Position paper on perioperative management and surgical risk in the patient with cirrhosis.

INTRODUCTION: Management of the patient with cirrhosis of the liver that requires surgical treatment has been relatively unexplored. In Mexico, there is currently no formal stance or expert recommendations to guide clinical decision-making in this context. AIMS: The present position paper reviews the existing evidence on risks, prognoses, precautions, special care, and specific management or procedures for patients with cirrhosis that require surgical interventions or invasive procedures. Our aim is to provide recommendations by an expert panel, based on the best published evidence, and consequently ensure timely, quality, efficient, and low-risk care for this specific group of patients. RESULTS: Twenty-seven recommendations were developed that address preoperative considerations, intraoperative settings, and postoperative follow-up and care. CONCLUSIONS: The assessment and care of patients with cirrhosis that require major surgical or invasive procedures should be overseen by a multidisciplinary team that includes the anesthesiologist, hepatologist, gastroenterologist, and clinical nutritionist. With respect to decompensated patients, a nephrology specialist may be required, given that kidney function is also a parameter involved in the prognosis of these patients.

Evaluation and management of emergencies in the patient with cirrhosis.

The approach to and management of critically ill patients is one of the most versatile themes in emergency medicine. Patients with cirrhosis of the liver have characteristics that are inherent to their disease that can condition modification in acute emergency treatment. Pathophysiologic changes that occur in cirrhosis merit the implementation of an analysis as to whether the overall management of a critically ill patient can generally be applied to patients with cirrhosis of the liver or if they should be treated in a special manner. Through a review of the medical literature, the available information was examined, and the evidence found on the special management required by those patients was narratively synthesized, selecting the most representative decompensations within chronic disease that require emergency treatment.

A Case of Cerebral Granuloma and Optic Papillitis due to Brucella sp.

We document a case of a 24-year-old woman who presented with cerebral granuloma and optic papillitis associated to Brucella sp. infection, whose diagnosis was made with a brain biopsy and serology tests, with clinical improvement following specific antibiotic therapy. The patient was followed up for over a year without evidence of relapse.

Conocimiento sobre melanoma y prácticas de protección frente al sol en pacientes del Hospital Cullen de Santa Fe, Argentina / Knowledge of melanoma and sun-protective practices in patients at José M. Cullen Hospital of Santa Fe, Argentine

Introducción. Melanoma es un cáncer de piel de mortalidad alta, cuya incidencia ha aumentado mundialmente en los últimos años. El siguiente estudio está destinado a detectar el conocimiento de la población sobre melanoma y las medidas de protección frente a la radiación UV (RUV), considerando que las dos terceras partes de los casos de melanoma se asocian al sol. Objetivo general. Detectar el conocimiento sobre melanoma y las prácticas de protección solar, en pacientes que consultan en el Servicio de Dermatología e internados en Clínica Médica del Hospital José M. Cullen. Materiales y métodos. Estudio observacional, prospectivo, longitudinal y descriptivo. La población abarcó 275 pacientes, entre 16 y 85 años, voluntarios del consultorio de Dermatología e internados en Clínica Médica del Hospital José M. Cullen. Mediante el programa Statistical Package for the Social Sciences 15.0, se realizó un análisis descriptivo y la prueba de Chi cuadrado, para determinar asociación estadística, entre variables cualitativas con significancia de p<0,05. Resultados. El conocimiento resultó escaso, sólo el 53% relacionó correctamente melanoma con cáncer de piel. El elemento de protección a la RUV más utilizado fue el sombrero y más frecuente en hombres (p<0,001). El uso de FPS es más común en mujeres (p= 0,003); de hecho, fueron las que en mayor frecuencia (p=0,011) lo utilizaron el verano pasado y en personas menores de 40 años (p=0,002). La utilización de ropas largas es más frecuente en hombres (p=0,006) y en personas mayores de 40 años (p=0,002). Se encontró un resultado significativo entre la utilización de FPS y su renovación periódica (p<0,001), entre la práctica de no utilizar ningún elemento de protección frente al sol y considerar que un lunar puede transformarse en cáncer de piel (p=0,014). Conclusión. Existe poco conocimiento, lo que se refleja en las prácticas inadecuadas de protección frente a RUV.

Background. Melanoma is one of the deadliest forms of skin cancer, showing an increasing incidence worldwide over the past years. The aim of this study was to assess people's knowledge about melanoma, and their protective measures against UV radiation, considering that two-thirds of melanoma cases are associated to sun exposure. General objective. To assess the knowledge about melanoma and the sun protective practices in patients who attended the Department of Dermatology and in those admitted to the General Internal Medicine Unit of José M. Cullen Hospital. Material and methods. It was an observational, prospective, longitudinal, descriptive study. A sample of 275 participants aged between 16-85 years was included, composed of voluntary patients from the Department of Dermatology and inpatients from the General Internal Medicine Unit of José M. Cullen Hospital. The Statistical Package for the Social Sciences 15.0 software was used to make a descriptive analysis; the chi-square test was performed with a significance level of p < 0.05 to determine the statistical association among qualitative variables. Results. The knowledge was poor, since only 53% of respondents associated melanoma to skin cancer correctly. Hats were the most used sun protection choice, specially in men (p < 0.001). The use of sunscreen was more common among women (p= 0.003) - in fact, they were the ones who used it more regularly (p= 0.011) last summer - and among people under 40 (p= 0.002). Using long clothing was more common in men (p= 0.006) and in people over 40 (p= 0.002). A significant result was found between the use of SPF and its daily reapplication (p < 0.001), between not using any sun protection element and considering that a mole can develop skin cancer (p= 0.014). Conclusion. There is little knowledge among people, which is reflected on the inadequate protective practices against UV radiation.

Gastric capacity is related to body mass index in obese patients. A study using the water load test.

BACKGROUND: The role of gastrointestinal function in obesity is unknown. Recent studies have shown that satiety in obese patients is influenced by an abnormal gastric capacity. AIM: An easy and non-invasive tool, the water load test (WLT) was used to evaluate gastric capacity and how it relates to body mass index (BMI) in obese patients. METHODS: The WLT was performed in 32 patients with high BMI and 12 healthy volunteers. Water was ingested at a 15 mL/min rate. The maximal tolerable volume (MTV) was defined as the total ingested volume when patients stopped the test. RESULTS: A BMI > 30 was significantly associated with higher water consumption (2339 ± 306 mL) compared to controls (1830 ± 240 mL, p = 0.001). The MTV had a positive correlation with BMI (r = 0.68, p = 0.001). CONCLUSIONS: Obese subjects have an increased gastric capacity, as measured with the WLT. This greater drinking capacity has a positive correlation with the subjects' BMI.

Antibody seroprevalences against rabies in dogs vaccinated under field conditions in Bolivia.

Bolivia currently has one of the highest numbers of cases for human and canine rabies and is thus clue to the elimination process. The objective of the present study was to assess antibody seroprevalences against rabies in dogs vaccinated under field conditions and other factors that might influence the success of the on-going rabies control programmes in an endemic area of the disease, Santa Cruz de la Sierra, Bolivia. All 240 study animals, selected using area-stratified random sampling, were investigated in April 2007. Test prevalences were adjusted for the imperfect test characteristics using the Rogan-Gladen estimator (deterministic and stochastic functions) and Bayesian inference. Ninety-four of the tested 240 vaccinated dogs were classified as test-positive for rabies-specific antibodies. With regard to adjusted overall antibody seroprevalence, Bayesian true prevalence estimates (41%, 95% CI: 37-46%) were lower than both of the Rogan-Gladen estimates. The effect of various epidemiological factors on post-vaccination response was also assessed.

Antibody response to an anti-rabies vaccine in a dog population under field conditions in Bolivia.

Rabies remains an important public health issue in Bolivia, South America. Public concern and fears are most focussed on dogs as the source of rabies. The objective of the present study was to assess immunity of an inactivated suckling mouse brain vaccine against canine rabies used for the official vaccination campaigns under field conditions in an endemic area of rabies in Bolivia. A total of 236 vaccinated and 44 unvaccinated dogs in Santa Cruz de la Sierra, selected using stratified random sampling, were investigated in order to obtain owned dog characteristics and antibody titres against rabies in April 2007. The proportion of vaccinated dogs with an antibody titre exceeded the protection threshold value of 0.5 EU/ml was 58% [95% confidence intervals (CI): 52-65], indicating that vaccination is likely to elicit an antibody response (odds ratio 6.3, 95% CI: 1.2-11.5). The range of geometric mean of antibody titre for vaccinated dogs (0.89 EU/ml; 95% CI: 0.75-1.04) was considered to meet the minimal acceptable level indicating an adequate immune response to the vaccine. However, the titre level was not satisfactory in comparison with the results from other field investigations with inactivated tissue culture vaccines. It is recommended for public health authorities to (1) consider modernizing their vaccine manufacturing method because the level of immunity induced by the current vaccine is comparably low, (2) conduct frequent vaccination campaigns to maintain high levels of vaccination coverage, and (3) actively manage the domestic dog population in the study area, which is largely responsible for rabies maintenance.

Distrofia miotónica or Steinert / Myotonic dystrophy or Steinert

La distrofia miotónica es la más común en personas adultas, aunque también existe una forma congénita. Se transmite en forma autonómica dominante por una alteración a nivel del cromosoma 19q; esta enfermedad se caracteriza por la afección de los músculos de la cara, cuello, parte distal de las extremidades y a otros órganos del cuerpo. En el Hospital General de las Fuerzas Armadas, un paciente con diagnóstico de distrofia miotónica fue sometido a exámenes complementarios: pruebas de neuroconducción y electromiografía con lo que se llegó al diagnóstico definitivo de distrofia miotónica o de Steinert.

Bovine trypanosomosis in the Bolivian Pantanal.

Trypanosomosis caused by Trypanosoma vivax has been a constraint for cattle production in the Bolivian lowlands, since it was introduced in 1996. Flooded areas like the Bolivian Pantanal have a suitable environment for the presence and transmission of Salivarian trypanosomes and farmers from that region often report trypanosomosis-like problems on their farms. The objective of the present study, therefore, was to characterize the epidemiology of bovine trypanosomosis in the Bolivian Pantanal. In order to achieve this objective, 202 cattle from the province of Angel Sandoval and 209 cattle from the province of German Busch were randomly sampled (the Pantanal is located in both provinces). Twenty-nine farms in both provinces were visited, the farmers interviewed, and biologic samples collected from their cattle. Samples were submitted for parasitological and PCR evaluation and the prevalence of bovine trypanosomosis was estimated for each province. Laboratory results were correlated with the sampled animals packed cell volume (PCV) and body condition (BC) scores and the observed T. vivax parasites measured for morphometry analysis. Results from this study show differences in morphometric measures between T. vivax parasites from each province. Differences between provinces were also observed in the T. vivax-related disease situation. While in Angel Sandoval the PCV and BC of T. vivax-affected animals were significantly lower than those of the T. vivax-negative animals, in German Busch no differences were observed in the PCV and BC of T. vivax-positive or negative animals. Animal prevalence of T. vivax in Angel Sandoval was 27.79% (95% CI: 14.52-44.28) and in German Busch was 19.03% (95% CI: 9.19-30.75). The T. evansi animal prevalence in each province was 0.99% (95% CI: 0.27-2.99) and 5.71% (95% CI: 2.43-12.19), respectively. Based on questionnaire and laboratory results, it was concluded that trypanosomosis is a primary constraint for cattle production in the Bolivian Pantanal.

[Seropositivity for Chlamydia pneumoniae in patients with primary biliary cirrhosis]. / Seropositividad para Chlamydia pneumoniae en pacientes con cirrosis biliar primaria.

INTRODUCTION: Primary biliary cirrhosis (PBC) is a chronic cholestatic liver disease characterized by inflammatory injury and bile duct destruction. Recent studies suggest that Chlamydia pneumoniae could be associated with the development of PBC. The aim of this study was to determine the seroprevalence of C. pneumoniae in a cohort of patients with PBC. PATIENTS AND METHODS: The presence of IgG antibodies against C. pneumoniae was investigated in 46 patients with PBC and in 105 subjects without cirrhosis. RESULTS: Twenty-one patients (46%) with PBC had antibodies against C. pneumoniae compared with 74 subjects (71%) in the control group (OR = 0.6; 95% CI, 0.3-1.2; p = NS). Subanalysis of the PBC group showed that patients with C. pneumoniae antibodies had a higher frequency of advanced Child-Pugh stages (24% A, 52% B and 24% C vs 64% A, 32% B and 4% C; p = 0.01), a higher score on the Mayo Clinic Prognostic Index (7.8 +/- 2.1 vs 5.6 +/- 1.2; p = 0.004), a higher frequency of ascites (29% vs 4%; OR = 9.6; 95% CI, 1-87; p = 0.02), higher total bilirubin levels (4.5 +/- 2.5 mg/dl vs 2.4 +/- 4.3 mg/dl, p = 0.001) and lower serum albumin levels (2.6 +/- 0.9 g/dl vs 3.3 +/- 0.6 g/dl, p = 0.02). CONCLUSION: No association was found between C. pneumoniae infection and PBC in this study. An association was found between the severity of PBC and C. pneumoniae, which may suggest a deleterious effect of C. pneumoniae infection or a predisposition in advanced stages of PBC to acquire infection with this microorganism.

[Predictive factors for portal hypertension in patients with primary sclerosing cholangitis]. / Factores predictores de hipertensión portal en los enfermos con colangitis esclerosante primaria.

BACKGROUND: Primary sclerosing cholangitis (PSC) is characterized by progressive destruction of bile ducts, which may lead to cirrhosis and portal hypertension. The factors associated with the presence of esophageal varices (EV) and the risk of bleeding have not been well defined. AIM: To determine the factors associated with the presence of EV and risk of bleeding in a cohort of patients with PSC. MATERIAL AND METHODS: We analyzed the demographic, biochemical and endoscopic characteristics, and follow-up of 32 patients with a diagnosis of PSC. All patients underwent endoscopic evaluation to determine the presence of EV at diagnosis and annually during follow-up. RESULTS: There were 24 men (75%) and 8 women (25%). The mean age was 40.2 years (range, 19-66). At diagnosis, none of the patients had a previous history of variceal bleeding and 4 (13%) had EV on endoscopic examination. In bivariate analysis, the factors associated with the presence of EV were: splenomegaly (4/6 vs 0/26; p < 0.001), ascites (2/4 vs 0/24; p < 0.001), thrombocytopenia (96 +/- 27 vs 299 +/- 135 x 10(3), p < 0.001), and hypoalbuminemia (2.4 +/- 0.6 vs 3.5 +/- 0.6 g/dl; p = 0.005). During a mean follow-up period of 7 years (range, 2-15 years), 6 patients developed EV and 7 patients had at least one episode of variceal bleeding. In logistic regression analysis, the factors independently associated with the presence of EV at diagnosis were thrombocytopenia (p = 0.001) and splenomegaly (p = 0.01). The factors associated with variceal bleeding were worsening of liver function (p = 0.01) and splenomegaly (p = 0.02). CONCLUSIONS: There are noninvasive indicators of portal hypertension that could predict the presence of EV and risk of bleeding in patients with PSC. The presence of thrombocytopenia, splenomegaly or worsening of liver function should be detected in these patients, as they could benefit from endoscopic surveillance.

Sensitivity of different Trypanosoma vivax specific primers for the diagnosis of livestock trypanosomosis using different DNA extraction methods.

There are several T. vivax specific primers developed for PCR diagnosis. Most of these primers were validated under different DNA extraction methods and study designs leading to heterogeneity of results. The objective of the present study was to validate PCR as a diagnostic test for T. vivax trypanosomosis by means of determining the test sensitivity of different published specific primers with different sample preparations. Four different DNA extraction methods were used to test the sensitivity of PCR with four different primer sets. DNA was extracted directly from whole blood samples, blood dried on filter papers or blood dried on FTA cards. The results showed that the sensitivity of PCR with each primer set was highly dependant of the sample preparation and DNA extraction method. The highest sensitivities for all the primers tested were determined using DNA extracted from whole blood samples, while the lowest sensitivities were obtained when DNA was extracted from filter paper preparations. To conclude, the obtained results are discussed and a protocol for diagnosis and surveillance for T. vivax trypanosomosis is recommended.

[Treatment modalities in patients with hepatocellular carcinoma: a retrospective series in a single institution in Mexico]. / Modalidades de tratamiento para pacientes con carcinoma hepatocelular: una serie retrospectiva de una sola institución en México.

BACKGROUND: To date, curative treatment options for hepatocellular carcinoma (HCC) include orthotopic liver transplantation or surgical resection. Most patients are detected with nonresectable or transplantable HCC due to disease extension or comorbid factors, and are therefore candidates for palliative treatments only. Few follow-up data are available in patients with HCC in Latin America. We therefore reviewed the experience of HCC treatment in a single institution over a 10-year period. PATIENTS AND METHOD: A total of 135 patients attending the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, a national referral center in Mexico, from January 1991 to December 2000 were included. In all patients etiology, stage, and diagnostic and therapeutic measures were documented. Survival time was calculated as a function of staging and therapy. RESULTS: Of 135 patients, 77 (57%) were men and 58 (43%) were women. The mean age at diagnosis was 59.17 years (range: 16-87 years). Cirrhosis was diagnosed in 89 patients (64.4%). The median overall survival for all patients with HCC was 7.9 months. Treatment included surgical resection (n=22), hepatic artery chemoembolization (n=10), percutaneous ethanol injection (n=6), systemic chemotherapy (n=5), tamoxifen (n=11), and thalidomide (n=1). Eighty patients received support measures. The median survival in the group of patients who underwent surgical resection (37.89 months) was significantly higher than that in the groups of patients who did not undergo resection. CONCLUSIONS: Patients with HCC who received no treatment had a median survival of 1.7 months. Hepatic resection offers the best chance of cure in patients with HCC. The strong association between HCC and cirrhotic liver disease makes surgical resection difficult in patients with low hepatic reserve.

[Pathogenesis of hepatitis C virus infection]. / Patogénesis de la infección por virus de hepatitis C.

The hepatitis C virus (HCV) is the leading cause of chronic liver disease worldwide. Chronic hepatitis C is a mayor cause of cirrhosis and hepatocellular carcinoma and HCV-related end-stage liver disease is, in many countries, the first cause of liver transplantation. HCV infection is characterized by its propensity to chronicity. Because of its high genetic variability, HCV has the capability to escape the immune response of the host. HCV is not directly cytopathic and liver lesions are mainly related to immune-mediated mechanisms that are characterized by a predominant type 1 helper cell response. Co-factor influencing the outcome of the disease including age, gender and alcohol consumption are poorly understood and other factors such as immunologic and genetic factors may play and important role. Recent studies have shown that the combination therapy with alpha interferon and ribavirin induces a sustained virological response in about 40% of patients with chronic hepatitis C. The lack of animal models and of in vitro cultures systems hampers the understanding of the pathogenesis of chronic hepatitis C and the development of new antivirals. The conjugation of polyethyleneglycol improved the pharmacodynamics and the efficacy of alpha interferon. The development of an effective vaccine remains the most difficult challenge. Because of the high protein variability of HCV, protective vaccines could be extremely difficult to produce and therapeutic vaccines seem more realistic. Considerable progress has been made in the field of HCV since its discovery 10 years ago but a major effort needs to be made in the next decade to control HCV-related disease.

Sex differences in the enzymatic hydrolysis of acetylsalicylic acid by microsomes from various rat tissues.

We studied the in vitro hydrolysis of acetylsalicylic acid (ASA) to salicylic acid (SA) catalysed by microsomal preparations from liver, kidney, small intestine and stomach mucosas and blood serum of adult female and male rats. Hepatic microsomes from male rats had the highest specific activity: 42.3 +/- 6.0 nmol SA mg(-1) min(-1) (mean +/- SEM). Kidney, intestine, stomach and serum activities were 60, 30, 14 and 0.7% with regard to the liver. In contrast, gastric microsomes from female rats showed the highest specific activity: 53 +/- 22.1 nmol SA mg(-1) min(-1) (mean +/- SEM) whereas intestine, liver, kidney and serum activities were 60, 43, 40 and 1.7% with regard to the stomach mucosa. Hepatic, renal and intestinal microsomes had a pH optimum of 5-6. Male rats had Vmax and Km values of 95.5, 83.4 and 29.4 nmol SA mg(-1) min(-1) and 2.9, 1.27 and 6.4 mM, while for female rats they were 54.8, 75.8 and 59.4 nmol SA mg(-1) min(-1) and 2.6, 1.35 and 3.4 mM for hepatic, renal and intestinal microsomes, respectively. Parathion inhibited the hydrolysis of ASA with an IC50 of 1.2 x 10(-5) M for liver and kidney and 5 x 10(6) M for intestine from male rats.