Un análisis del problema ético y legal del tratamiento del cáncer cervicouterino en mujeres embarazadas: [revisión] / Ethical and legal problem in the treatment of cervical cancer in pregnant women: [review]

Se analiza el problema ético y jurídico del tratamiento del cáncer cervicouterino en mujeres embarazadas. Se realizó una revisión del tema, de las leyes chilenas y de algunas normativas europeas para después analizar la aplicación de los principios de No Maleficencia, Beneficencia, Autonomía y del Doble Efecto. El tema genera una difícil discusión e interpretación, pues tanto las leyes como los principios son orientadores, pero no explícitos para decidir la conducta más adecuada en cada caso. Lo ideal es preservar la vida materna y fetal, pero hay casos en los que, finalmente, es necesario priorizar una sobre la otra. Corresponde al equipo tratante, la madre, el padre, la familia y la sociedad concordar las conductas más responsables y justas posibles.

Authors analyze the ethical and legal problem about the treatment of cervical cáncer in pregnant women. A review of the Chilean laws and European regulations was made in order to analyze the application of the principies of Non maleficence, Beneficence, Autonomy and the Double Effect. The subject generates a difficult discussion and interpretation since both, law and principies, are guiding but do not give an explicit answer to choose the more appropriate behavior in each case. The goal is to preserve maternal and fetal life, but there are cases in which it is necessary to prioritize one over the other. A consensus between medical staff, the mother, the father, the family and society is necessary for a more responsible and fair decision.

A hydrodynamic model of labyrinth to study the stimulation of perilymph compartments by audioprostheses.

CONCLUSIONS: The hydrodynamic model of the labyrinth spaces (LHM) is a useful tool for research on implantable audioprostheses, in particular to develop suitable actuators using MEMS technology (micro-electromechanic machine system). It has other potential applications for auditory research. OBJECTIVES: The energy reaching the labyrinth fluids is crucial information for developing prostheses to substitute the tympanic-ossicular system because adequate stimulation of the cochlear partition is essential. However, in vivo measurements in human ears are not currently available. Therefore a model of the normal labyrinth resembling its hydrodynamic properties becomes a valuable tool. It could allow comparison of different processing systems, algorithms and transducers, to develop new audioprostheses and improve their effectiveness and efficiency. MATERIALS AND METHODS: This work presents one LHM that emulates the conduction of the stimuli from the stapes footplate through the labyrinthine fluids, including its dimensions and physical properties, and some examples of measurements of perilymph stimulation by different audioprostheses and algorithms. RESULTS. As shown in the reported examples, this LHM provided effective measurement of acoustic stimulation across the whole human auditory frequency and intensity spectrum. Air-delivered and direct stimulation methods are possible. This provided convenient information for the actuator development and allowed comparison between different prototypes, stimulation patterns and algorithms.

Effectiveness assessment of otosclerosis surgery.

CONCLUSIONS: The epidemiological characteristics of otosclerosis and its treatment in Andalusia resemble those of other populations with similar socioeconomic levels. Two complementary approaches, such as questionnaires and pure-tone audiometry, are required to assess the effectiveness of otosclerosis surgery (OS) reliably and precisely. OBJECTIVES: We describe a new method to assess effectiveness in OS. It is based on the results of pure-tone audiometry and a specially designed quality of hearing questionnaire (QHQ). The objectives of the study are: (i) to report the general epidemiologic profile of otosclerosis in Andalusia; (ii) to study the effectiveness of OS in our community using conventional methods; and (iii) to study the outcomes of OS using the QHQ and to compare them to those obtained using conventional methods. MATERIAL AND METHODS: All 31 hospitals in the public healthcare system of Andalusia were studied. They were graded into four groups using a specially designed grouping system. The data were obtained from the minimum basic dataset. The prevalence of otosclerosis in Andalusia was calculated from the incidence data, the duration of the disease and life expectancy. To assess the effectiveness of OS, 475 clinical records from 15 hospitals representing all 4 groups were analysed. Effectiveness was assessed by conventional methods, using data obtained from pure-tone audiometry, and by using version 1.02 p of the QHQ. RESULTS: The incidence of clinical otosclerosis was 5.67 patients/100,000 inhabitants/year. The calculated prevalence was 0.287%. The number of cases increased progressively during the study period (p<0.001). The 15-45-year age group was the largest (62.2%) and 68.4% of patients were females. The most frequent type of otosclerosis was estapediovestibularis (fenestral), non-obliterative (91.8%). Only 48 cases (2.3%) of cochlear and 45 (2.2%) of obliterative otosclerosis were reported. The most frequently employed therapeutic procedures were stapedectomy and stapedotomy (75.70%). The average total and preoperative lengths of stay were 3.59 and 1.04 days, respectively. There were significant differences between the different types of otosclerosis. Improvement in the air-bone gap was 15.37+/-1.19 dB (n=164) and the overclosure or operative damage was 0.49+/-0.85 dB (n=164). A gap improvement of 10-40 dB was observed in 61.4% of patients. The > 65 years age group showed the best gap improvement but the largest variability. The quality of hearing measured by the QHQ showed that, in general, a better gap improvement was associated with a higher quality of hearing (Pearson correlation r=0.183; p<0.05). The 15-45-year age group had the worst gap improvement but, in contrast, the better quality of hearing.

[Small-cell carcinoma of the larynx]. / Carcinoma de células pequeñas de laringe.

Primary small-cell (also known as oat-cell) neuroendocrine carcinoma of the larynx is an infrequent tumor. We report a case of epiglottic oat-cell carcinoma in a 57-year-old man. Its association with other malignant neoplasms and aggressive behavior in spite of treatment are discussed.

Carcinoma de células pequeñas de laringe / Small-cell carcinoma of the larynx

El carcinoma neuroendocrino de células pequeñas primario de laringe es un tumor infrecuente. Presentamos un caso del también llamado 'carcinoma de células en avena': oat-cell, epiglótico, diagnosticado en un varón de 57 años. Se discuten su asociación a otras neoplasias malignas y su comportamiento agresivo a pesar del tratamiento (AU)

Primary small-cell (also known as oat-cell) neuroendocrine carcinoma of the larynx is an infrequent tumor. We report a case of epiglottic oat-cell carcinoma in a 57-year-old man. Its association with other malignant neoplasms and aggressive behavior in spite of treatment are discussed (AU)

Clinical design and evaluation of the prototype of a new digital audioprosthesis for profound hearing loss: speech recognition aspects.

The design and implementation of the prototype of a digital hearing aid and its computerized fitting interface, followed by a basic preliminary clinical evaluation concerning speech recognition aspects, is reported. The final device is particularly destined to those patients suffering sensorineural hearing losses with recruitment and problems for speech recognition. The prototype is based on the digital signal processor TMS320C30. The host is a personal computer. The primary concept of the processing strategy is the 'integral treatment of acoustic information' within the remaining auditory field of the patient leading to minimum modification of the signal profile. The processing stages include linear amplification, specially designed AD conversion, real fast Fourier transform, 128 multiband single treatment (compression threshold and magnitude of compression), inverse fast Fourier transform, and DA conversion. Compression parameters and pure-tone audiometry data are entered by the computerized fitting interface which also provides real time information of input and output spectral profile. The preliminary clinical evaluation here reported corresponds to a series of 13 patients and it is focused on speech recognition performances. Ten patients had sensorineural hearing loss. Three subjects served as controls. All subjects were studied by an extensive audiological protocol. In 6 patients the prototype improved the maximum intelligibility with respect to unaided hearing reaching levels in the range of 90-100%. In 4 patients using conventional hearing aids, the prototype improved the maximum intelligibility with respect to the previous aided hearing. Values reached the same range as in the former 6 patients. Straightening of the speech audiometry curves was observed in those patients with recruitment. Two controls with previously normal speech recognition showed no worsening and others with conductive deafness reported additional improvement of the responses in noisy conditions with respect to the audioprosthesis in use.

[Rh (D) alloimmunization and pregnancy. Analysis of the causes after prophylaxis introduction]. / Aloinmunización Rh (D) y embarazo. Análisis de las causas tras la introducción de la profilaxis.

PURPOSE: Prenatal and postnatal prophylaxis of the Rh (D) haemolytic disease of the newborn have clearly reduced the number of cases but still there are alloimmunizations. PATIENTS AND METHODS: All cases detected in our Hospital in the last 24 years have been reviewed and possible causes analyzed. RESULTS: From a total of 10,332 deliveries in Rh (D) negative women we have detected 114 anti-D in 86 women. In 74 women anti-D was the only antibody and in 12 there were more antibodies. Data were managed in 3-year periods and we see a progressive decrease in the incidence of alloimmunization with a minimum of 0.03 per 1000 pregnancies in the period 89-91 and a posterior progression to an incidence of 0.12 in the last 3-year period 95-97. The causes were: pregnancies before 1970 in 31, incorrect prophylaxis in 12, despite a correct prophylaxis in 6, previous pregnancies without complete information about the prophylaxis in 13, previous transfusion in 6, previous pregnancies or transfusion in 8 and indetermined in 10. CONCLUSION: It is desirable to reduce at minimum the number of Rh (D) alloimmunizations by strictly following the prophylaxis protocols.

[The sensorineural component of hearing loss associated with cholesteatoma]. / El componente neurosensorial de la hipoacusia asociada al colesteatoma.

Patients with cholesteatoma often suffer neurosensorial hearing loss with variable bone conduction thresholds. Its origin is debated and has been attributed to the ototoxicity of topical drugs, immune reactions, effects of ototoxic antibiotics applied to the ear, etc. A selected series of 50 patients who underwent surgery for chronic ear disease due to cholesteatoma in our ENT department were studied to evaluate the possible origin of the bone conduction component of hearing loss. Different clinical, audiological, and surgical aspects were analyzed, including cholesteatoma site and extension, age, sex, evolution of the symptoms, pure tone audiometry data, middle ear involvement, the operation performed, and the occurrence of complications. Bone conduction thresholds were reported as pure tone differential thresholds (affected vs non-affected ear). A specific cholesteatoma-related neurosensorial hearing loss was observed that might lead to irreversible hearing loss. Neurosensorial involvement seems to be related mainly to the duration of symptoms, type of surgery, certain specific clinical aspects, and complications.

[Conditions of maternal work and low birth weight in Mexico City]. / Condiciones de trabajo materno y bajo peso al nacer en la Ciudad de México.

OBJECTIVE: To study the association between maternal working conditions and low birth-weight in Mexico City. MATERIAL AND METHODS: Interviews of 2623 workers who gave birth in Mexico City hospitals during 1992 were analyzed. Information on the main biologic and social factors associated to low birth-weight was registered. Occupational stress was determined with the instrument designed by Karasek. Logistic regression models to evaluate the relationship between working conditions and low birth-weight were used, controlling by confounding variables. RESULTS: Low birth-weight was more frequent in workers with working periods of more than 50 h/week (OR = 1.6; 95% CI = 1.17, 2.28) and with problems at work (OR = 1.5; 95% CI = 1.0, 2.25). Lack of tangible social support was identified as a risk factor for low birth-weight (OR = 1.7; 95% CI = 1.20, 2.33). Preventive working measures such as changes in tasks, shortening of working hours and leaves of absence due to illness did not show a beneficial effects on birth-weight, except for the maternity leave of absence. Mothers with no right to this had a 2.2 higher probability of giving birth to low weight children (95% CI = 1.66, 2.93). CONCLUSIONS: These results emphasize the importance of identifying the occupational risk factors during pregnancy.

Traditional birth attendants in Mexico: advantages and inadequacies of care for normal deliveries.

In Mexico, traditional birth attendants (TBAs) are an essential resource for health care, especially in small rural communities where they attend approximately 45% of all deliveries. Both rural and urban women seek care with the TBAs because, amongst other things, they share the same cultural codes. In this study, qualitative and quantitative methods were used to analyze the concepts, resources and process of care during birth in rural areas of the state of Morelos. Results show that the socio-economic characteristics of the TBAs are similar to those of the patients, that they share the same precarious living conditions, and the resources to which they have access for providing care during births. When choosing a TBA as a health care provider, both the economic aspect and the importance of a shared symbolism come into play. We observed advantages in some of the traditional practices which should be incorporated into the medical system, for example protection through the massage of the perineum at the moment of expulsion. Nevertheless, there are inadequacies for which the implementation of training programs is fundamental, before articulate primary care programs using the TBAs can be promoted.

Cisplatin, 5-fluorouracil, and high-dose folinic acid in patients with advanced unresectable head and neck cancer.

For patients with advanced, unresectable head and neck (HN) cancer, surgery and/or radiotherapy are the standard treatments but have poor results. A phase II trial of a continuous infusion of cisplatin, 5-FU, and high dose folinic acid (PFL) as induction chemotherapy in patients with previously untreated, locally advanced HN cancer was performed in an attempt to confirm the encouraging results reported by Dana Farber investigators using an identical regimen. Forty-five consecutive patients with unresectable HN cancer were treated every 28 days with a continuous infusion of cisplatin 25 mg/m(2)/day (days 1-5), 5-FU 800 mg/m(2)/day (days 2-6), and folinic acid 500 mg/m(2)/day (days 1-6). After three courses of chemotherapy, patients were treated with surgery and/or radiotherapy. Objective responses were observed in 26 of 38(69%) evaluable patients with 14(37%) clinical complete responses. Grade III-IV toxicity was important and consisted mainly of mucositis and neutropenia that were found in 47 and 18%, respectively , of patients after the first course. There was one toxic death. PFL is an active, toxic induction regimen for far-advanced HN cancer, yielding a response rate in the range of the widely used cisplatin and 5-FU (PF) schedule; a comparative trial is warranted before concluding that PFL is superior to the latter combination.

Neonatal tetanus mortality in Veracruz, Mexico, 1989.

This article describes a survey conducted in the State of Veracruz, Mexico, to estimate neonatal tetanus (NNT) mortality. The survey, which entailed visits to 72,720 households, collected data on 8,401 live births and 209 infant deaths occurring between April 1988 and May 1989. Twenty-six of the 209 fatalities conformed to a WHO standard case definition of death from neonatal tetanus. The estimated neonatal tetanus mortality was thus 3.1 deaths per 1,000 live births (95% confidence limits = 1.7, 4.5). Comparison of this rate to reported figures suggests that for every NNT death recorded in Veracruz during the study period, as many as 50 others went unreported. A case-control study nested within the survey was conducted to assess preventable NNT risk factors. Limited information on 13 NNT deaths and 217 controls showed an increased risk for neonates who were delivered at home and whose parents' ethnic background was Mexican Indian. Five of the 13 fatalities had their umbilical cords cut with a domestic or traditional cutting tool such as a reed cane, as compared to none of the 217 controls. The observed vaccine efficacy of 2+ doses of tetanus toxoid was 70% (95% confidence limits = 52, 100). Both the mothers of neonates who died of NNT and their controls missed an average of five opportunities to receive tetanus toxoid. These findings underscore the need to launch a perinatal health program serving Mexico's high-risk populations.

Epidemiología de la enfermedad de Chagas en la provincia de Entre Ríos, Argentina / Epidemiology of the chases disease in Entre Rios province, Argentina

El presente trabajo resume una labor de evaluación epidemiológica para la enfermedad de Chagas, en la Provincia de Entre Ríos y en especial en su Departamento Uruguay, que se extendiera por más de 12 años. El rango etáreo de la muestra de población general estudiada fue de 5 a 65 años, y también se realizaron estudios sobre conscriptos entrerrianos, de entre 18 y 20 años (media de 19 años) y dadores de sangre del Departamento Uruguay (media 35 años). Excepto en estas dos últimas muestras poblacionales, en todas las demás se efectuaron visitas domiciliarias para la extracción de muestras, con la realización de un completo relevamiento de indicadores socioeconómicos, sanitarios, educativos, ambientales y culturales, y la inspección ocular de la vivienda en búsqueda de vectores y su grado de infestación. La presencia de anticuerpos para T. cruzi fue estudiada mediante cuatro técnicas serológicas (Hemoaglutinación indirecta; Aglutinación directa, Test de inmunofluorescencia indirecta y ELISA), y los individuos con serología positiva, sometidos a un estudio clínico y cardiológico. Los resultados indican una prevalencia provincial actual media de 4,6 por ciento de serología positiva, con una tendencia decreciente, al parecer relacionada con las campañas de fumigación, control de bancos de sangre y educación sanitaria, con un rango de 3,5 por ciento en el Dpto. Uruguay hasta un 6,8 por ciento en el Departamento Gualeguay. Al parecer, una asociación positiva se presenta entre seropositividad y baja estructura educacional, indisponibilidad de agua corriente, vivienda anterior precaria, techo de la vivienda anterior de paja o cartón y la presencia en las cercanías de criaderos de pollos parrilleros y gallinas ponedoras, en tanto que ninguna diferencia resultó significativa entre seropositivos y seronegativos para los indicadores de las siguientes variables del contexto de la población estudiada: conformación del núcleo familiar, tipo de baño, recolección de basura, tenencia de animales domésticos, ocupación laboral, disponibilidad de energía eléctrica y corrales aledaños. Sobre la base de los estudios cardiológicos, resultó bastante menor que la informada en la bibliografía, la asociación entre cardiopatologías por ECG de reposo y seropositividad, y ninguna en los 1.620 monitoreados por ECG de los 18.881 pre-conscriptos estudiados, lo que reafirma cuestionamientos recientes acerca de la utilidad de dicha técnica de diagnóstico cardiopatológico, para inducir una relación de cardiopatías con la infectación chagásica (AU)

Epidemiología de la enfermedad de Chagas en la provincia de Entre Ríos, Argentina / Epidemiology of the chases disease in Entre Rios province, Argentina

El presente trabajo resume una labor de evaluación epidemiológica para la enfermedad de Chagas, en la Provincia de Entre Ríos y en especial en su Departamento Uruguay, que se extendiera por más de 12 años. El rango etáreo de la muestra de población general estudiada fue de 5 a 65 años, y también se realizaron estudios sobre conscriptos entrerrianos, de entre 18 y 20 años (media de 19 años) y dadores de sangre del Departamento Uruguay (media 35 años). Excepto en estas dos últimas muestras poblacionales, en todas las demás se efectuaron visitas domiciliarias para la extracción de muestras, con la realización de un completo relevamiento de indicadores socioeconómicos, sanitarios, educativos, ambientales y culturales, y la inspección ocular de la vivienda en búsqueda de vectores y su grado de infestación. La presencia de anticuerpos para T. cruzi fue estudiada mediante cuatro técnicas serológicas (Hemoaglutinación indirecta; Aglutinación directa, Test de inmunofluorescencia indirecta y ELISA), y los individuos con serología positiva, sometidos a un estudio clínico y cardiológico. Los resultados indican una prevalencia provincial actual media de 4,6 por ciento de serología positiva, con una tendencia decreciente, al parecer relacionada con las campañas de fumigación, control de bancos de sangre y educación sanitaria, con un rango de 3,5 por ciento en el Dpto. Uruguay hasta un 6,8 por ciento en el Departamento Gualeguay. Al parecer, una asociación positiva se presenta entre seropositividad y baja estructura educacional, indisponibilidad de agua corriente, vivienda anterior precaria, techo de la vivienda anterior de paja o cartón y la presencia en las cercanías de criaderos de pollos parrilleros y gallinas ponedoras, en tanto que ninguna diferencia resultó significativa entre seropositivos y seronegativos para los indicadores de las siguientes variables del contexto de la población estudiada: conformación del núcleo familiar, tipo de baño, recolección de basura, tenencia de animales domésticos, ocupación laboral, disponibilidad de energía eléctrica y corrales aledaños. Sobre la base de los estudios cardiológicos, resultó bastante menor que la informada en la bibliografía, la asociación entre cardiopatologías por ECG de reposo y seropositividad, y ninguna en los 1.620 monitoreados por ECG de los 18.881 pre-conscriptos estudiados, lo que reafirma cuestionamientos recientes acerca de la utilidad de dicha técnica de diagnóstico cardiopatológico, para inducir una relación de cardiopatías con la infectación chagásica

[Analysis of the blood-labyrinthine barrier in a model of progressive osmotic change]. / Análisis de la barrera hematolaberíntica en un modelo de cambio osmótico progresivo.

The AA. working with Gerbils (Meriones unguiculatus) experimentally deprived of their kidneys attempt to find out the behaviour of the BLB. The study was accomplished through the dynamic examination of the osmolality and ureic concentrations of the perilymph, the blood and in spinal fluid as well. Furthermore the role of the BLB in the origin of labyrinthine osmotic variations, as provocative cause of the inner ear pathology, is contemplated.

Effects of renal insufficiency on the cochlear absorptive-secretory areas. A morphological study in the Mongolian gerbil.

In order to evaluate the effects of experimental renal insufficiency (RI) on the labyrinthine absorptive-secretory areas (ASA), 54 adult Mongolian gerbils were submitted to bilateral nephrectomy or to sham procedure. At different intervals (3, 6, 9, 12, 15, 18, 21, 24 hours) after the surgical procedures, or during the terminal stage (28 h) the animals were decapitated and both temporal bones were dissected to obtain selected specimens of the cochlear ASA. The specimens were processed and analysed by light and electron microscopy. Structurally, RI induced progressive thickening of the epithelial components (stria, prominentia, sulcus); separation by fluid accumulation between stria and mesodermal layer; and frequent dilatation of intraepithelial vessels. Ultrastructurally, diverse signs were observed parallel to the evolution of the RI. After 12 h a progressive enlargement of the intercellular spaces, which was particularly evident in the stria surrounding the vessels and in the other sulcus, was observed. Its latest expression was a marked widening of the basolateral spaces containing a granular substance. After 12 h the formation of large cytoplasmic perinuclear spaces containing small rounded vesicles, probably secondary to fluid accumulation, could be observed in the marginal cells. After 24 h diverse signs of organellar damage became evident (schedule: mitochondrial swelling, lysosome like figures, myelin like figures). In the terminal stage, a general homogenization of the cytosol was common. The findings suggest a definite re-distribution of fluids in the inner ear. A close relationship between renal dysfunction and labyrinthine microhomeostasis is therefore proposed.

Effect of gentamicin on the carbohydrates of the vestibular end organs: an investigation by the use of FITC-lectins.

The effect of gentamicin on the glycoconjugates in the vestibular end organs is demonstrated using FITC-lectins. Five milligrams of gentamicin dissolved in 0.1 ml. saline was injected in a single dose into the middle ear of adult guinea pigs. Seven days after the injection, the fluorescent reactivity of Wheat germ agglutinin (WGA), Abrus precatorius agglutinin (APA), Concanavaline A (Con A), and Latyrus odoratus agglutinin (LOA) was decreased in the apical epithelial cell surface as well as in the gelatinous layer of the otolithic membrane of the maculae. In the cupula of the crista ampullaris, the reactivity for WGA and Con A was reduced. The otoconia, however, showed no detectable changes. This indicates that gentamicin may induce an altered carbohydrate metabolism resulting in a decrease of N-acetyl-glucosamine, mannose, galactose and glucose in the glycocalyx lining the epithelial cells as well as in the gelatinous layer of the otolithic membrane or cupula in the vestibular end organs.