Síndrome de DRESS en el diagnóstico diferencial de las complicaciones postquirúrgicas / DRESS syndrome, a differencial diagnosis in late postoperative complications

El síndrome de DRESS (reacción de sensibilidad a medicamentos con eosinofilia y síntomas sistémicos) es una farmacodermia grave que debe ser conocida para instaurar un tratamiento óptimo precoz, evitando así una evolución sistémica y potencialmente letal. Las farmacodermias son la tercera causa de efectos adversos en las plantas de hospitalización quirúrgica, precedida por las infecciones nosocomiales y las complicaciones intraoperatorias. La mayoría de los casos suponen un reto diagnóstico para el cirujano, ya que su debut es inespecífico y, por tanto, son fácilmente confundibles con una complicación derivada de una cirugía reciente. Presentamos el caso de un varón de 54 años, sano y sin antecedentes personales, intervenido en dos ocasiones por sangrado abdominal espontáneo que tres semanas después de la última cirugía, y coincidiendo con la toma de metamizol oral, desarrolló un síndrome de DRESS. El deterioro inicial inespecífico, característico de este síndrome, motivó el retraso diagnóstico y terapéutico del paciente, y la consecuente evolución hacia la afectación sistémica

The DRESS syndrome (drug rash with eosinophilia and systemic symptoms) is a serious pharmacodermia which must be taken into account when establishing an optimal early treatment to prevent a systemic and potentially lethal evolution. Pharmacodermias are the third most frequent cause of adverse effects during surgical hospitalization, after nosocomial infections and intraoperative complications. In most cases, they pose a challenge to the surgeon, since their onset is nonspecific and, therefore, can be easily mistaken for a surgery complication. We present the case of a 54-year-old man, healthy and without relevant background, who was operated on two times due to spontaneous abdominal bleeding. Three weeks after the last surgery, and coinciding with the administration of oral metamizole, the patient developed a DRESS syndrome. The initial unspecific deterioration, characteristic of this syndrome, is the main cause of the delay in diagnosis and correct treatment, causing the resulting evolution to systemic affectation

[DRESS syndrome, a differencial diagnosis in late postoperative complications]. / Síndrome de DRESS en el diagnóstico diferencial de las complicaciones postquirúrgicas.

The DRESS syndrome (drug rash with eosinophilia and systemic symptoms) is a serious pharmacodermia which must be taken into account when establishing an optimal early treatment to prevent a systemic and potentially lethal evolution. Pharmacodermias are the third most frequent cause of adverse effects during surgical hospitalization, after nosocomial infections and intraoperative complications. In most cases, they pose a challenge to the surgeon, since their onset is nonspecific and, therefore, can be easily mistaken for a surgery complication. We present the case of a 54-year-old man, healthy and without relevant background, who was operated on two times due to spontaneous abdominal bleeding. Three weeks after the last surgery, and coinciding with the administration of oral metamizole, the patient developed a DRESS syndrome. The initial unspecific deterioration, characteristic of this syndrome, is the main cause of the delay in diagnosis and correct treatment, causing the resulting evolution to systemic affectation.

Growth hormone receptors in the atherinid Odontesthes bonariensis: characterization and expression profile after fasting-refeeding and growth hormone administration.

In order to improve the understanding of pejerrey Odontesthes bonariensis, growth hormone (Gh)-insulin-like growth factor-1(Igf1) axis, O. bonariensis growth hormone receptor type 1 (ghr1) and type 2 (ghr2) mRNA sequences were obtained. Both transcripts were ubiquitously expressed except in kidney, encephalon and anterior intestine. Alternative transcripts of both receptors were found in muscle. Interestingly, two different ghr2 transcripts with alternative polyadenylation (APA) sites located in the long 3' untranslated region (UTR-APA) were also found in liver. Hepatic ghr1, ghr2 and insulin-like growth factor type 1 (igf1) transcript levels were examined under two different metabolic conditions. In the first experimental condition, fish were fasted for 2 weeks and then re-fed for another 2 weeks. Despite igf1 mRNA relative expression did not show significant differences under the experimental period of time examined, both ghr transcripts decreased their expression levels after the fasting period and returned to their control levels after re-feeding. In the second treatment, recombinant O. bonariensis growth hormone (r-pjGh) was orally administered once a week. After 4 weeks of treatment, liver igf1, ghr1 and ghr2 mRNA relative expression increased (13, 4·5 and 2·1 fold, P < 0·05) compared to control values. These results add novel information to the growth hormone-insulin-like growth factor system in teleosts.

[Primary care centers and breast-feeding]. / Centros de atención primaria y lactancia materna.

OBJECTIVE: To study activities that promote, maintain and support breast feeding in primary care centers in our health district and to evaluate the commitment of health center directors' to breast feeding, their knowledge of the subject, and programs involved in the promotion of natural breast-feeding. MATERIAL AND METHODS: A cross-sectional study was carried out through surveys to those in charge of health centers, nursing, pediatric programs and pregnancy programs. RESULTS: Eighty surveys were sent to center and program directors. Answers were obtained from 66.2 %. A total of 6.9 % of the centers had no program or protocol for the promotion and maintenance of breast-feeding, nor did they seek the collaboration of support groups. Only 28.8 % of the centers surveyed carried out activities that provided special support to mothers with difficulties in breast-feeding. In contrast, 80.4 % possessed an adequate register on the incidence of breast-feeding. In 74.5 % of the centers, health professionals were given no specific training on the subject. Only 14.9 % of the centers had rules prohibiting visible leaflets, posters or samples of formula milk. In 84.6 % of the centers, no place was provided where breast-feeding could be carried out, observed, and possible problems corrected. CONCLUSIONS: Most of the primary care centers surveyed do not promote programmed activities favoring the promotion and maintenance of breast-feeding. Nevertheless, many centers provide advice on breast-feeding. Collaboration with support groups or other resources that might exist in the community is not generally sought. Specific training in breast-feeding is not given to the centers' health professionals. Only a minority of the centers possesses an appropriate place where mothers can breast-feed if they wish and where the process of breast-feeding can be observed and modified. The results suggest that primary care centers do not provide the necessary support to ensure successful breast-feeding and that they lack the resources necessary to achieve this aim.

Centros de atención primaria y lactancia materna / Primary care centers and breast-feeding

Objetivo: Estudiar el estado de las actividades de promoción, protección y apoyo a la lactancia materna en los centros de atención primaria (CAP) de nuestra área de salud y el compromiso y conocimientos sobre la alimentación al pecho de los responsables de estos centros y de los programas implicados en la promoción de la lactancia natural. Material y métodos: Se realizó un estudio transversal mediante encuesta dirigida a los responsables de los centros y a los responsables de enfermería, así como a los responsables de los programas del niño y de la mujer embarazada. Resultados: Se remitieron 80 encuestas dirigidas a los responsables de centros y programas, de las que se contestaron el 66,2%. Se observa que en el 56,9% de los centros no se dispone de programa o de protocolo de promoción y de protección de la lactancia materna ni se busca la cooperación con grupos de apoyo. Únicamente en el 28,8% se realizan actividades de apoyo especial a las madres que presentan dificultades con la lactancia. En cambio, el 80,4% tiene un adecuado registro sobre incidencias de la lactancia. En el 74,5% de los centros no se facilita formación específica sobre este tema a los profesionales. Sólo en el 14,9% existen normas para evitar la presencia visible de folletos, carteles o muestras de leche de fórmula. En el 84,6% de los centros no se dispone de un lugar para poder alimentar al pecho, observar la lactancia y corregir los posibles problemas que existan. Conclusiones: La mayoría de los CAP consultados no realizan actividades programadas que favorezcan la protección y la promoción de la lactancia natural. Aun así, las futuras madres reciben consejo sobre aspectos de la lactancia materna en muchos centros. No se busca, en general, la cooperación de grupos de apoyo mutuo u otros recursos que pueden existir en la población. Tampoco se ha facilitado a los profesionales formación específica sobre los aspectos relacionados con la lactancia materna. La minoría de los centros de atención primaria dispone de un lugar adecuado para poder lactar las madres que lo deseen, y donde pueda observarse la lactancia y modificar los aspectos que lo requieran. Se desprende de los resultados que no se dan todos los apoyos necesarios para poder lactar en los CAP y que estos centros tienen importantes carencias para conseguir este objetivo (AU)

Postprandial remnant-like lipoproteins in hypertriglyceridemia.

It has been proposed that remnants of chylomicrons and very-low-density lipoproteins (VLDL) are atherogenic. We have used an immunochemical method to isolate remnant-like particles (RLP) and measured them in terms of their cholesterol and triglycerides (TG). RLP consist of apoB-48-containing triglyceride-rich lipoproteins and remnant-like VLDL containing apoB-100. The study aim was to look for information from postprandial RLP data that could not be known from other markers of triglyceride-rich lipoproteins and fasting TG and RLP data alone. A total of 41 subjects were studied. Eight subjects had hypertriglyceridemia (HTG) and low high-density lipoprotein (HDL), 14 had combined hyperlipidemia (CH), 5 had the apo E2/2 genotype receiving gemfibrozil, 10 were normolipidemic (NL) controls, and 4 had hypercholesterolemia. As a whole group, there was correlation among 1) fasting TG, RLP cholesterol (RLP-C), and RLP-TG but not VLDL apo B100, VLDL apo B48 and their respective postprandial responses measured as incremental area under the curve (IAUC), 2) fasting TG and postprandial IAUC of RLP-C and RLP-TG, 3) RLP-C IAUC, RLP-TG IAUC, and TG IAUC, retinyl palmitate (RP) IAUC, and VLDL apo B48 IAUC but not VLDL apo B100 IAUC. The HTG/low HDL-C and CH groups had higher IAUC for RLP-C, RLP-TG, TG, and RP than the NL group. Fasting and postprandial RLP were triglyceride enriched in the HTG/low HDL-C group and to a lesser extent in the CH group. The HTG/low HDL-C and CH groups had a delay in their RLP-C but not RLP-TG peaks suggesting a delay in hepatic clearance of RLP and/or a protracted period of lipolysis and/or processing of RLP. The fasting and postprandial RLP-C/RLP-TG and RLP-C/TG ratios were elevated in the apo E2/2 group in spite of gemfibrozil therapy. The increment in postprandial RLP was, however, not exaggerated. Our data indicate that 1) postprandial RLP lipemia is enhanced in HTG subjects when compared with NL subjects, 2) postprandial RLP lipemia is proportional to fasting RLP and TG levels and mirrors, to a large extent, increases in postprandial TG, RP, and VLDL apo B48 but not VLDL apo B100, 3) there are compositional differences in fasting and postprandial RLP in the three forms of HTG studied, RLP being triglyceride enriched in the HTG/low HDL-C group and to a lesser extent in the CH group, and cholesterol-enriched in the apo E2/2 group, and 4) apo E2/2 subjects had high fasting and postprandial RLP-C concentrations in spite of being on treatment with gemfibrozil and having normal fasting and postprandial TG concentrations.

[Emphysematous cholecystitis. Diagnosis, clinical course, and treatment]. / Colecistitis enfisematosa. Diagnóstico, evolución y tratamiento.

Emphysematous cholecystitis is the most severe acute cholecystitis with infection by gas-producing organism. The morbidity and mortality rate are 15%. We present a retrospective study of emphysematous cholecystitis seen in our department during three years (1992-1994). Inclusion criteria were made on the basis of a characteristic history, physical examination and radiology findings. Eight patients were studied. All were men, medium age 75 years (range: 45-88). None of them was diabetic. Clinical history was typical for the disease. Radiological examinations included abdominal X-ray (none of them was demonstrative), abdominal ultrasound (carry out in five patients and diagnosis in two) and computerised tomography scanning was necessary in the others three patients. Surgery was required since complication occurred in two patients. The mean duration until surgery was 5.21 day. Only three patients had any postoperative complication and nobody death. We concluded that the treatment of choice is cholecystectomia, except for high risk patient in whom puncheon and drainage is required.

Effect of gemfibrozil and lovastatin on postprandial lipoprotein clearance in the hypoalphalipoproteinemia and hypertriglyceridemia syndrome.

Eleven men with hypoalphalipoproteinemia (HPAL; fasting plasma high density lipoprotein (HDL) cholesterol level of < 0.9 mmol/l), mild hypertriglyceridemia (HTG; triglycerides (TG) level of 1.75-7.5 mmol/l) and a normal calculated LDL cholesterol level (< 3.7 mmol/l) participated in a randomized, double-blind, double-placebo, crossover trial to compare the effect of two drugs, lovastatin (40 mg once daily) and gemfibrozil (600 mg twice daily), on clearance of postprandial lipoproteins. A 2-week washout period separated drug treatment periods of 6 weeks each. Ten subjects completed each treatment period. After ingestion of a vitamin A fat load, plasma, chylomicron and non-chylomicron retinyl palmitate (RP) and TG responses (areas under curves) were reduced in all subjects on gemfibrozil therapy and in 7 on lovastatin therapy. There was close correlation between change in fasting TG (but not fasting HDL-cholesterol) and change in postprandial RP areas on gemfibrozil but not lovastatin therapy. Postheparin lipoprotein lipase (LPL) and hepatic lipase (HL) activities were increased by gemfibrozil therapy while only a mild elevation in LPL activity alone was seen on lovastatin therapy. These data indicate that improvement in HTG is the main feature associated with improvement in postprandial lipemia and this is likely due to LPL-mediated enhancement of lipolytic hydrolysis. Gemfibrozil is more effective than lovastatin in attenuating postprandial lipemia in the HPAL/HTG syndrome.

Delayed clearance of postprandial chylomicrons and their remnants in the hypoalphalipoproteinemia and mild hypertriglyceridemia syndrome.

Hypoalphalipoproteinemia (HPAL) with mild hypertriglyceridemia (HTG) is associated with increased coronary artery disease (CAD) risk. The aim of this study was to examine the metabolism of postprandial lipoproteins in HPAL/HTG subjects (n = 21). They had a fasting plasma high density lipoprotein (HDL) cholesterol level < 0.9 mmol/l, a triglycerides (TG) level of 2.0-7.1 mmol/l, and a normal low density lipoprotein (LDL) cholesterol level (< 3.7 mmol/l). They were either homozygous for apoprotein E3 (n = 13) or heterozygous for apoprotein E4 (n = 5) or E2 (n = 3). After ingestion of a vitamin A fat load, plasma and chylomicron (CM) retinyl palmitate (RP) response (areas under curves) was three times and non-CM RP response 2.5 times greater than in normolipidemic control subjects (n = 13). There was close correlation between fasting plasma TG level and postprandial RP response in HPAL/HTG subjects (plasma, r = 0.87; CM, r = 0.89; and non-CM, r = 0.84). In control subjects this correlation was present for plasma RP (r = 0.80) and CM RP (r = 0.61) but not for non-CM RP (r = 0.53). In contrast, postprandial RP response was not correlated with fasting plasma HDL cholesterol levels for both groups. There was also no correlation between fasting TG and fasting HDL cholesterol. Postheparin lipoprotein lipase and hepatic lipase activities were slightly higher in HPAL/HTG subjects. The pattern of postprandial change in HDL composition was similar to that in control subjects. These data indicate enhanced postprandial lipemia in the HPAL/HTG syndrome, and this may account for their increased CAD risk.(ABSTRACT TRUNCATED AT 250 WORDS)

Falsely high high-density lipoprotein triglyceride values by the heparin-manganese precipitation method.

Recent evidence indicates that high-density lipoprotein triglyceride (HDL-Tg) may be a predictor of coronary artery disease. We examined three methods for HDL-Tg measurement, comparing results obtained by measurement of Tg in the supernate after heparin-manganese chloride (heparin-Mn) precipitation of EDTA-treated plasma (I) with results obtained after preparative ultracentrifugation (II and III). In II, we used heparin-Mn precipitation of low-density lipoprotein (LDL) from the infranate after ultracentrifugation at d 1.006 to remove very-low-density lipoprotein (VLDL). In III, we performed sequential flotation ultracentrifugation at d 1.006 and 1.063, then measured Tg in the d greater than 1.063 fraction. Method I gave significantly higher HDL-Tg results than II and III, which gave essentially identical results. The difference in results between I and II was not caused by the presence of heparin or manganese chloride, because these were used in both methods. Prior removal of VLDL in II and III resulted in lower HDL-Tg values, and subsequent removal of LDL by precipitation or ultracentrifugation did not alter final HDL-Tg values. The higher values obtained in I were the result of the presence of VLDL-rich unsedimented precipitate in the supernate.

Change in composition of high density lipoprotein during gemfibrozil therapy.

We investigated the high density lipoprotein cholesterol (HDL-C) response in 20 middle-aged males during a 12-week course of gemfibrozil. Three aspects of the increase in HDL-C (25%) were studied and our observations are as follows: (1) subfraction analysis showed that HDL3-C rose earlier and to a larger extent (28%) than HDL2-C (15%), (2) analysis of variance group--time interaction effect and correlation studies of HDL-C and total triglycerides suggest the increase in HDL-C was due to a direct effect of gemfibrozil on HDL metabolism, and (3) HDL-C was the only one of 4 HDL components to increase. Apoprotein A-I (apo A-I) and HDL-phospholipid (HDL-PL) did not change, and HDL-triglyceride (HDL-TG) decreased. This pattern is consistent with a change in composition of HDL, i.e. cholesterol enrichment and triglyceride depletion.

Changes in serum lipoproteins and high-density lipoprotein composition during isotretinoin therapy.

Oral isotretinoin has been reported to increase serum total triglycerides (TG), cholesterol (TC), phospholipids (TPL), apoprotein B (apo B), and to reduce high-density lipoprotein cholesterol (HDL-C). To investigate the effects of isotretinoin on HDL, we measured HDL-C, HDL phospholipids (HDL-PL), apoprotein A1 (apo A-1), and HDL-C subfractions (HDL2-C and HDL3-C) in 24 healthy, male patients receiving a 16-week course of isotretinoin (1.0 mg/kg/day) for treatment of severe acne vulgaris. Patients were placed on a constant diet and fasting lipid parameters were measured every 4 weeks. Analysis of the data from the 20 patients who completed the study confirmed the reported increase in TG, TC, LDL-C, apo B, and LDL-C/HDL-C (all p less than 0.01) observed during isotretinoin therapy. Reduction occurred in HDL-C (p less than 0.05) and HDL2-C (p less than 0.01) while HDL3-C remained unchanged, indicating that the effect of isotretinoin is on the HDL2-C subfraction. Apo A-1 and HDL-PL did not change significantly, suggesting that the reduction in HDL-C represents cholesterol depletion of the HDL particle rather than a reduction in HDL mass. After discontinuing isotretinoin, serum lipid parameters returned to baseline levels.

Presence of unsedimented precipitate in visually non-turbid supernates in the heparin-manganese method for HDL-cholesterol quantitation.

An inherent problem with the heparin-manganese precipitation procedure for high density lipoprotein-cholesterol (HDL-C) quantitation is the inability to sediment all the precipitated lipoproteins, especially in hypertriglyceridemic samples. This results in overestimation of HDL-C. Thus ultrafiltration has been recommended for turbid supernates. We have investigated 47 non-turbid supernates for possible presence of unsedimented precipitate. Optical turbidity in these samples was found to correlate with the serum triglyceride level. With ultrafiltration of the supernates, there was a significant decrease in cholesterol, optical turbidity and apoprotein A-I. The percent change in turbidity correlated with the percent change in cholesterol. There was also correlation between percent change in cholesterol and the prefiltration supernate turbidity. These results indicate that visually clear supernates may show optical turbidity; the turbidity is likely due to triglyceride-rich particles, which contain cholesterol; the fall in cholesterol with ultrafiltration is due to removal of these floating particles and some adsorbance of HDL particles to the filters.