Usefulness of Inhaled Sedation in Patients With Severe ARDS Due to COVID-19.

BACKGROUND: Sedation in intensive care is fundamental for optimizing clinical outcomes. For many years the world has been facing high rates of opioid use, and to combat the increasing opioid addiction plans at both national and international level have been implemented.1 The COVID-19 pandemic posed a major challenge for health systems and also increased the use of sedatives and opioid analgesia for prolonged periods of time, and at high doses, in a significant proportion of patients. In our institutions, the shortage of many drugs for intravenous (IV) analgosedation forces us to alternatives to replace out-of-stock drugs or to seek sedation goals, which are difficult to obtain with traditional drugs at high doses.2 METHODS: This was an analytical retrospective cohort study evaluating the follow-up of subjects with inclusion criteria from ICU admission to discharge (alive or dead). Five end points were measured: need for high-dose opioids (≥ 200 µg/h), comparison of inhaled versus IV sedation of opioid analgesic doses, midazolam dose, need for muscle relaxant, and risk of delirium. RESULTS: A total of 283 subjects were included in the study, of whom 230 were administered IV sedation and 53 inhaled sedation. In the inhaled sedation group, the relative risks (RRs) were 0.5 (95% CI 0.4-0.8, P = .045) for need of high-dose fentanyl, 0.3 (95% CI 0.20-0.45, P < .001) for need of muscle relaxant, and 0.8 (95% CI 0.61-1.15, P = .25) for risk of delirium. The median difference of fentanyl dose between the inhaled sedation and IV sedation groups was 61 µg/h or 1,200 µg/d (2.2 ampules/d, P < .001), and that of midazolam dose was 5.7 mg/h. CONCLUSIONS: Inhaled sedation was associated with lower doses of opioids, benzodiazepines, and muscle relaxants compared to IV sedation. This therapy should be considered as an alternative in critically ill patients requiring prolonged ventilatory support and where IV sedation is not possible, always under adequate supervision of ICU staff.

Prescription of DPP4 inhibitors: Indication and effect on glycosylated hemoglobin in a primary care institution of Colombia / Prescripción de inhibidores de la DPP-4: indicación y efecto sobre la hemoglobina glicosilada en un primer nivel de Colombia

Abstract Introduction and objective: In Colombia, Dipeptidyl-Peptidase IV (DPP4) inhibitors are recommended as second-best choice for type 2 diabetes mellitus treatment. However, no evaluation of the accomplishment or impact of this recommendation was performed. The objective was to determine the prescription of the DPP4 inhibitor according to the Colombian Clinicial Practice Guide regarding type 2 diabetes mellitus treatment, and its effects on glycosylated hemoglobin (HbAlc). Materials and methods: A descriptive study that included patients with type 2 diabetes mellitus who attended a first level between 2016 and 2018, had a prescription for DPP4 inhibitor and at least two control appointments. Variables included were sociodemographic, clinics, treatment and comorbidities. The unadjusted prescription was defined as the lack of accomplishment of Colombian guidelines. Descriptive statistics and X2 test were used for the comparison of categorical variables. A binary logistic regression model was applied. Results: 112 out of 207 patients accomplished inclusion criteria, of which 77 were women (68.8%). Also, 68.8% of the patients had an unadjusted prescription of the iDPP4. There was a 0.21% total reduction in HbA1c levels, with a mean of 198.2 ± 124 days between the first and second control measurement (reduction of 0.55% when the prescription was adjusted to the guidelines and 0.05% if it was unadjusted). Conclusion: There is a limited impact of DPP4 inhibitors regarding the reduction of HbA1c and metabolic control, and there is a slight follow-up to the Colombian guidelines in patients who attend a first level.

Resumen Introducción y Objetivo: En Colombia se recomiendan los inhibidores de la Dipeptidil Peptidasa-IV (iDPP4) como segunda opción para el manejo de la diabetes mellitus tipo 2. No se ha evaluado el cumplimiento e impacto de esta recomendación. Como objetivo se buscó determinar la prescripción de los iDPP4 según las recomendaciones de la Guía de Práctica Clínica colombiana, y su efecto sobre la hemoglobina glicosilada (HbA1c). Materiales y métodos: Estudio descriptivo que incluyó pacientes con diabetes mellitus tipo 2 que consultaron a un primer nivel entre 2016 y 2018, y tenían formulado un iDPP4, con al menos dos consultas de seguimiento. Se incluyeron variables sociodemográficas, clínicas, tratamiento y comorbilidades. La prescripción no ajustada se definió como la falta de cumplimento de la recomendación de la guía colombiana. Se empleó estadística descriptiva y pruebas X2 para la comparación de variables categóricas. Se aplicó un modelo de regresión logística binaria. Resultados: Hubo 207 pacientes de los cuales 112 cumplieron criterios de inclusión, 77 eran mujeres (68,8%). El 68,8% de los pacientes presentaron una prescripción no ajustada del iDPP4. Hubo una reducción total de 0,21%, con una media de 198,2±124 días entre la primera y segunda medición de HbA1c de control (reducción de 0,55% cuando la prescripción se ajustaba a la guía colombiana y 0,05% cuando no). Conclusión: Hay un limitado impacto de los iDPP4 frente a la reducción de HbA1c y poco seguimiento de la guía colombiana en pacientes de primer nivel de atención.

Mycobacterium tuberculosis Shikimate Pathway Enzymes as Targets for the Rational Design of Anti-Tuberculosis Drugs.

Roughly a third of the world's population is estimated to have latent Mycobacterium tuberculosis infection, being at risk of developing active tuberculosis (TB) during their lifetime. Given the inefficacy of prophylactic measures and the increase of drug-resistant M. tuberculosis strains, there is a clear and urgent need for the development of new and more efficient chemotherapeutic agents, with selective toxicity, to be implemented on patient treatment. The component enzymes of the shikimate pathway, which is essential in mycobacteria and absent in humans, stand as attractive and potential targets for the development of new drugs to treat TB. This review gives an update on published work on the enzymes of the shikimate pathway and some insight on what can be potentially explored towards selective drug development.

Contractura de Dupuytren. Estudio de 33 casos en Colombia / Dupuytren's contracture. Study of SS cases in Colombia

RESUMEN Objetivo: Describir el comportamiento clínico y epidemiológico de la contractura de Dupuytren (CD) en la población colombiana y comparar nuestros resultados con otras series publicadas en la literatura. Materiales y métodos: Estudio descriptivo observacional de 33 casos de CD presentados en el hospital San Pedro y San Pablo de la Virginia, Risaralda, durante los últimos 6 arios. Los pacientes cumplieron con el diagnóstico de CD de acuerdo con el parámetro establecido. Se compararon los resultados con diferentes series de casos de CD publicadas en la literatura. Resultados: La edad promedio al momento del diagnóstico fue de 61,3 años con mayor prevalencia en hombres (64% de los casos). La forma de presentación más frecuente fue unilateral en mano derecha (73%), a diferencia de lo reportado en otras series, donde el compromiso usualmente fue bilateral. La diabetes mellitus fue la comorbilidad con mayor asociación a la CD (24,24%), hallazgo similar a lo publicado previamente. La mayoría de los pacientes requirió tratamiento quirúrgico. Conclusiones: La CD es una entidad de mayor ocurrencia en hombres de la sexta a la séptima década de la vida. La diabetes mellitus es la enfermedad que más se asocia a su aparición, sin encontrase diferencias entre los estudios realizados. En población colombiana no hay relación aparente con epilepsia. La presentación de la CD es variable, encontrándose en nuestra serie un mayor compromiso unilateral a diferencia de otras poblaciones donde la presentación usualmente es bilateral.

ABSTRACT Objective: To describe the clinical and epidemiological behavior of Dupuytren's contracture (DC) in the Colombian population, and to compare the results of this study with other series published in the literature. Materials and methods: A descriptive, observational study of 33 cases of DC presented at the Hospital San Pedro y San Pablo, La Virginia Risaralda, over the last 6 years. The patients were diagnosed with DC according to the established parameter. The results were compared against different series of DC cases published in the literature. Results: The mean age at diagnosis was 61.3 years, with a higher prevalence of men (64% of cases). The most frequent form of presentation was unilateral in the right hand (73%), unlike the reports from other series with usually bilateral involvement. Diabetes mellitus was the comorbidity most often associated with DC (24.24%), a finding similar to those of previous publications. Most patients required surgical treatment. Conclusions: DC is a condition that occurs more often in men in the sixth or seventh decade of life. Diabetes mellitus is the most frequently associated disease, with no differences being found among the various studies. In the Colombian population there is no apparent association with epilepsy. The presentation of DC is variable, but our series showed more unilateral involvement as compared to other populations where the presentation is usually bilateral.

Frecuencia de lesiones dermatológicas en pacientes adultos de cuidado intensivo / Frequency of dermatológical lesions in adult intensive care patients

Resumen Objetivo: describir la frecuencia de las lesiones dermatológicas en pacientes de la Unidad de Cuidados Intensivos (UCI) de adultos del Hospital de San José y del Hospital Infantil Universitario de San José entre enero y abril de 2012. Pacientes y métodos: se realizó un estudio descriptivo de corte transversal. Se incluyeron pacientes mayores de 18 años con estancia mínima de 72 horas en UCI, ingresados por patología dermatológica o valorados por dermatología por aparición de lesiones en piel durante su estancia. Resultados: se evaluaron 595 pacientes, encontrando lesiones dermatológicas en 30% (182 pacientes). La edad promedio fue de 63.5 años ± 19.1 sin diferencias de género. La admisión a la UCI se debió principalmente a motivos no quirúrgicos con un porcentaje de 57.3% (105 pacientes). Las lesiones cutáneas más frecuentes fueron las lesiones terciarias observada en 91.8% (168 pacientes), seguida por lesiones secundarias, con predominio infeccioso 6% (11 pacientes) y las últimas fueron las primarias con sólo 1.6% (3 pacientes). Conclusiones: las lesiones dermatológicas en los pacientes de UCI son más frecuentes de lo esperado y en algunos casos pueden ser la causa directa del ingreso a la UCI poniendo en riesgo la vida de los pacientes, por lo tanto, consideramos importante un examen exhaustivo de piel en estos pacientes y el trabajo interdisciplinario con dermatología que permita disminuir el riesgo de mortalidad a causa de complicaciones de origen dermatológico. (Acta Med Colomb 2019; 44: 25-30).

Abstract Objective: to describe the frequency of dermatological lesions in patients of the Intensive Care Unit (ICU) of adults of the Hospital de San José and the Hospital Infantil Universitario de San José between January and April 2012. Patients and Methods: a descriptive cross-sectional study was carried out. Patients older than 18 years with a minimum stay of 72 hours in the ICU admitted for dermatological pathology or assessed by dermatology due to the appearance of skin lesions during their stay, were included. Results: 595 patients were evaluated, finding dermatological lesions in 30% (182 patients). The average age was 63.5 years ± 19.1 without gender differences. Admission to the ICU was mainly due to non-surgical reasons with a percentage of 57.3% (105 patients). The most frequent skin lesions were the tertiary lesions observed in 91.8% (168 patients), followed by secondary lesions, with an infectious predominance of 6% (11 patients) and the last ones were the primary ones with only 1.6% (3 patients). Conclusions: dermatological lesions in ICU patients are more frequent than expected and in some cases may be the direct cause of admission to the ICU putting patients' lives at risk; therefore, we consider important a thorough skin examination in these patients and interdisciplinary work with dermatology to reduce the risk of mortality due to dermatological complications. (Acta Med Colomb 2019; 44: 25-30).

The impact of smoking on disease activity, disability, and radiographic damage in rheumatoid arthritis: is cigarette protective?

The ojective of this study is to assess the effect of tobacco smoking on disease activity, functional ability, and joint damage in a cohort of patients with early onset rheumatoid arthritis (EORA). 129 EORA patients attending the Rheumatology Unit of the School of Medicine of the "Universidad Nacional de Colombia" and the "Clínica de Artritis y Rehabilitación" in Bogota, Colombia, were enrolled in a prospective observational cohort study with 3-year follow-up. Clinical, biological, immunogenetics, and radiographic data were analyzed. Active disease was defined as DAS28 > 2.6. Smoking status was assessed by self-report as "never smokers" and "ever smokers". Patient groups with different smoking status were compared for RA measures. Status as "never smokers" and "ever smokers" was reported by 81.3 and 18.7%. Ever smokers had less risk of disability (HAQ-DI ≥ 0.5) at 36 month (Ever smokers vs. Never smokers OR for HAQ ≥ 0.5 0.25, 95% CI 0.06-0.97, p = 0.04). When former smokers were excluded in analysis, we found that current smoking was also associated with less disability and less risk of active disease. The percentage of erosive disease, radiographic progression, and SvdH score were similar in all smoking categories. In Colombian patients with EORA, smoking was associated with less disease activity and disability. Radiographic joint damage progressed at an equivalent rate in smokers and non-smokers. These data suggest a more benign, or at least not deleterious clinical course in smokers with RA.

The Role of 25-Hydroxyvitamin D as a Predictor of Clinical and Radiological Outcomes in Early Onset Rheumatoid Arthritis.

OBJECTIVE: The aims of this study were to compare the levels of 25-hydroxyvitamin D (25(OH)D) in patients with early-onset rheumatoid arthritis (EORA) versus a healthy control group and to assess the association of 25(OH)D deficiency and the BsmI polymorphism of the vitamin D receptor gene with clinical, radiological, and laboratory parameters. METHODS: Early-onset RA Colombian patients were enrolled in a 3-year follow-up study. Vitamin D deficiency was diagnosed for 25(OH)D levels of less than 20 ng/mL. Pearson and Spearman correlation coefficients were used to assess data. RESULTS: Seventy patients and 70 matched healthy subjects were included. 25-Hydroxyvitamin D was lower in the EORA group (27.13 [SD, 13.4] ng/mL vs. 33.74 [SD, 16.7] ng/mL; P = 0.01); 31.4% of EORA patients were vitamin D deficient. Remission was higher in subjects without 25(OH)D deficiency (22.7% vs. 47.9%; P = 0.04). Patients with 25(OH)D deficiency at baseline had higher Health Assessment Questionnaire and Physician Global Disease Activity Assessment scores, fatigue levels, erythrocyte sedimentation rate, and morning stiffness after 3 years. At disease onset, only a relationship between 25(OH)D deficiency with fatigue and morning stiffness was found. Neither radiographic progression nor Sharp van der-Heidje score was associated to hypovitaminosis D after 36-month follow-up. The bb genotype was less frequent in patients with vitamin D deficiency (0% vs. 16.6%; P = 0.04). Patients with BB-Bb genotype had lower 25(OH)D and a propensity to more severe disease. CONCLUSIONS: Our data provide further support for a role of vitamin D as a clinical biomarker for RA. Baseline 25(OH)D could have potential as a predictor of disease severity in EORA.

Dual Emission of a Novel (P,N) Re(I) Complex: A Computational and Experimental Study on [P,N-{(C6H5)2(C5H4N)P}Re(CO)3Br].

The spectroscopic, electrochemical, and photophysical properties of the new complex [P,N-{(C6H5)2(C5H4N)P}Re(CO)3Br] are reported. The UV-vis spectrum in dichloromethane shows an absorption maximum centered at 315 nm and a shoulder at 350 nm. These absorption bands have been characterized to have MLCT character. Excitation at both wavelengths (maximum and shoulder) leads to an emission band centered at 550 nm. Cyclic voltammetry experiments show two ill-defined irreversible oxidation waves around +1.50 and 1.80 V that are assigned to Re(I)/Re(II) and Re(II)/Re(III) couples whereas an irreversible reduction signal centered at -1.80 V is likewise assigned to a ligand reduction process. These results support the proposal of the MLCT nature of the states implied by the emission of the complex. The luminescent decay fits to a biexponential function, where the lifetimes and emission quantum yields are dependent on the solvent polarity. DFT calculations suggest that dπ → π*pyridine and dπ → π*phenyl excited states may account for the existence of two decay lifetimes.

Enfermedades osteocondensantes con compromiso de huesos largos: presentación de dos casos y revisión de la literatura / Sclerosing bone diseases with involvement of long bones: report of two cases and literature review

Las enfermedades osteocondensantes son un grupo de patologías poco frecuentes que se caracterizan por aumento de la masa ósea, comprometiendo tanto a huesos largos como a huesos planos. Tradicionalmente, la radiología simple ha permitido su diagnóstico al identificar patrones de afectación ósea característicos de cada enfermedad. Actualmente, la caracterización molecular y genética ha facilitado la comprensión del sustrato fisiopatológico y la expresión fenotípica de estás patologías, sin embargo, la radiología simple continua teniendo un valor inconmesurable en el reconocimiento de las enfermedades osteocondensantes.

Sclerosing bone disorders are a rare group of diseases characterized by increased bone mass in both long and flat bones. Traditionally, plain radiography has allowed the diagnosis of these diseases identifying characteristic patterns of bone involvement. At present, the molecular and genetic characterization of these diseases has provided a better understand of their pathophysiology and phenotypic expression, however plain radiography continues to have an important role in the recognition of sclerosing bone disorders.

El sistema de la proteína C activada en el cuadro séptico / The effects of activated protein c on the sepsis syndrome

Durante los últimos años y con el advenimiento del conocimiento y las técnicas de biología molecular, las concepciones fisiopatológicas del cuadro séptico han cambiado en forma dramática. Prueba de ello es la aprobación del empleo de formas recombinantes de la proteína C activada por parte de la Administración Federal de Alimentos y Medicamentos de Estados Unidos (FDA). Con la presente revisión se pretende hacer un análisis del estado general del conocimiento respecto al papel que la proteína C activada y su sistema de respuesta cumplen en el contexto del cuadro séptico...

The concepts on the pathophysiology of the clinical manifestations of sepsis have changed dramatically during recent years due to the development of knowledge and techniques in molecular biology. A proof of this is the approval by the US Food and Drug Administration (FDA) of the use of recombinant forms of activated protein C. This review attempts to analyze the overall state of knowledge regarding the role activated protein C and its response system play on the sepsis syndrome...

Composición y funciones de la flora bacteriana intestinal / Composition and functions of intestinal bacterial flora

Las enfermedades gastrointestinales son una causa importante de morbilidad y mortalidad alrededor del mundo. Involucran enfermedades inflamatorias crónicas como colitis ulcerativa y enfermedad de Crohn, además de afecciones infecciosas y funcionales como el síndrome de intestino irritable. El tratamiento ha sido de difícil manejo dada la ambigüedad y las múltiples teorías que rodean la etiología. Se han relacionado elementos psicosociales, cambios en la motilidad gastrointestinal, factores inmunológicos, genéticos y hace poco alteraciones en la flora intestinal. Esta microflora bacteriana es un tema complejo y olvidado que contribuye de manera importante no sólo en los procesos de degradación y absorción de sustratos de la dieta, sino que cumple funciones inmunológicas y protectoras en cada organismo. Conocer su composición, distribución y las múltiples acciones que cumple para mantener el equilibrio en el ecosistema gastrointestinal, resulta esencial para comprender su participación en la prevención y tratamiento de trastornos inflamatorios y de la motilidad gastrointestinal.

Gastrointestinal disorders are an important cause of morbidity and mortality worldwide. They involve chronic inflammatory bowel diseases such as ulcerative colitis and Crohn´s disease, and infectious and functional disorders such as irritable bowel syndrome. Treatment has been difficult due to the ambiguity and multiple theories that are involved in their etiology. Psychological and social elements, changes in gastrointestinal motility, immunologic and genetic factors and recently, alterations of the intestinal flora, have been related. This bacterial microflora is a complex and forgotten topic with an important contribution not only to dietary substrate degradation and absorption processes but also fulfilling immunologic and protection functions in every organism. Knowing its composition, distribution and its multiple actions in maintaining proper balance of the gastrointestinal ecosystem is essential to understanding its role in preventing and treating inflammatory and gastrointestinal motility disorders.

Cuándo operar un paciente con sepsis en estado crítico / When to operate a septic critically ill patient

La infección intraabdominal de cualquier origen es la segunda causa de muerte por sepsis en los pacientes en estado crítico y continúa siendo un reto para el médico tratante, dado que existen muchos factores que afectan el enfoque del manejo racional. La creciente tasa de resistencia de los gérmenes intrahospitalarios a las terapias antibióticas convencionales, las diferentes visiones que existen sobre cómo dilucidar el dilema de definir una conducta médica o quirúrgica y la falta de ensayos clínicos con suficiente validez que nos proporcionen una guía que cambie el curso de la enfermedad, hacen de este problema un objeto de constante discusión y discrepancia entre los especialistas que intervienen en su solución. Esta revisión actualiza los conceptos de grupos multidisciplinarios que ayudarán a definir la conducta para el manejo apropiado de esta grave situación clínica.

Regardless its origin, intra-abdominal infection is the second cause of death due to sepsis in critically ill patients and remains a challenge for the treating physician due to the many factors affecting the approach of a rational management. The increase of the resistance rate to conventional antimicrobial therapy of nosocomial organisms, different opinions on how to work out the dilemma of defining a medical or surgical treatment and the lack of valid clinical trials providing guidelines which change the disease´s course, makes this problem a subject of constant discussion and discrepancy between intervening specialists. This review updates the concepts of various multidisciplinary groups which will help define the conduct for appropriate handling of this serious clinical condition.

Osteomalacia inducida por tumor / Tumor-induced osteomalacia

La osteomalacia inducida por tumor es un síndrome paraneoplásico secundario en la mayoría de los casos a tumores de origen mesenquimal. Se caracteriza por pérdida aumentada de fosfato a nivel urinario por el efecto inhibidor que ejerce el factor de crecimiento fibroblástico 23 sobre el transporte de fósforo en el túbulo renal proximal. Debe sospecharse en un paciente con debilidad y dolor osteomuscular generalizado que se presente con hipofosfatemia, normocalcemia, fosfatasa alcalina elevada y niveles de 25 hidroxivitamina D y PTH normales. El tratamiento definitivo de la enfermedad es la resección quirúrgica del tumor. Cuando se desconozca la neoplasia primaria o no sea posible el tratamiento quirúrgico debe iniciarse reposición de fósforo y calcitriol. En este artículo se presenta el primer caso de una paciente con osteomalacia inducida por tumor asociada a un carcinoma lobulillar infiltrante de seno.

The tumor-induced osteomalacia is a paraneoplastic syndrome secondary in most cases to tumors of mesenchymal origin. It is characterized by increased lost of urinary phosphate by the inhibitory effect exerted by the fibroblast growth factor 23 on phosphorus transport in the proximal renal tubule. Should be suspected in a patient with weakness and generalized muscle in addition to hypophosphatemia, normocalcemia, elevated alkaline phosphatase and normal serum 25-hydroxyvitamin D and PTH. The definitive treatment of the disease is surgical resection of the tumor. When the primary tumor is unknown or is not possible the surgical treatment should be initiated replacement of phosphorus and calcitriol. This paper presents the first case of a patient with tumor-induced osteomalacia associated with lobular breast cancer.

Hepatitis B inactiva. Decisiones en la práctica clínica / Inactive hepatitis B. Decisions in the clinical practice

La mayoría de portadores crónicos del HBsAg son portadores inactivos de la hepatitis B. A pesar de que en términos generales tiene buen pronóstico a largo plazo, posee un riesgo incrementado de cirrosis hepática y hepatocarcinoma respecto a la población general. Además, es un grupo con alto riesgo de complicaciones, incluso letales, en caso de recibir medicamentos hepatotóxicos o inmunosupresores, lo cual requiere una serie de medidas diagnósticas y terapéuticas oportunas por parte del médico tratante. En este artículo presentamos una revisión de la hepatitis B inactiva, haciendo énfasis en el abordaje que debe realizarse en los escenarios clínicos que con mayor frecuencia ocurren en este grupo de pacientes.

Most chronic carriers of HBsAg are inactive carriers. Although in general have a good prognosis in the long term, have an increased risk of liver cirrhosis and hepatocellular carcinoma with respect to the general population. It is also a group at high risk of complications, even lethal, if given hepatotoxic or immunosuppressive drugs, which requires a series of diagnostic and therapeutic measures necessary for the treating physician. In this article we present a review of inactive hepatitis B, emphasizing the approach to be implemented in clinical scenarios that occur most frequently in this patient group.

Inhibidores de bomba de protones y riesgo de osteoporosis / Proton pump inhibitors and risk of osteoporosis

La asociación entre los inhibidores de bomba de protones (IBPs) y osteoporosis es un tema que ha suscitado recientemente bastante interés en la literatura médica. Existe evidencia proveniente de estudios epidemiológicos, que relaciona los IBPs con un mayor riesgo de osteoporosis y específicamente con uno de sus desenlaces más temidos, la fractura de cadera. Aunque se han propuesto varios mecanismos para explicar dicha asociación, no se ha logrado establecer claramente la plausibilidad biológica de este fenómeno. Destacados expertos en el tema discuten la relación causal entre el uso de IBPs y osteoporosis con base en el modelo de causalidad propuesto por Bradford-Hill. A futuro se hacen necesarios estudios para definir cuál es la dosis y tiempo de exposición conque realmente se incrementa el riesgo y el tipo de estrategia para disminuir el riesgo de fracturas. En este artículo hacemos una revisión crítica de la literatura publicada a la fecha sobre el tema.

The association between proton pump inhibitors and osteoporosis is a topic that has recently attracted considerable interest in the medical literature. There is evidence from epidemiological studies, which relates IBPs with an increased risk of osteoporosis and specifically with one of their most feared outcome, the hip fracture. Although several mechanisms have been proposed to explain this association has not been able to establish clearly the biological plausibility of this phenomenon. Leading experts in the field discuss the causal relationship between the use of IBPs and osteoporosis based on the causal model proposed by Bradford-Hill. In future studies are necessary to define what is the dose and exposure time with it actually increases the risk and type of strategy to reduce the risk of fractures. In this article we critically review the literature to date on the subject.

Osteonecrosis and antiphospholipid syndrome.

Osteonecrosis (ON), or avascular necrosis of bone, has been related to decreased blood flow to the bone. Many local and systemic factors have been implicated in the pathogenesis of ON, involving corticosteroid therapy, systemic lupus erythematosus (SLE), hemoglobinopathies, alcohol abuse, Caisson disease, Gaucher disease, and hypercoagulability states. We describe the case of a previously healthy young male with no history of corticosteroid therapy, who developed ON initially on the femoral head, and later on the humeral head with high levels of anticardiolipin antibodies (aCL), beta-2-glycoprotein 1 antibodies and positive lupus anticoagulant. The association between primary antiphospholipid syndrome (PAPS) and ON is controversial and few cases without other risk factors have been described. A review of ON pathogenesis and its relation with thrombotic microangiopathy because of PAPS is presented.

Manifestaciones osteoarticulares por amiloidosis sistémica / Osteoarticular manifestations by systemic amyloidosis

La amiloidosis es un grupo de enfermedades cuyo común denominador es el depósito extracelular de fibrillas insolubles derivadas de proteínas en órganos y tejidos. De acuerdo a su etiología y al tipo de proteína depositada existen varias clases de amiloi-dosis. A pesar que la incidencia de amiloidosis sisté -mica secundaria (AA) ha disminuido notoriamente con el advenimiento de drogas modificadoras de la enfermedad (DMARD) y terapia biológica, continúa siendo el tipo de amiloidosis más frecuentemente observada por el reumatólogo. En este artículo revisamos la historia, clasificación, epidemiología, diagnóstico y tratamiento de la amiloidosis sistémica haciendo énfasis en las manifestaciones osteoar-ticulares que produce la enfermedad y en las distintas enfermedades reumatológicas que pueden originar una amiloidosis secundaria (AA). Así mismo publicamos un material fotográfico recopilado durante 20 años en diferentes centros de reumatología del país que es de gran ayuda para realizar el diagnóstico clínico de esta infrecuente patología.

Amyloidosis is a generic term that refers to the extracellular tissue deposition of fibrils composed of low molecular weight subunits of a variety of proteins. Amyloidosis classification depends on its etiology and subtype of protein involved. Systemic secondary amyloidosis (AA) is the most frequent subtype seen on rheumatology services because rheumatoid arthritis is currently the most frequent cause of AA, although its incidence has been declined because a better treatment of rheumatoid arthritis with disease-modifying anti-rheumatic drugs (DMARD). In this review we provide a general overview of the pathogenesis, clinical manifestations, diagnosis, and treatment of the systemic amyloidosis, emphasizing on the rheu-matic manifestations of these disorders. Besides, we present a photographic material obtained in the last 20 years in several rheumatologic centers in our country that it has a crucial role in the diagnosis and follow-up of this infrequent pathology.

Policondritis recurrente. Estudio de 19 casos en Colombia / Relapsing polychondritis. An study of 19 cases in Colombia

Objective: To describe clinical and paraclinical involvement in RP in a Colombian populationand compare it with another series previously published.Methods and materials: Retrospective review of 19 cases of RP presented in 4 rheumatologycenters in our country in the last 10 years. All patients met diagnostic criteria previouslyestablished. In every case, each clinical feature was analized and then compared with another9 series of RP previously published between 1966 y 2007.Results: Mean age at diagnosis was 46 years. A female predominance was observed ina relation 4:1. Mean follow-up was 4 years. Auricular condritis was the initial clinicalfeature in 89 percent of patients and finally was observed in the 100 percent of our report. Comparedwith other series, we found less frequently arthritis (21percent), ocular (10percent) and dermatologicinvolvement (10percent). Renal and neurologic involvement and the association between RPand another autoimmune disorder were found in the expected frequency. We not observedany cardiovascular involvement in our serie. All of the patients received corticosteroidsand 57percent had had another immunosuppressive medication. Observed mortality was 10percentby complications associated to RP.Conclusions: In contrast with another series from Caucasian and Oriental population, weobserved a marked predominance of female sex, a minor frequency of systemic involvementand auricular condritis is our most frequent initial clinical feature. Probably, these findingsare the result of a different genetic, immunological and environmental background.

Objetivo: Describir el comportamiento clínico y paraclínico de la PR en la poblacióncolombiana y comparar nuestros resultados con otras series publicadas.Materiales y métodos: Estudio descriptivo observacional de 19 casos de PR presentadosen 4 centros de reumatología del país durante los últimos 10 años. Los pacientes cumplieroncon el diagnóstico de PR de acuerdo al parámetro establecido...

Manejo y enfoque inicial del dolor abdominal en un paciente inmunosuprimido / Management and initial work up of abdominal pain in an immunodepressed patient

En este artículo describimos el caso de una paciente con abdomen agudo y antecedente de púrpura trombocitopénica idiopática, trasplante hepático y tratamiento inmunosupresor. Ante la duda diagnóstica, la paciente fue llevada a laparoscopia exploratoria encontrándose una apendicitis aguda. Presentamos el enfoque y manejo de la patología abdominal quirúrgica en pacientes con enfermedad autoinmune y tratamiento inmunosupresor exponeniendo las ventajas de la invasión mínima frente al procedimiento convencional.

In this article we described the case of a patient with acute abdomen and previous history of idi-opathic thrombocytopenic purple, liver transplant and immunosuppressor treatment. Because of the doubt in the diagnosis, an exploratory laparoscopic was done and an acute appendicitis was found. We presented the initial surgical approach of abdominal pathology in patients with autoimmune disease and immunosuppressor treatment and also explain the advantages of the minimum invasion compared with conventional procedure.

Enfermedad reumatológica y embarazo / Rheumatic diseases and pregnancy

La presencia de enfermedad reumatológica en el embarazo no es infrecuente. Este hecho se favorece por la mayor prevalencia de enfermedades reumáticas en mujeres en edad fértil. El efecto del embarazo en la enfermedad reumatológica varía de acuerdo a la enfermedad; en algunos casos se tiende a exacerbar la patología de base, mientras que en otros tiende a remitir. Independiente de cuál sea la situación, la enfermedad reumática en el embarazo siempre representa un desafío importante para el equipo médico tratante. El tratamiento de cada condición difiere del estándar porque muchos medicamentos poseen efectos adversos para el embarazo y adicionalmente, en los estudios clínicos con frecuencia se excluye a la población obstétrica por lo que muchas de las recomendaciones en este grupo de pacientes provienen de observaciones clínicas. El conocimiento preciso del problema y la inclusión del médico reumatólogo en el equipo de tratamiento son pasos fundamentales para obtener un mejor resultado materno-fetal. En este artículo analizamos las enfermedades reumáticas más frecuentes y su relación con el embarazo.

The association between rheumatic diseases and pregnancy is not uncommon. This is due to the high prevalence of the rheumatic diseases among young women. The effect of pregnancy on any rheumatic disease is unique to each rheumatologic condition; in some cases pregnancy is the trigger for a flare-up, while in other cases the disease tends to go to remission. Independent to the clinical scenario, rheumatic diseases on a pregnant women is always a challenge for the medical team. Treatment for each condition differs from the standard of care, because many drugs may have serious side effects on pregnancy. Besides, obstetric population is commonly excluded from clinical trials, so most recommendations are made by expert opinion and clinical observations. The precise understanding of this situation and the participation of a rheumatologist in the medical team are essential elements to achieve the best outcomes. In this paper we review the most frequents rheumatic diseases and its relation with pregnancies.