[Ethical dilemmas in gastroenterology practice in Latin-American countries: the AIGE survey]. / Dilemas éticos en la asistencia de la gastroenterología en países latinoamericanos: la encuesta AIGE.

A survey sponsored by the Interamerican Association of Gastroenterology (AIGE) related to decision making in conflictive ethical situations in the setting of gastroenterological practice was designed (AJ-JCG). Seven problem-cases with 3 to 5 pre-established and not-excluding answers each, demographic and occupational data were included, by public invitation during 1996-97 AIGE educational activities in La Plata (Argentina), Montevideo (Uruguay) and Santo Domingo (Dominican Republic). Data were inserted in a computerised data base, and chi square, Fischer and Maentel-Henzel tests were used for statistical studies. 118 out of 460 doctors registered to educational activities answered at the survey (25.6%). Mean age was 42 +/- 15 years and 57.6% were male; 48.5% were under 10 years of professional practice and 19.5% were over 20 years. Gastroenterology was the main specialty in 89.8%. Although only 15.2% of participants reported as not having Ethical Committee (EC) in their institutions, the option of consulting was not very frequently selected, except in cases of request about pregnancy interruption in the HCV infected mother (22.9%), inclusion of the young alcoholic cirrhotic man in the waiting list for liver trasplant (17.8%), and the Jehova's Witness conscious patient with bleeding esophageal varices (13.5%). Cases of direct communication to the patient of early colon cancer diagnosis (66.1%), and inclusion of the young end stage alcoholic cirrhotic patient in the waiting list for liver trasplantation (65.2%), had the higher consensus. On the other hand, lower consensus (39%) was seen in the case of variceal bleeding in the encephalopathic Witness of Jehova patient. Differential criterla were observed related to sex: 38% of women versus 14.7% of men (p < 0.01) refuse the interruption of pregnancy to the infected HCV patient because of personal convictions against abortion. In the case of suspected HIV co-infection in the IVD HBsAG + carrier, 46% of women vs. 27.9% of men (p < 0.05) indicate HIV screening test without any explanation to the patient because "he could transmit a fatal disease". In this same case, time from graduation was related to differences in option selection: 80.9% in the group > 20 years of professional exercise asked for patient consent and accepted his decision, versus 52.7 and 27.5% in 0-9 and 10-19 years group respectively (p < 0.05). Usual medical and social worries as communication (truth, informed consent), the autonomic decision of biological death versus the sacrament of life, justice in allocation resources, confidentiality and social concern, abortion, and many other controversies linked to tecno-scientific development, impact the practice of Gastroenterology in latinoamerican countries. However medical answers to ethical dilemmas are not uniform. Although our results ought to be verified by other studies they clearly suggest the needs for systematic incorporation of applicated Ethics in pre and postgraduate Gastroenterology curricula, besides the regular activities of our regional institutions.

Dilemas éticos en la asistencia de la gastroenterología en países latinoamericanos: la encuesta AIGE. / [Ethical dilemmas in gastroenterology practice in Latin-American countries: the AIGE survey]

A survey sponsored by the Interamerican Association of Gastroenterology (AIGE) related to decision making in conflictive ethical situations in the setting of gastroenterological practice was designed (AJ-JCG). Seven problem-cases with 3 to 5 pre-established and not-excluding answers each, demographic and occupational data were included, by public invitation during 1996-97 AIGE educational activities in La Plata (Argentina), Montevideo (Uruguay) and Santo Domingo (Dominican Republic). Data were inserted in a computerised data base, and chi square, Fischer and Maentel-Henzel tests were used for statistical studies. 118 out of 460 doctors registered to educational activities answered at the survey (25.6

). Mean age was 42 +/- 15 years and 57.6

were male; 48.5

were under 10 years of professional practice and 19.5

were over 20 years. Gastroenterology was the main specialty in 89.8

. Although only 15.2

of participants reported as not having Ethical Committee (EC) in their institutions, the option of consulting was not very frequently selected, except in cases of request about pregnancy interruption in the HCV infected mother (22.9

), inclusion of the young alcoholic cirrhotic man in the waiting list for liver trasplant (17.8

), and the Jehovas Witness conscious patient with bleeding esophageal varices (13.5

). Cases of direct communication to the patient of early colon cancer diagnosis (66.1

), and inclusion of the young end stage alcoholic cirrhotic patient in the waiting list for liver trasplantation (65.2

), had the higher consensus. On the other hand, lower consensus (39

) was seen in the case of variceal bleeding in the encephalopathic Witness of Jehova patient. Differential criterla were observed related to sex: 38

of women versus 14.7

of men (p < 0.01) refuse the interruption of pregnancy to the infected HCV patient because of personal convictions against abortion. In the case of suspected HIV co-infection in the IVD HBsAG + carrier, 46

of women vs. 27.9

of men (p < 0.05) indicate HIV screening test without any explanation to the patient because [quot ]he could transmit a fatal disease[quot ]. In this same case, time from graduation was related to differences in option selection: 80.9

in the group > 20 years of professional exercise asked for patient consent and accepted his decision, versus 52.7 and 27.5

in 0-9 and 10-19 years group respectively (p < 0.05). Usual medical and social worries as communication (truth, informed consent), the autonomic decision of biological death versus the sacrament of life, justice in allocation resources, confidentiality and social concern, abortion, and many other controversies linked to tecno-scientific development, impact the practice of Gastroenterology in latinoamerican countries. However medical answers to ethical dilemmas are not uniform. Although our results ought to be verified by other studies they clearly suggest the needs for systematic incorporation of applicated Ethics in pre and postgraduate Gastroenterology curricula, besides the regular activities of our regional institutions.

[Electro-cardiographic correlation in the diagnosis of left ventricular hypertrophy]. / Correlação eletro-ecocardiográfica no diagnóstico da hipertrofia ventricular esquerda.

PURPOSE: To compare the efficacy of four electrocardiographic criteria: Sokolov, Gubner, Cornell and Romhilt indexes, in the diagnosis of left ventricular hypertrophy (LVH) in hypertensive patients. METHODS: LVH was analyzed in the electrocardiogram of 30 ambulatory patients presenting with systemic arterial hypertension, classified as mild, moderate and severe, according to the following indexes: Sokolov > or = 35 mm, Gubner > or = 22 mm, Romhilt > or = 5 points and Cornell > or = 20 mm for women and 28 mm for men. Sensitivity, specificity, diagnostic accuracy and other diagnostic variables were determined Mass index of the left ventricle, > or = 98 g/m2 for women and > or = 120 g/m2 for men, obtained by echocardiography, was considered the gold standard for the diagnosis of LVH. RESULTS: When electrocardiographic criteria were considered separately, the Sokolov index showed the highest accuracy, with a sensitivity of 40%, diagnostic accuracy of 50% and specificity of 100%; the second most accurate index was Gubner, and Romhilt and Cornell indexes followed. When at least one of the indexes was positive, the sensitivity was 52% and diagnostic accuracy was 57%. CONCLUSION: The four electrocardiographic indexes were not diagnostic of LVH, when analyzed either separately or together. Considering the high prevalence of this pathological condition, we conclude that a more accurate diagnostic method should be used in this diagnosis.

Correlação eletro-ecocardiográfica no diagnóstico da hipertrofia ventricular esquerda / Electro-echocardiographic correlation in the diagnosis of left ventricular hypertrophy

OBJETIVO - Comparar a eficácia diagnóstica de 4 critérios eletrocardiográficos: índices de Sokolov, Gubner, Cornell e Romhilt, na detecção da hipertrofia ventricular esquerda (HVE) em pacientes hipertensos. MÉTODOS - Foram avaliados 30 pacientes ambulatoriais, com hipertensão arterial sistêmica leve, moderada ou grave, sendo considerado o diagnóstico de HVE quando os índices eram: Sokolov 'maior ou igual' 35mm, Gubner 'maior ou igual' 22mm, Romhilt 'maior ou igual' 5 pontos e Cornell 'maior ou igual' 20mm para mulheres e 28mm para homens. Determinaram-se, então, a sensibilidade, especificidade, eficácia diagnóstica e outras variaáveis diagnósticas para cada um dos critérios, isoladamente, e para os 4 considerados simultaneamente, utilizando-se como padrão ouro para HVE o índice de massa do ventrículo esquerdo 'maior ou igual'98g/m² para mulheres e 'maior ou igual' 120g/m² para homens, obtidos ao ecocardiograma. RESULTADOS - Considerando cada critério eletrocardiográfico isolado, o índice de Sokolov apresentou a melhor eficácia, com sensibilidade = 40 'por cento', eficácia diagnóstica de 50 'por cento' e especificidade 100 'por cento'; o 2§ critério mais eficaz foi o índice de Gubnere, em 3§ lugar, empatados, os índices de Romhilt e Cornell. Quando considerados, simultaneamente, ou seja, a presença de pelo menos um dos quatro critérios, a sensibilidade foi 52 'por cento' e a eficácia diagnóstica 57 'por cento'. CONCLUSÄO - Os quatro critérios eletrocardiográficos considerados individualmente ou em conjunto foram pouco eficazes na detecção da HVE e, considerando a importância desta entidade patológica, concluímos que é imprescindível a utilização de método propedêutico mais sensível para tal diagnósticos.

Terapia trombolítica del infarto agudo del miocardio / Trombolytic therapy in acute myocardial infarction

Se presentan los resultados del estudio prospectivo del uso de la Streptokinasa como terapia trombolítica en pacientes con infarto agudo del miocardio, realizado en el Hospital General de Enfermedad Común del IGSS, durante los meses de enero-agosto de 1992. Se incluyeron los pacientes con infarto diagnósticado por clínica, electrocardiograma y enzimas cardíacas, menores de 75 años, con menos de 24 hrs. de inicio del dolor. A todos se les aplicó tratamiento con Streptokinasa 1.5 millones de unidades intravenosa. 29 pacientes llenaron los criterios ya mencionados, oscilando de 24 a 75 años, con un mayor porcentaje entre los 40 y 60 años (55/100); de los cuales el 90/100 pertenenecían al sexo masculino. Por Killip al ingreso, el mayor porcentaje se agrupó en el primer grado (55/100), con 4 casos de Killip del grupo IV inclusive. La supersificie cardíaca anterolateral resultó ser la m s afectada (39/100). La trombolisis se aplicó en promedio 6 horas después de inicio del dolor (75/100 de los pacientes), aplicando en un caso 36 horas después por extensión del infarto. Las complicaciones se presentaron en un escaso porcentaje, 3 arritmias de reperfusión no significativas 4 pacientes con hemorragia: l gastrointestinal y 3 con hematuria, 2 con hipotensión; siendo la mortalidad en general de un 13/100, distruibuidos estos últimos en estadíos Killip III y IV. La estancia en general fue de 7 días promedio y 4 días en intensivo. Se recomienda el utilizar la Streptokinasa como terapia trombolítica en pacientes con infarto agudo del miocardio, que cumplan criterios según protocolos previamente establecidos y dar seguimiento a la experiencia en nuestro hospital

Estudo das arritmias cardíacas maternas durante o trabalho de parto e o parto / Maternal cardiac arrhythmias during labor and delivery

Quarenta e sete gestantes foram estudadas através do sistema Holter para detecção de arritmias durante o trabalho de parto e parto, que alcançaram prevalência de 72,3% com caráter benigno. As arritmias supraventriculares foram as mais frequentes parecendo mais vinculadas a hipertonia vagal. As ventriculares foram representadas por extra-sístoles, que ocorreram de preferencia antes do parto da cabeça fetal e nas gestantes de 16 a 25 anos. Admitimos sejam devidas a alterações estruturais miocárdicas provocadas pelos distúrbios hemodinâmicos e hormonais durante a gestação, culminando com o estresse físico e psíquico do trabalho de parto a parto. Não foram identificadas repercussões atribuíveis as arritmias, dispensando-se terapêutica própria imediata ou ulterior