QoL, again. While several treatment regimens do exist for such conditions, some of which have been standardized for use over the years, most continue to lack proper evidence-based literature support. Hence, (1) caution is to be exercised; and (2) the need for alternative therapeutic strategies is amplified, subsequently, the door for innovation is wide open. Indeed, neuromuscular electrical stimulation or "NMES", is perhaps a fine example. Herein, we present the interested oro-dental health care provider with an up-dated revision of this therapeutic modality, its potential benefits, risks and concerns, to best handle the dysphagic patient: an intra-disciplinary approach or strategy bridging contemporary dentistry with speech and language therapy; a rather obscure and un-discovered yet critical allied health profession. A pre-clinical and clinical prospectus on employing inventive NMES-based regimens and devices to manage TMD is also highlighted.

[Intra-aortic balloon counterpulsation placed through the subclavian artery as a bridge to heart transplantation. Case report]. / Balón de contrapulsación intraaórtico por acceso subclavio como puente a trasplante cardíaco. Reporte de casos.

Advanced heart failure is a major health problem for which heart transplantation or left ventricular assist devices are the only effective treatments. Intra-aortic balloon pump inserted using femoral artery access as a bridge to heart transplantation is still frequently used, but has the disadvantage of limiting the patient's movements, hence exposing him or her to the hazards of immobility and threatening the success of the procedure or hindering recovery. Access through the subclavian artery has become an attractive alternative since it doesn't impair the patient's mobility, and there is increasing evidence supporting its use. We present the first case of subclavian counterpulsation balloon implantation in a cardiovascular care center in Colombia.

Disección espontánea de arterias coronarias en una mujer embarazada / Spontaneous coronary artery dissection in a pregnant woman

Resumen La disección espontánea de las arterias coronarias representa entre 0,2 al 4% de las causas de síndrome coronario agudo, y es más común en mujeres jóvenes, especialmente en estado de embarazo, en cuyo caso el riesgo es tres a cuatro veces mayor. Usualmente, afecta la arteria coronaria izquierda pero también puede haber compromiso de múltiples vasos. Los pacientes que la presentan no tienen los factores de riesgo clásicos descritos de la enfermedad coronaria, como diabetes mellitus, hipertensión o dislipidemia. En las gestantes se puede presentar en cualquier trimestre del embarazo y hasta varios meses después del parto, pero es más común en el último trimestre del embarazo y en las primeras seis semanas posparto. El diagnóstico de disección de arteria coronaria es difícil; el estándar de oro es la coronariografía con ecografía intravascular o la tomografía de coherencia óptica; esta última no se encuentra ampliamente disponible. Además, existe controversia en cuanto a la decisión de manejo médico o manejo invasivo.

Abstract Spontaneous coronary artery dissection accounts for between 0.2% and 4% of the causes of acute coronary syndrome. It is more common in young women, particularly during pregnancy, when the risk is three to four times higher. It usually involves the left coronary, but it can also compromise several vessels. The patients that present with one do not have the classic risk factors described for coronary disease, such as diabetes mellitus, hypertension, or dyslipidaemia. Although it can present in any trimester of the pregnancy, and up to several months after delivery, it is more common in the last trimester of pregnancy, and in the first six months post-partum. The diagnosis of coronary artery dissection is difficult. Although the reference method is coronary angiography with intravascular ultrasound or optical coherence computed tomography, these are not widely available, as well as there being controversy as regards the decision of medical management or invasive management.

Coagulation Factor Xa Promotes Solid Tumor Growth, Experimental Metastasis and Endothelial Cell Activation.

Hypercoagulable state is linked to cancer progression; however, the precise role of the coagulation cascade is poorly described. Herein, we examined the contribution of a hypercoagulative state through the administration of intravenous Coagulation Factor Xa (FXa), on the growth of solid human tumors and the experimental metastasis of the B16F10 melanoma in mouse models. FXa increased solid tumor volume and lung, liver, kidney and lymph node metastasis of tail-vein injected B16F10 cells. Concentrating on the metastasis model, upon coadministration of the anticoagulant Dalteparin, lung metastasis was significantly reduced, and no metastasis was observed in other organs. FXa did not directly alter proliferation, migration or invasion of cancer cells in vitro. Alternatively, FXa upon endothelial cells promoted cytoskeleton contraction, disrupted membrane VE-Cadherin pattern, heightened endothelial-hyperpermeability, increased inflammatory adhesion molecules and enhanced B16F10 adhesion under flow conditions. Microarray analysis of endothelial cells treated with FXa demonstrated elevated expression of inflammatory transcripts. Accordingly, FXa treatment increased immune cell infiltration in mouse lungs, an effect reduced by dalteparin. Taken together, our results suggest that FXa increases B16F10 metastasis via endothelial cell activation and enhanced cancer cell-endothelium adhesion advocating that the coagulation system is not merely a bystander in the process of cancer metastasis.

Fibrosis miocárdica: hacia una nueva aproximación / Myocardial fibrosis: towards a new approach

Resumen La fibrosis miocárdica, que se evidencia en aquellas enfermedades que se presentan con sobrecarga de presión, como la estenosis aórtica o la cardiopatía hipertensiva, constituye una forma difusa de fibrosis progresiva y de tipo reactivo, con gran impacto en la función cardíaca, manifestada como disfunción diastólica y/o sistólica, desarrollo de arritmias e isquemia miocárdica. Se considera que precede los demás cambios estructurales del ventrículo izquierdo en este tipo de enfermedades y se caracteriza por la presencia de una matriz extracelular rica en fibras de colágeno tipos I y III con alto grado de entrecruzamiento. Constituye un marcador pronóstico y existe una correlación directa entre el grado de fibrosis miocárdica y desenlaces como hospitalización por insuficiencia cardiaca y mortalidad. El abordaje diagnóstico de la fibrosis miocárdica en este grupo de pacientes puede realizarse a través de biomarcadores químicos o de imagen; los primeros aún son materia de estudio para conseguir mayor precisión en sus resultados y la resonancia nuclear cardíaca con técnica de mapeo de T1 es la técnica de imagen más atractiva. El tratamiento de la fibrosis miocárdica en las enfermedades por sobrecarga de presión, está dado por el manejo estándar de la insuficiencia cardíaca, en cuyo caso los antihipertensivos de la familia de los IECA/ARAII se han relacionado en mayor nivel con modificación en el grado de fibrosis miocárdica; sin embargo, se necesitan más estudios para definir el uso de nuevos blancos terapéuticos que complementen el tratamiento y mejoren los desenlaces en este grupo de pacientes.

Abstract Myocardial fibrosis, which is present in those diseases that have a pressure overload, such as aortic stenosis or hypertensive heart disease, are a diffuse form of progressive and reactive-type fibrosis. This has a large impact on cardiac function, manifested as a diastolic and/or systolic dysfunction, development of arrhythmias or myocardial ischaemia. It is believed that it precedes the rest of the left ventricular structural changes in this type of disease, and is characterised by the presence of an extracellular matrix rich in collagen type I and III fibres with a high level of cross-linking. It is a prognostic marker and there is a direct correlation between the level of myocardial fibrosis and outcomes, such as heart failure and mortality. The diagnostic approach of myocardial fibrosis in this group of patients could be made using chemical or imaging biomarkers. The first ones are still study material in order to achieve a better precision in their results, and cardiac nuclear resonance with T1 mapping technique is the most attractive imaging technique. The treatment of myocardial fibrosis in diseases with pressure overload, is given by the standard management of heart failure, in which case the ACEI/ARAII family of hypertensive drugs have been associated at a higher level with a change in the grade of myocardial fibrosis. However, more studies are needed in order to define the use of new therapeutic targets that may complement the treatment and improve the outcomes in this group of patients.

Evaluación de la respuesta a la terapia de resincronización cardíaca en un grupo de pacientes que asisten a un programa de falla cardíaca / Evaluation of the response to cardiac resynchronisation therapy in a group of patients taking part in a heart failure program

Resumen Introducción: la terapia de resincronización cardiaca es una de las estrategias de tratamiento actuales para pacientes con insuficiencia cardiaca y función sistólica deprimida, que ha demostrado producir un alivio significativo en los síntomas, así como mejoría en la función ventricular izquierda y en la supervivencia a largo plazo. Objetivo: evaluar la respuesta a la terapia de resincronización cardíaca después de seis meses de seguimiento. Metodología: estudio observacional analítico de cohorte retrospectivo, con análisis anidado de casos y controles, en el que se incluyeron pacientes mayores de 18 años pertenecientes a una clínica de falla cardíaca y que fueran portadores de un dispositivo de resincronización cardíaca. Se realizó análisis univariado de las características clínicas y ecocardiográficas y posteriormente un análisis bivariado a las variables relacionadas con la respuesta a la terapia. Resultados: se incluyeron 92 pacientes con historia de falla cardíaca e indicación de terapia de resincronización; el 32,6% de los pacientes tenían cardiopatía isquémica y el 67,4% no isquémica, con una fracción de eyección promedio de 18,9%. Durante el seguimiento a los 6 primeros meses no se presentó ningún caso de muerte ni de trasplante cardíaco. Se definieron como respondedores el 47,8% de los pacientes, en tanto que el 52,2% restante fue clasificado como no respondedores. El porcentaje de pacientes que no requirieron hospitalizaciones luego de la terapia fue del 51,1%, y el 65,2% mejoró la clase funcional y 68,5% la fracción de eyección. Conclusión: en el 47,8% de la población estudiada se observó una respuesta a la terapia de resincronización cardiaca adecuada evaluada de forma combinada con parámetros clínicos y ecocardiográficos, hecho que se tradujo en una mejoría relevante en términos de fracción de eyección y clase funcional, además de menor número de hospitalizaciones por falla cardíaca, al igual que ausencia de requerimiento de trasplante cardíaco y de muertes por causa cardiovascular.

Abstract Introduction: Cardiac resynchronisation therapy (CRT) is one of the current strategies for patients with heart failure and depressed systolic dysfunction. It has shown to produce a significant reduction in the symptoms, as well as an improvement in left ventricular function and long-term survival. Objective: To evaluate the response to CRT after 6 months of follow-up. Materials and method: A retrospective, observational, analytical cohort study, with nested case-control analysis, was conducted, which included patients over 18 years of age attending a heart failure clinic, and were carriers of a CRT device. A univariate analysis was performed on the clinical and echocardiographic characteristics. A bivariate analysis was subsequently performed on the variables associated to the treatment response. Results: The study included 92 patients with a history of heart failure and an indication of CRT, of whom 32.6% had ischaemic heart disease, and with a mean ejection fraction of 18.9%. There no deaths or heart transplants during the first 6 months of follow-up. Just under half (47.8%) of the patients were considered responders to the therapy, with the remaining 52.2% classified as non-responders. The percentage of patients that did not require hospital admission after the therapy was 51.1%, 65.2% improved functional class, and 68.5% their ejection fraction. Conclusion: Just under half (47.8%) of the population studied had an adequate response to CRT, when evaluated combined with the clinical and echocardiographic parameters. This led to a significant improvement in terms of ejection fraction and functional class, including a lower number of hospital admissions due to heart failure, as well as the absence of heart transplants and deaths by cardiovascular cause.

[Chronic recurrent multifocal osteomyelitis in a pediatric patient, a case report]. / Osteomielitis crónica multifocal recurrente en paciente pediátrico, reporte de caso.

INTRODUCTION: Chronic recurrent multifocal osteomyelitis (CRMO) is a very rare disease, of unknown origin that affects primarily the metaphysis of long bones. It is characterized by an insidious onset of symptoms and multiple remissions. The chronicity of symptoms, the diagnostic imaging and the lack of response to first line antibiotic treatment, should be helpful for diagnostic. OBJECTIVE: Present a clinical case, based on clinical, laboratory, radiologic imaging and histopathological results, that ultimately led to the diagnostic of CRMO. CASE REPORT: 9 year old, female patient, with one month of bilateral knee and left ankle arthralgia. Bone Gammagraphy and full body MRI, showed multifocal bone inflammation. These findings led to a biopsy, that turned negative for malignancy and infection. Given all the information available from the laboratory test results, radiologic imaging and histopathological findings, CRMO diagnosis was made. NSAID treatment was order, with good results. CONCLUSIONS: CRMO is a rare disease that even to date and with cutting edge technology, still represents a diagnostic challenge that primarily relies on a high level of suspicion, for a timely and correct treatment.

Osteomielitis crónica multifocal recurrente en paciente pediátrico, reporte de caso / Chronic recurrent multifocal osteomyelitis in a pediatric patient, a case report

Introducción: La osteomielitis crónica multifocal recurrente (OCMR) es una enfermedad rara de causa desconocida, que afecta principalmente la metáfisis de los huesos largos; se caracteriza por un cuadro clínico insidioso de exacerbaciones y remisiones; la cronicidad de los síntomas, los hallazgos imagenológicos y la falta de respuesta al manejo con antibióticos, orientan al diagnóstico. Objetivo: Presentar los datos clínicos, resultados de laboratorio, imagenológicos y estudios histo- patológicos que permiten realizar el diagnóstico de OCMR. Caso clínico: Paciente de sexo femenino de 9 años, con artralgias en ambas rodillas y tobillo izquierdo de 1 mes de duración. Los estudios de gammagrafía ósea y resonancia corporal total evidenciaron compromiso óseo multifocal; con estos hallazgos, se realizó biopsia que fue negativa para infección y malignidad. Por la evolución, estudios de laboratorio, radiológicos e histo-patológicos se diagnosticó OCMR. Se inició tratamiento con anti-inflamatorios no esteroides con adecuada respuesta. Conclusiones: La OCMR es una patología poco frecuente de difícil diagnóstico, por lo que se requiere de una alta sospecha clínica para realizar un adecuado enfoque y tratamiento oportuno.

Introduction: Chronic recurrent multifocal osteomyelitis (CRMO) is a very rare disease, of unknown origin that affects primarily the metaphysis of long bones. It is characterized by an insidious onset of symptoms and multiple remissions. The chronicity of symptoms, the diagnostic imaging and the lack of response to first line antibiotic treatment, should be helpful for diagnostic. Objective: Present a clinical case, based on clinical, laboratory, radiologic imaging and histopathological results, that ultimately led to the diagnostic of CRMO. Case report: 9 year old, female patient, with one month of bilateral knee and left ankle arthralgia. Bone Gammagraphy and full body MRI, showed multifocal bone inflammation. These findings led to a biopsy, that turned negative for malignancy and infection. Given all the information available from the laboratory test results, radiologic imaging and histopathological findings, CRMO diagnosis was made. NSAID treatment was order, with good results. Conclusions: CRMO is a rare disease that even to date and with cutting edge technology, still represents a diagnostic challenge that primarily relies on a high level of suspicion, for a timely and correct treatment.

Programa de intervención para promoción de salud mental en una comunidad de personas mayores / Intervention program to promote mental health on an elderly community

En Chile muchas veces la atención primaria no es capaz de profundizar en los programas educativos hacia la Salud Mental. Por esto, es importante que los profesionales de salud logren desarrollar su rol educativo en contacto estrecho con la comunidad. Dentro del curso de Enfermería en Salud Mental y Psiquiatría II del Certificado Académico de Salud Mental y Psiquiatría de la Escuela de Enfermería de la Pontificia Universidad Católica de Chile, internos realizaron un programa de promoción de salud mental. Este fue dirigido a adultos mayores, por lo que se basó en el Modelo de educación para adultos propuesto por la Dra. Jane Vella. Se realizaron doce sesiones de una hora y treinta minutos en un lugar facilitado por la comuna de Estación Central. A través de un diagnóstico participativo se identificaron variados temas de interés, como el envejecimiento saludable, la memoria, la depresión, las redes de apoyo, relaciones saludables, cuidados del cuidador, utilizando la psicoeducación con un enfoque promocional. Se obtuvieron resultados positivos en relación a la obtención de herramientas para el autocuidado en salud mental. Como elemento negativo a destacar se encuentra la convivencia entre los participantes durante las sesiones debido a opiniones contradictorias, aspecto a tener en cuenta al implementar programas educativos futuros. En conclusión, esta intervención basada en la educación para adultos, demostró ser efectiva para abarcar temas de salud mental, promoviendo el envejecimiento saludable, el autocuidado y las relaciones interpersonales, en una población de personas mayores con diversos niveles educacionales y estilos de vida.

The Chilean Primary Care services are not able to deepen their educational programs towards Mental Health. It is therefore important that health professionals manage to develop their educational role in close contact with the community.In the context of a nursing mental health class of Pontificia Universidad Católica de Chile, 7 interns developed a health promotion intervention, which was created focusing in elderlypopulation. The intervention was based on Adult EducationalModel proposed by Jane Vella. There were 12 sessions of 1 hour anda half, conducted at Casa de la Mujer in Estación Central.The themes of the program were decided through a participative diagnosis. The themes chosen were healthy aging, memory, depression, support system, and caregive-care, which were treated using psychoeducation with a promotional emphasis.There were achieved positive results in relation to obtaining tools for self-care in mental health. As a negative element to highlight were the interactionsbetween the participants during the sessions due to conflicting opinions, aspect to be taken into account when implementing future educational programs.In conclusion, this intervention based on adult education proved to be effective in addressing mental health issues, promoting healthy aging, self-care and interpersonal relationships in a population of older people with different educational levels and lifestyles.

Estridor en neonatos con encefalopatía hipóxica sometidos a hipotermia terapéutica / Stridor in neonates with hypoxic encephalopathy undergoing therapeutic hypothermia

Resumen Introducción: la hipotermia terapéutica para el tratamiento de la encefalopatía hipóxico isquémica ha demostrado reducción en la mortalidad y secuelas neurológicas, dentro de los eventos adversos asociados a esta terapia se ha descrito la presencia de estridor. Objetivo: describir las características y la incidencia de estridor en un grupo de neonatos sometidos a hipotermia terapéutica para encefalopatía hipóxica. Resultados: en 34 neonatos con encefalopatía hipóxico isquémica sometidos a terapia con hipotermia en una unidad neonatal, se encontró predominio del sexo masculino y de encefalopatía hipóxico isquémica clasificación Sarnat II, de los cuales 12 neonatos (35.3 %) presentaron estridor. En total 7 de los 34 pacientes recibieron esteroide previo a la extubación y sólo 1 de ellos presentó estridor (14 %). Los pacientes que no recibieron esteroide previo a la extubación presentaron estridor en 40 % de los casos. De los pacientes que desarrollaron estridor, el 33 % requirió intubación por esta causa. Conclusiones: nuestra serie de casos no encontró diferencias con el uso de adrenalina o esteroides previo a la extubación para la prevención de estridor en pacientes con hipotermia; además se presentaron 2 casos de estridor en pacientes sin manipulación previa de la vía aérea, lo que soporta que el mecanismo inflamatorio no es el único involucrado en el estridor en los pacientes sometidos a hipotermia terapéutica.

Summary Introduction: Therapeutic hypothermia used for term and late preterm newborns with hypoxic ischemic encephalopathy has shown decrease in mortality and neurocognitive impairment, stridor has been recently described as an adverse effect of this therapy. Results: In 34 newborns with hypoxic ischemic encephalopathy treated with therapeutic hypothermia in a neonatal unit, we found male sex and Sarnat II hypoxic encephalopathy predominance, 12 patients (35.3%) developed stridor. 7 out of the 34 patients received steroid therapy previous to extubation and only 1 (14%) presented stridor. The patients that didn't received steroids 40% presented stridor. Out of the patients that developed stridor 33% required intubation because of this cause. Conclusion: Our series didn't find difference in the use of adrenaline or steroids previous to extubation to prevent stridor in hypothermic patients. We also had 2 cases that developed stridor without airway manipulation, these supports that inflammatory mechanism is not the only one involved in the development of stridor in newborns under cooling therapy.

Erosión muy tardía de la aurícula derecha con dispositivo Amplatzer®; reporte de un caso / Very late erosion of the right atrium with Amplatzer® device

Resumen La erosión tardía de la pared auricular y de la aorta es una causa infrecuente, pero potencialmente mortal en los pacientes que han sido sometidos al cierre percutáneo de un defecto del septum auricular, en especial cuando existe una alta relación entre el tamaño del dispositivo escogido con el tamaño del defecto y la presencia de bordes insuficientes. Presentamos el caso de un hombre de 70 años con un episodio de colapso hemodinámico secundario a taponamiento cardiaco debido a erosión muy tardía de la aurícula derecha por un Amplatzer® implantado 4 años atrás para el cierre de un defecto septal auricular. Conclusión La erosión tardía de los dispositivos de cierre percutáneo para los defectos atriales, aunque infrecuente, deberá ser tenida en cuenta en los pacientes que presentan colapso hemodinámico.

Abstract Late atrial wall and aorta erosion is a rare cause of potential fatallity in patients who have undergone percutaneous closure of an atrial septal defect, especially when a high ratio device to defect is chosen, and an insufficient aortic rim is present. We report the case of a 70 year old male with an episode of hemodinamic collapse secondary to cardiac tamponade due to a late erosion of a 4 years ago implanted Amplatzer® used to close an atrial septal defect. Conclusion Very late wall erosion of an atrial septal closure device, although uncommon, should be suspected in patients presenting with hemodynamic collapse.

Chronic Chagas cardiopathy in Chile. Importance of Trypanosoma cruzi burden and clinical evaluation.

Currently there are no biological markers to indicate which individuals with chronic indeterminate period of Chagas disease develop heart disease and who will remain all his life in this phase. The aim of this survey was to determine if Trypanosoma cruzi burden is related to the presence of heart disease in patients with chronic Chagas disease. 200 patients who had not been treated, 100 with cardiopathy and 100 without, groups A and B respectively, were submitted to clinical study and electrocardiogram, Echo-Doppler was performed for group A in which all important known causes of cardiopathy were discarded. In both groups xenodiagnosis, conventional PCR and quantitative PCR were undertaken. The 100 cardiopaths had 133 electrocardiographic alterations most of them in grade II of the New York Heart Association classification. 98 cardiopaths were classified in grade I by Echo-Doppler and only 2 cases were in grade III due to low ejection fraction. The difference in average parasitemia in patients of group A and B was not significant and no statistically differences were observed between average parasitemia of cardiopaths grade II versus grade I of NYHA. This results allow to characterize same clinical, electrocardiographical and parasitological features in chagasic cardiopaths of Chile.

[Very late erosion of the right atrium with Amplatzer(®) device]. / Erosión muy tardía de la aurícula derecha con dispositivo Amplatzer(®); reporte de un caso.

UNLABELLED: Late atrial wall and aorta erosion is a rare cause of potential fatallity in patients who have undergone percutaneous closure of an atrial septal defect, especially when a high ratio device to defect is chosen, and an insufficient aortic rim is present. We report the case of a 70 year old male with an episode of hemodinamic collapse secondary to cardiac tamponade due to a late erosion of a 4 years ago implanted Amplatzer(®) used to close an atrial septal defect. CONCLUSION: Very late wall erosion of an atrial septal closure device, although uncommon, should be suspected in patients presenting with hemodynamic collapse.

Evaluation of nifurtimox treatment of chronic Chagas disease by means of several parasitological methods.

Currently, evaluation of drug efficacy for Chagas disease remains a controversial issue with no consensus. In this work, we evaluated the parasitological efficacy of Nifurtimox treatment in 21 women with chronic Chagas disease from an area of endemicity in Chile who were treated according to current protocols. Under pre- and posttherapy conditions, blood (B) samples and xenodiagnosis (XD) samples from these patients were subjected to analysis by real-time PCR targeting the nuclear satellite DNA of Trypanosoma cruzi (Sat DNA PCR-B, Sat DNA PCR-XD) and by PCR targeting the minicircle of kinetoplast DNA of T. cruzi (kDNA PCR-B, kDNA PCR-XD) and by T. cruzi genotyping using hybridization minicircle tests in blood and fecal samples of Triatoma infestans feed by XD. In pretherapy, kDNA PCR-B and kDNA PCR-XD detected T. cruzi in 12 (57%) and 18 (86%) cases, respectively, whereas Sat DNA quantitative PCR-B (qPCR-B) and Sat DNA qPCR-XD were positive in 18 cases (86%) each. Regarding T. cruzi genotype analysis, it was possible to observe in pretherapy the combination of TcI, TcII, and TcV lineages, including mixtures of T. cruzi strains in most of the cases. At 13 months posttherapy, T. cruzi DNA was detectable in 6 cases (29.6%) and 4 cases (19.1%) by means of Sat DNA PCR-XD and kDNA PCR-XD, respectively, indicating treatment failure with recovery of live parasites refractory to chemotherapy. In 3 cases, it was possible to identify persistence of the baseline genotypes. The remaining 15 baseline PCR-positive cases gave negative results by all molecular and parasitological methods at 13 months posttreatment, suggesting parasite response. Within this follow-up period, kDNA PCR-XD and Sat DNA qPCR-XD proved to be more sensitive tools for the parasitological evaluation of the efficacy of Nifurtimox treatment than the corresponding PCR methods performed directly from blood samples.