Evaluación de la implementación de la iniciativa HEARTS en una comunidad rural de Venezuela, 2023 / Evaluation of Implementation of the HEARTS Initiative in a Rural Community in Venezuela, 2023 / Avaliação da implementação da iniciativa HEARTS em uma comunidade rural da Venezuela, 2023

[RESUMEN]. Objetivo. Evaluar la implementación de estrategias de la iniciativa HEARTS en una comunidad de la República Bolivariana de Venezuela. Métodos. Estudio cuasiexperimental, con la evaluación de la cascada de cuidado, factores impulsores e índices de madurez y desempeño cuatro meses después de la implementación de la iniciativa HEARTS en la comunidad La Marroquina en 52 pacientes con hipertensión (HTA). Los datos se procesaron en el programa SPSS® versión 25.0. Se aplicaron las pruebas t-Student y de ji cuadrado para determinar la significancia estadística. Resultados. Completaron los cuatro meses de seguimiento 50 pacientes, 63,5% con baja escolaridad y estrato socioeconómico bajo o muy bajo. Al inicio, 11,5% estaba controlado, y 40,4% inició con monoterapia. Al cuarto mes, 100% de las personas hipertensas recibieron el diagnóstico, 92% recibió tratamiento y 52% alcanzó la meta de control de HTA. El 72% recibía terapia combinada. De las personas hipertensas, 70% mantenía cifras de presión arterial <140/90 mmHg. El índice de madurez alcanzó nivel 4 de 5, y el índice de desempeño se clasificó en incipiente. Conclusión. Este trabajo muestra, en un corto tiempo, un buen índice de madurez en la implementación de un protocolo estandarizado de diagnóstico, tratamiento y seguimiento de la HTA en una población rural, por parte de personal médico y no médico supervisado, que mejora las tasas de diagnóstico, tratamiento y control en los hipertensos, y empieza a mostrar su desempeño. El mantenimiento de esta iniciativa tendrá un gran impacto en la salud de esta población. Se recomienda su implementación como política de salud pública nacional.

[ABSTRACT]. Objective. To evaluate the implementation of HEARTS strategies in a community in the Bolivarian Republic of Venezuela. Methods. Quasi-experimental study evaluating the cascade of care, driving factors, and maturity and performance indicators four months after implementation of the HEARTS initiative in 52 patients with high blood pressure (BP) in the community of La Marroquina. The data were processed using SPSS® Statistics, version 25.0. Student's t-distribution and chi-square tests were applied to determine statistical significance. Results. Fifty patients, 63.5% of them with a low educational level and low or very low socioeconomic status, completed the four-month monitoring period. At baseline, 11.5% had controlled BP and 40.4% initiated monotherapy. By the fourth month, 100% of patients with high BP had been diagnosed, 92% had received treatment, and 52% had achieved control of their BP. Seventy-two percent were receiving combined therapy. Seventy percent of the hypertensive individuals maintained blood pressure levels <140/90 mmHg. The maturity index score was 4 of 5, and the performance index was classified as incipient. Conclusion. This work shows that, in a short time, a good maturity index was achieved through the implementation, by medical and supervised non-medical personnel, of a standardized protocol for diagnosis, treatment, and monitoring of high blood pressure in a rural population. Rates of diagnosis, treatment, and BP control improved, with incipient performance results. Sustaining this initiative will have a major impact on the health of this population. Its implementation as a national public health policy is recommended.

[RESUMO]. Objetivo. Avaliar a implementação das estratégias da iniciativa HEARTS em uma comunidade da República Bolivariana da Venezuela. Métodos. Estudo quase-experimental que avaliou a cascata de cuidados, fatores determinantes e índices de maturidade e desempenho quatro meses após a implementação da iniciativa HEARTS na comunidade de La Marroquina, Venezuela. Foram avaliados 52 pacientes com hipertensão arterial. A análise estatística foi realizada no software SPSS®, versão 25.0. O teste t de Student e o teste qui-quadrado foram usados para determinar a significância estatística. Resultados. Cinquenta pacientes completaram o acompanhamento de quatro meses. Desses, 63,5% tinham baixa escolaridade e nível socioeconômico baixo ou muito baixo. No início do estudo, 11,5% apresentavam doença controlada e 40,4% estavam em monoterapia. No quarto mês, 100% dos pacientes com hipertensão arterial haviam sido diagnosticados, 92% haviam recebido tratamento, 52% haviam atingido a meta de controle da hipertensão e 72% estavam recebendo terapia combinada. Dos pacientes com hipertensão, 70% mantinham níveis pressóricos <140 × 90 mmHg. O índice de maturidade foi avaliado como nível 4 (de 5), e o desempenho foi classificado como incipiente. Conclusão. Este estudo demonstra, após pouco tempo, um bom índice de maturidade na implementação de um protocolo padronizado de diagnóstico, tratamento e acompanhamento da hipertensão arterial em uma população rural atendida por pessoal médico e não médico supervisionado. Observa-se melhoria das taxas de diagnóstico, tratamento e controle dos pacientes com hipertensão, demonstrando de forma incipiente seu desempenho. Dar continuidade a essa iniciativa terá uma repercussão importante na saúde dessa população. Recomendando-se que a iniciativa seja implementada como política nacional de saúde pública.

[Evaluation of Implementation of the HEARTS Initiative in a Rural Community in Venezuela, 2023Avaliação da implementação da iniciativa HEARTS em uma comunidade rural da Venezuela, 2023]. / Evaluación de la implementación de la iniciativa HEARTS en una comunidad rural de Venezuela, 2023.

Objective: To evaluate the implementation of HEARTS strategies in a community in the Bolivarian Republic of Venezuela. Methods: Quasi-experimental study evaluating the cascade of care, driving factors, and maturity and performance indicators four months after implementation of the HEARTS initiative in 52 patients with high blood pressure (BP) in the community of La Marroquina. The data were processed using SPSS® Statistics, version 25.0. Student's t-distribution and chi-square tests were applied to determine statistical significance. Results: Fifty patients, 63.5% of them with a low educational level and low or very low socioeconomic status, completed the four-month monitoring period. At baseline, 11.5% had controlled BP and 40.4% initiated monotherapy. By the fourth month, 100% of patients with high BP had been diagnosed, 92% had received treatment, and 52% had achieved control of their BP. Seventy-two percent were receiving combined therapy. Seventy percent of the hypertensive individuals maintained blood pressure levels <140/90 mmHg. The maturity index score was 4 of 5, and the performance index was classified as incipient. Conclusion: This work shows that, in a short time, a good maturity index was achieved through the implementation, by medical and supervised non-medical personnel, of a standardized protocol for diagnosis, treatment, and monitoring of high blood pressure in a rural population. Rates of diagnosis, treatment, and BP control improved, with incipient performance results. Sustaining this initiative will have a major impact on the health of this population. Its implementation as a national public health policy is recommended.

Objetivo: Avaliar a implementação das estratégias da iniciativa HEARTS em uma comunidade da República Bolivariana da Venezuela. Métodos: Estudo quase-experimental que avaliou a cascata de cuidados, fatores determinantes e índices de maturidade e desempenho quatro meses após a implementação da iniciativa HEARTS na comunidade de La Marroquina, Venezuela. Foram avaliados 52 pacientes com hipertensão arterial. A análise estatística foi realizada no software SPSS®, versão 25.0. O teste t de Student e o teste qui-quadrado foram usados para determinar a significância estatística. Resultados: Cinquenta pacientes completaram o acompanhamento de quatro meses. Desses, 63,5% tinham baixa escolaridade e nível socioeconômico baixo ou muito baixo. No início do estudo, 11,5% apresentavam doença controlada e 40,4% estavam em monoterapia. No quarto mês, 100% dos pacientes com hipertensão arterial haviam sido diagnosticados, 92% haviam recebido tratamento, 52% haviam atingido a meta de controle da hipertensão e 72% estavam recebendo terapia combinada. Dos pacientes com hipertensão, 70% mantinham níveis pressóricos <140 × 90 mmHg. O índice de maturidade foi avaliado como nível 4 (de 5), e o desempenho foi classificado como incipiente. Conclusão: Este estudo demonstra, após pouco tempo, um bom índice de maturidade na implementação de um protocolo padronizado de diagnóstico, tratamento e acompanhamento da hipertensão arterial em uma população rural atendida por pessoal médico e não médico supervisionado. Observa-se melhoria das taxas de diagnóstico, tratamento e controle dos pacientes com hipertensão, demonstrando de forma incipiente seu desempenho. Dar continuidade a essa iniciativa terá uma repercussão importante na saúde dessa população. Recomendando-se que a iniciativa seja implementada como política nacional de saúde pública.

Infección grave de piel y partes blandas por Fusarium oxysporum asociado a la administración subcutánea de insulina / Severe skin and soft tissue infection due to Fusarium oxysporum associated with subcutaneous insulin administration

Resumen La diabetes mellitus (DM) es una enfermedad crónica muy prevalente. Dentro de los tratamientos para la DM se encuentra la insulina que es el agente antidiabético más potente, sin embargo, una proporción significativa de pacientes no logra alcanzar el objetivo de hemoglobina glicosilada (HbA1c). Los errores en la aplicación de insulina son un factor importante y corregible en muchos casos. Se presenta el caso de una paciente con DM, antecedentes de neuropatía diabética, enfermedad renal crónica estadio V en hemodiálisis, hipertensión arterial, estenosis aórtica con recambio por válvula protésica, y anticoagulada, con escasa adherencia a recomendaciones higiénico dietéticas. Debido a la mala técnica de aplicación de insulina y falta de higiene, desarrolló varias infecciones polimicrobianas de piel y partes blandas, con evolución tórpida de las úlceras y mala respuesta al tratamiento indicado. Durante su internación, de una úlcera se aisló Fusarium oxysporum. Es importante jerarquizar la relevancia de la educación diabetológica en pacientes insulinizados y el rol de los educadores en diabetes en el cuidado de los mismos. Por otro lado, destacar la importancia de la toma de cultivos mediante punción de partes blandas ante la aparición de signos locales de infección.

Abstract Diabetes mellitus (DM) is a very prevalent chronic disease. Among the treatments for DM, insulin is the most potent antidiabetic agent. However a significant proportion of patients fail to achieve Errors in the application of insulin are an important and correctable factor in many cases. We present the case of a patient with DM who, due to poor insulin application technique and hygiene, develops a skin and soft tissue infection with subsequent appearance of Fusarium oxysporum. It is important to emphasize the relevance of diabetes education in insulin ized patients and the role of diabetes educators in their care. On the other hand, it is important to emphasize the importance of taking cultures by soft tissue puncture in case of local signs of infection.

[Severe skin and soft tissue infection due to Fusarium oxysporum associated with subcutaneous insulin administration]. / Infección grave de piel y partes blandas por Fusarium oxysporum asociado a la administración subcutánea de insulina.

Diabetes mellitus (DM) is a very prevalent chronic disease. Among the treatments for DM, insulin is the most potent antidiabetic agent. However a significant proportion of patients fail to achieve Errors in the application of insulin are an important and correctable factor in many cases. We present the case of a patient with DM who, due to poor insulin application technique and hygiene, develops a skin and soft tissue infection with subsequent appearance of Fusarium oxysporum. It is important to emphasize the relevance of diabetes education in insulinized patients and the role of diabetes educators in their care. On the other hand, it is important to emphasize the importance of taking cultures by soft tissue puncture in case of local signs of infection.

La diabetes mellitus (DM) es una enfermedad crónica muy prevalente. Dentro de los tratamientos para la DM se encuentra la insulina que es el agente antidiabético más potente, sin embargo, una proporción significativa de pacientes no logra alcanzar el objetivo de hemoglobina glicosilada (HbA1c). Los errores en la aplicación de insulina son un factor importante y corregible en muchos casos. Se presenta el caso de una paciente con DM, antecedentes de neuropatía diabética, enfermedad renal crónica estadio V en hemodiálisis, hipertensión arterial, estenosis aórtica con recambio por válvula protésica, y anticoagulada, con escasa adherencia a recomendaciones higiénico dietéticas. Debido a la mala técnica de aplicación de insulina y falta de higiene, desarrolló varias infecciones polimicrobianas de piel y partes blandas, con evolución tórpida de las úlceras y mala respuesta al tratamiento indicado. Durante su internación, de una úlcera se aisló Fusarium oxysporum. Es importante jerarquizar la relevancia de la educación diabetológica en pacientes insulinizados y el rol de los educadores en diabetes en el cuidado de los mismos. Por otro lado, destacar la importancia de la toma de cultivos mediante punción de partes blandas ante la aparición de signos locales de infección.

Thallium poisoning: a case report.

Thallium poisoning is usually accidental. We present a case of a 51-year-old woman who was evaluated in June 2018 for myalgia, vertigo, asthenia, and abdominal pain. Physical examination revealed temporal-spatial disorientation, jaundice, and asterixis. The laboratory reported the following: bilirubin, 10.3 mg/dL; aspartate transaminase, 78 U/L; alanine transaminase, 194 U/L; albumin, 2.3 g/dL; prothrombin time, 40%; and platelet count, 60,000/mm3. Serology performed for hepatitis A, B, and C; Epstein-Barr virus; cytomegalovirus; and human immunodeficiency virus was negative, and a collagenogram was negative. Physical reevaluation revealed alopecia on the scalp, armpits, and eyebrows; macules on the face; plantar hyperkeratosis; and ulcers on the lower limbs. Tests for lead, arsenic, copper, and mercury were carried out, which were normal; however, elevated urinary thallium (540 µg/g; range, 0.4-10 µg/g) was observed. The patient was treated with ᴅ-penicillamine 1,000 mg/day and recovered her urinary thallium levels were within normal range at annual follow-up. Thallium poisoning is extremely rare and can be fatal in small doses. An adequate clinical approach can facilitate early diagnosis.

Síndrome PHACES: comunicación de un caso con compromiso hepático e intestinal / PHACES syndrome: a report of a case with liver and intestinal involvement

El síndrome PHACES representa un espectro de anormalidades: malformaciones de la fosa posterior, hemangiomas segmentarios, anomalías vasculares, cardíacas, oculares y hendidura esternal o rafe supraumbilical, asociado también a hemangiomatosis extracutánea.Comunicamos el caso de una paciente de 4 meses de edad, con un hemangioma segmentario gigante en la hemicara izquierda, además de la presencia de una malformación de Dandy-Walker, malformación cardiovascular, hendidura esternal e hipotiroidismo.También tenía un hemangioma en el hígado y otras lesiones vasculares en el intestino.

PHACES syndrome represents a spectrum of anomalies such as posterior fossa malformations, segmental hemangiomas, vascular and cardiac abnormalities, eye abnormalities and sternal cleft or raphe supraumbilical, hemangiomatosis extracutánea. We present a 4 months of age female, who presented a segmental giant hemangioma in the left hemiface with Dandy-Walker malformation, cardiovascular malformation, sternal cleft and hypothyroidism, who also presented an hemangioma in the liver and other vascular lesions in the intestine.

Leishmaniasis cutánea difusa transformada por corticoides / Cutaneous leishmaniasis diffuse transformed by corticoids

Las leishmaniasis cutáneas son un grupo de enfermedades parasitarias con gran polimorfismo clínico, producidas por protozoarios del género Leishmania; los cuales son transmitidos al hombre por la picadura de un mosquito (Lutzomia). El Perú sigue siendo una zona endémica, por lo que se presenta el caso de un paciente cuya enfermedad tuvo una evolución prolongada, con cuadro clínico atípico, el cual fue modificado por el uso de corticoides. El caso constituyó un reto diagnóstico, que requirió del estudio histopatológico de las lesiones, donde se observaron múltiples macrófagos vacuolados conteniendo amastigotes de Leishmania. El paciente recibió tratamiento con anfotericin B con remisión del cuadro.

Cutaneous leishmaniasis is a parasitic disease with great clinical polymorphism, caused by protozoa of the genus Leishmania, which is transmitted to humans through the bite of mosquito (Lutzomia). Peru remains an endemic area, and for that reason we present the case of a patient whose disease had a prolonged course, with atypical clinical picture sintomatology, which was modified by the use of corticosteroids. The case was a diagnostic challenge, requiring the histopathology study of the lesions, which showed multiple vacuolated macrophages containing amastigots of Leishmania. The patient was treated with amphotericin B with remission of the lesions.

Escrofuloderma asociada a osteítis tuberculosa / Scrofuloderma associated with tuberculous osteitis

La escrofuloderma es una forma de tuberculosis cutánea que resulta de la extensión directa a la piel de un foco tuberculoso contiguo (linfático u óseo), con frecuente fistulización y evolución crónica, pudiendo ocurrir curación espontánea que deja cicatriz retráctil. Se presenta el caso de un paciente varón de 7 años de edad, que presenta dos úlceras en la pared torácica izquierda con un aumento del volumen torácico del mismo lado de 7 meses de evolución; recibe tratamientos antibióticos múltiples y curaciones sin mejoría. En la radiografía de tórax se evidencia compromiso de pleura y arcos costales izquierdos, que es compatible con osteítis tuberculosa. Se realiza biopsia de piel, observándose granulomas tuberculoides con necrosis caseosa y coloración Ziehl Neelsen positiva para BAAR. Inicia tratamiento con tuberculostáticos obteniendo una mejoría clínica evidente. A las 8 semanas de iniciado el tratamiento, se obtiene cultivo positivo para Mycobacterium tuberculosis.

The scrofuloderma is a form of cutaneous tuberculosis that results of the extension of a contiguous tuberculous focus (lymphatic or bone) to the skin, with frequent fistulization and chronic evolution; spontaneous healing may occur in some cases leaving a scar. We present the case of a 7 years old male patient who complained of two ulcers with deformation of the thoracic wall that started 7 months previous to the diagnosis. He received multiple antibiotic treatments without improvement. The chest radiograph showed left pleura and costal arches involvement. Skin biopsy showed the presence of tuberculoid granulomas with caseous necrosis, and Ziehl Neelsen staining was positive for BAAR. The patient received tuberculostatic treatment and had clinical improvement. After 8 weeks of treatment, the culture resulted positive for Mycobacterium tuberculosis.

Estudio de casos de urticaria anular aguda en pacientes hospitalizados en el servicio de Dermatología del Instituto de Salud del Niño durante el período 2003 al 2004 / Acute annular urticaria case study in patients hospitalized in the service of Dermatology of the Institute of Health of the Child during the period 2003 to 2004

La urticaria aguda en niños es una entidad frecuente, sin embargo su incidencia no está bien establecida. Una variante es la urticaria anular aguda o gigante que ha sido caracterizada en varios trabajos. Objetivo: Caracterizar la urticaria anular aguda en el Instituto Nacional de Salud del Niño. Material y métodos: Estudio observacional no concurrente de serie de casos. Se revisaron historias clínicas de pacientes hospitalizados del servicio de Dermatología del Instituto Nacional de Salud del Niño, Lima-Perú, con criterios de inclusión y exclusión. Resultados:Se hallaron 27 niños con diagnóstico de urticaria anular aguda,las lesiones más frecuentes fueron las placas violáceas y manchas residuales. El área más afectada fue el tórax y dentro de los factores desencadenantes más importantes se encontró el uso de furazolidona en el 59% de los casos. Conclusiones: La urticaria anular aguda o gigante es una reacción de hipersensibilidad con características propias asociada en un alto porcentaje al uso de furazolidona (AU)

Acute urticaria in children is a frequent disorder; however its incidence has not been established. Annular acute urticaria or giant urticaria is a variant which has been reported in several surveys. Objetive: Characterize acute annular urticaria at Instituto Nacional de Salud del Niño, Lima-Peru. Methods: Observational non-concurrent series of cases. We reviewed the medical records of hospitalized patients at Dermatology Service, Instituto Nacional de Salud del Niño, with inclusion and exclusion criteria. Results: We found 27 children with diagnosis of acute annular urticaria; the most frequent lesions were lilaceous plaques and residual patches.The most frequently affected area was chest and the most important triggering factor was the use of furazolidone. Conclusions: Acute annular urticaria is a hypersensitivity reaction with special characteristics, which is associated in a high percentage to use of furazolidone (AU)

Hydroa-like cutaneous T-cell lymphoma: a clinicopathologic and molecular genetic study of 16 pediatric cases from Peru.

Hydroa-like cutaneous T-cell lymphoma (hydroa-like CTCL) is an unusual pediatric malignancy with a poor prognosis. An impressive cutaneous rash characterized by edema, blisters, ulcers, crusts, and scars, resembling hidroa vacciniforme, is seen mainly on the face and sometimes on the extremities. The lesion consists of lymphomatous T-cell infiltration of the skin and subcutis with variable exocytosis and angiocentricity. It has been also called edematous, scarring vasculitic panniculitis and hydroa-like lymphoma. An association with Epstein-Barr virus has been suggested. The differential diagnosis includes other cutaneous lymphomas, particularly the cutaneous nasal type T/natural killer-cell lymphoma, mycosis fungoides, precursor T-cell lymphoblastic lymphoma, nonspecific peripheral T-cell lymphoma, cutaneous anaplastic large cell lymphoma, and subcutaneous panniculitic T-cell lymphoma. Other differential diagnoses are inflammatory dermatopathies and panniculitides. Based on a series of 16 such cases referred to the Institute of Neoplastic Diseases, the objective of this report is not only to provide a better clinicopathologic understanding of this entity but also a reappraisal of it as a malignancy. The male/female frequency ratio was 1:1. The median age was 10 years old. All cases showed predominant facial involvement with edema, blisters, ulcers, crusts, and scars. Chemotherapy and/or radiotherapy had little or no benefit. The prognosis was usually dismal. The lymphoma extended from the epidermis to the subcutis, with frequent angiocentric and periadnexal array. Lymphoma cells were mostly of intermediate size with dense hyperchromatic nuclei, inconspicuous nucleoli, and infrequent mitosis. A scanty and variable inflammatory background was found. The lymphoma cells displayed T-cell cytotoxic phenotype. In addition, they were negative for the natural killer cell antigens CD56 and CD57. Epstein-Barr virus in situ hybridization was positive in the six cases in which it was assayed. T-cell receptor gamma (TCRgamma) displayed monoclonal-type rearrangement in four cases studied. Our findings indicate that hydroa-like CTCL is an independent clinicopathologic entity that affects children. Consequently, it should be considered an independent subset of CTCLs and be included as such in the classification of neoplastic diseases of the lymphoid tissues.

Dermatitis atópica: primera parte / Atopic dermatitis: part I

En los últimos años hemos experimentado un notable avance en la comprensión de la dermatitis atópica, sobre todo en lo concerniente a los aspectos moleculares de su inmunopatogénesis y por ende en la aplicación de una terapéutica racional. Sin embargo, aún estamos lejos de entender completamente los detalles de esta entidad cuya incidencia se encuentra en alarmante incremento. Presentamos una revisión actualizada con aportes de nuestra experiencia, tocando los aspectos históricos, epidemiológicos, clínicos, etiopatogénicos y terapéuticos de esta enfermedad.

Tiña capitis neonatal: reporte de dos casos tratados con itraconazol / Neonatal tinea capitis: report of two cases treated with itraconazole

La tiña capitis es la infección micótica más común en niños de edad preescolar y escolar. Aunque el perfil clínico y epidemiológico de esta dermatofitosis ha experimentado notables cambios en los últimos años y existen algunos reportes de tiña capitis neonatal, la presentación en este grupo etáreo sigue considerándose poco frecuente. Reportamos los primeros casos de tiña capitis neonatal tratados satisfactoriamente con itraconazol, que no respondieron al tratamiento con griseofulvina

Melanoma juvenil benigno en niño de 8 años / Bening juvenile melanoma in an 8-year-old Boy

El melanoma juvenil o nevo de Spitz es una rara forma de nevo melanocítico benigno que puede ser confundido fácilmente, no sólo con un verdadero melanoma maligno, sino también con lesiones vasculares, tales como el hemangioma capilar. Presentamos el caso de un niño de 8 años con nevo de Spitz en el lóbulo nasal desde el año de edad, que fue diagnosticado y tratado como un hamangioma capilar inmaduo. El estudio histopatológico demostró células melanocíticas epiteloides sin signo de atipia. La lesión fue extirpada quirúrgicamente con resultados estéticos satisfactorios.