Terapias adyuvantes a la terapia antifibrótica en la fibrosis pulmonar idiopática: importancia del manejo multidisciplinario / Adjuvant therapies to antifibrotic therapy in IPF: importance of multidisciplinary management

La fibrosis pulmonar idiopática (FPI) se caracteriza por presentar una capacidad funcional reducida, disnea e hipoxia inducida por el ejercicio, lo que disminuye su tolerancia al esfuerzo y limita su capacidad de realizar actividades diarias. Las comorbilidades son frecuentes y su presencia contribuyen al empeoramiento de la calidad de vida y aumento de la mortalidad. Por lo anterior, es que además de las terapias antifibróticas, los pacientes con FPI se benefician de un enfoque integral de la atención que puede incluir: pesquisa, diagnóstico y tratamiento de comorbilidades, ingreso a protocolos de investigación, manejo sintomático, cuidados paliativos, oxígeno suplementario, rehabilitación pulmonar, educación y apoyo por un equipo multidisciplinario.

Idiopathic pulmonary fibrosis (IPF) is characterized by reduced functional capacity, dyspnea and exercise-induced hypoxia, which decreases tolerance to exertion and limits the ability to perform daily activities. Comorbidities are frequent and their presence contribute to worsening quality of life and increased mortality. Therefore, in addition to antifibrotic therapies, patients with IPF benefit of a comprehensive approach to care that may include: screening, diagnosis and treatment of comorbidities, admission to research protocols, symptomatic management, palliative care, supplementary oxygen, pulmonary rehabilitation, education and support by a multidisciplinary team.

Fracturas de cadera y calidad de vida: la ortogeriatría en el ojo del huracán / Hip fractures and quality of life: Orthogeriatrics in the eye of the hurricane

Se revisan algunas áreas de desarrollo de la Ortogeriatría que inciden sobre la calidad de vida tanto de los equipos de salud como de los pacientes. En particular, se aborda la clasificación de los Modelos de Atención en Ortogeriatría, la investigación en Ortogteriatría en hispanoamérica, la definición nosológica de las fracturas de cadera, y la estandarización de la atención ortogeriátrica bajo conceptos de calidad. Se desarrolla la importancia que tienen estos aspectos sobre la calidad de vida relacionada con salud, se señalan los elementos más importantes a desarrollar en el futuro y se sugieren algunas propuestas de investigación.

We review developing areas of orthogeriatrics which impact quality of life in both patients and health teams. We highlight orthogeriatric models of care, orthogeriatric research in Latin America, the nosological definition of hip fractures and the standardization of orthogeriatric treatment with regards to quality. We expand on the importance of these aspects on quality of life with relation to health, point out the most important aspects to be developed, and suggest some lines of research.

Modelos de atención en ortogeriatría: ¿qué tipo es éste o aquel? revisión y propuesta taxonómica / Models of care in orthogeriatrics: what type is this or that? systematic review and taxonomic proposal

Aunque la Ortogeriatría ha experimentado un explosivo desarrollo en los últimos 50 años, es difícil encontrar puntos de comparación entre los diferentes modelos de atención existentes. Se sabe relativamente poco acerca de cómo comparar entre sí los resultados obtenidos por unos y otros, y de cómo clasificarlos. Objetivo: Evaluar si es posible construir una propuesta taxonómica de los Modelos de Atención en Ortogeriatría (MAO) basada en la secuencia de momentos que conforman el curso clínico de la Fractura de Cadera (FC), la más importante patología ortogeriátrica. Diseño: Revisión sistemática. Método: Se revisó bases de datos electrónicas (Medline, NCBI (PubMed), TRIPy Google Scholar).Criterios de inclusión: Publicaciones en inglés o castellano, en revistas de impacto, entre enero 1990 y julio 2013, reportando intervenciones clínicas, exclusivamente de Ortogeriatría, de al menos 1 año de duración, sobre personas de 60 o más años con FC o para prevenir FC, explicitando el lugar donde se llevaron a cabo, el momento que abordaron en la evolución de la FC y concluyendo efectos beneficiosos. Resultados: 1044 coincidencias, 37 reportes seleccionados. Se identificó 4 tipos básicos de MAO, que sirvieron como base para construir una propuesta de clasificación. Conclusiones: La secuencia de momentos que conforman el curso clínico de la FC podría ser de utilidad para clasificar estos modelos. El sistema obtenido facilitaría la elección de uno u otro para implementar en diferentes situaciones, y homogenizaría la comparación de resultados de MAO similares...

Although orthogeriatrics have been explosively developed in last 50 years, is difficult to find points of comparison between different types of orthogeriatric care models (OCM). Relatively little is known about how to compare different outcomes between each other, and how to classify different OCM. Objectives: To develop a taxonomic proposal of OCM based on the sequence of moments in which each different OCM is implemented for managing hip fracture (HIF), the main orthogeriatric pathology. Methods: We reviewed electronic data bases (Medline, NCBI (PubMed), TRIP and Google Scholar) for OCM reports. We include studies reporting clinical experiences suggesting a specific orthogeriatric model centered in older people (60 or over) with HIF, explaining clearly the place where they were performed and the HIF evolutionary moment they approached. Results: After 1044 coincidences, 37 reports of 37 different OCM were selected. OCM were ordered following the care continuum criteria. Finally, 4 basic types of OCM were obtained, which served as the basis to develop a taxonomic proposal. Conclusions: The HIF clinical course was useful for generating a classification system for the different OCM. This taxonomic approach could help to take decisions to implement one or another kind of OCM in one or another situation, and to compare clinical indicators and outcomes between similar OCM...

Notas históricas a propósito de la reacción de Kahn / Historical notes about the Kahn reaction

El presente artículo se origina en la publicación del laboratorista Armando Honorato, que aparece en el primer número del Boletín del Hospital de Viña del Mar, en 1945. En ese artículo el autor comenta la reacción de Kahn de verificación. En esos años, como estudio rutinario para pesquisar sífilis, en Chile todavía era común realizar la reacción de precipitación de Kahn. Las pruebas de verificación correspondientes buscaban disminuir los falsos positivos y falsos negativos. En este artículo se busca dar un contexto histórico a la reacción de Kahn a partir de una breve biografía de su creador, el Dr. Reuben Leon Kahn (1887 – 1979). También se revisa sucintamente aspectos de la amistad del Dr. Kahn con el Dr. Eduardo Dussert, Director del Instituto Bacteriológico de Chile, habiéndose conocido en 1941, mismo año en que Mary Pangborn describiera la reacción de VDRL, que terminó por reemplazar a la reacción de Kahn...

The origin of this revision is one publication made by the laboratorist Armando Honorato in 1945 in our Bulletin (Bol Hosp Viña del Mar 1945 (1):26-30). In that paper, the author comments Kahn reaction of verification. In 1945, as a routine in the diagnostic study of syphilis, in Chile was still common perform the Kahn reaction, and the verification tests were to reduce cases of false positive and false negative. In this paper we make a brief biographic revision of Dr. Reuben Leon Kahn (1887-1979), in order to contextualize the reaction he created. Also, aspects of the friendship of Dr. Kahn with Dr. Eduardo Dussert (Director of the Instituto Bacteriológico de Chile) are briefly reviewed. They met in 1941, the same year that Mary Pangborn described the VDRL reaction, which will eventually replace the Kahn reaction.

Genética de la diabetes mellitus tipo 1 / Genetic of type 1 diabetes mellitus

Type 1 diabetes (T1D) results from autoimmune-mediated destruction of the pancreatic beta cells, a process that is conditioned by multiple genes and environmental factors. The process that destroys the pancreatic b cells in T1D is mediated by T cells and leads to a complex phenotype influenced by multiple factors. It has been more than 30 years since the publication of the first evidence suggesting the involvement of a specific chromosomal region, HLA, in modulating the risk for T1D. HLA locus has been known for decades to contribute strongly with the attributable to genetic risk. In addition to HLA, many proposed candidate loci have been described that are associated with risk of developing the disease, including the insulin gene (INS), PTPN22,CTLA-4, PD-1, IL2-RA and IFIH1 which together do not contribute more than 15 percent of the risk. This review compiled the data on T1D genes and discusses the major genetic impact of these genetic aspects in T1D etiology.

Validación factorial de un cuestionario para medir la conducta de comer en ausencia de hambre y su asociación con obesidad infantil / A questionnaire to measure eating behavior in the absence of hunger and its association with childhood obesity

Background: It has been observed that some psychological factors tend to stimulate food intake in the absence of hunger in obese children. objective: To evaluate whether obese children have a greater tendency to eat in the absence of hunger, in response to various emotional and environmental factors versus normal weight children. subjects and Methods: Obese patients were selected according to NCHS/CDC2000 (n = 49 and n = 99 for non-obese children), males and females in the age group of 6-12 years who consulted in the UC health network and also children that were evaluated in schools located in southeastern Santiago. The questionnaire "Eating in the absence of hunger" was used, which measures three subscales: external stimuli, fatigue/boredom and negative feelings. results: Factor analysis showed a significant degree of overlap between the "fatigue/boredom" and "negative feelings" subscales. Obese children had higher scores on "external stimuli" versus normal weight children (median 2.7 compared to 1.7, p < 0.001). In the "fatigue/boredom" subscale, scores of 2.5 versus 1.2 (p < 0.001) were obtained, while in "negative feelings", scores reported 2.0 versus 1.2 (p = 0.0013). Conclusions: Obese patients reported higher scores on the questionnaire "Eating in the absence of hunger" than non-obese children, identifying modifiable and educable stimuli that could prevent this eating behavior.

Introducción: Se ha observado que en los niños obesos, algunos factores psicológicos tienden a estimular la ingesta de alimentos en ausencia de hambre. objetivo: Evaluar si los niños obesos presentan mayor tendencia a comer en ausencia de hambre, en respuesta a distintos factores emocionales y ambientales, en comparación con niños normopeso. Pacientes y Método: Se seleccionaron pacientes obesos según NCHS/CDC2000 (n = 49) y normopeso (n = 99) de ambos sexos y con edades entre 6-12 años, que consultaron en forma espontánea en la Red de Salud UC y niños evaluados en colegios del sector suroriente de Santiago. Se aplicó el cuestionario "Comer en ausencia de hambre" que mide tres subescalas: Estímulos externos, cansancio/aburrimiento y sentimientos negativos. resultados: El análisis factorial reveló un importante grado de solapamiento entre las ponderaciones de las subescalas "cansancio/aburrimiento" y "sentimientos negativos". Los niños con obesidad presentaron mayores puntajes en la dimensión "estímulos externos" que los niños normopeso (mediana de 2,7 versus 1,7; p < 0,001). En "cansancio/aburrimiento" se obtuvieron puntajes de 2,5 versus 1,2 (p < 0,001) mientras que en "sentimientos negativos" los puntajes fueron 2,0 versus 1,2 (p = 0,0013). Conclusiones: Los pacientes obesos presentaron mayores puntajes en la encuesta alimentaria "Comer en ausencia de hambre" que los niños normopeso, pudiendo identificarse estímulos modificables y educables que podrían prevenir esta conducta alimentaria.

Hipertrigliceridemias de origen genético / Hypertriglyceridemias of genetic origen

Hypertriglyceridemia (HTG) is defined as plasma triglycerides (TG) > 150 mg/dL, and it is a frequent disease in the general population. When plasma TG reach concentrations > 500 mg/dL (severe HTG), there is usually a genetic defect involved. This defect can involve a single gene or be of polygenic inheritance. In polygenic HTG, the phenotypic expression of the disease is usually associated to the presence of certain diseases such as diabetes, obesity or insulin resistance. The most common known genes associated with monogenic hypertriglyceridemia are LPL and APOC2, but in recent years a few cases caused by mutant APOA5, GPIHBP1 and LMF1, have been identified. Furthermore, genome wide association studies (GWA) have brought up new genes that are related to discrete changes in triglyceride plasma levels of the general population. Among them, it is worth mentioning GCKR, TRIB1, MLXIPL, GALNT2, APOB, APOC2, APOA5, APOE, LPL, ANGPTL3 and NCAN. It is remarkable that most severe hypertriglyceridemias are of polygenic origin, and they could involve a major susceptibility gene. Only in a few cases of severe or very severe HTG (TG > 2.000 mg/dL) the genetic cause is known.

Detección de lesiones premalignas y malignas en población de la isla Robinson Crusoe, archipiélago Juan Fernández / Malignant and premalignant lesions in Juan Fernández Archipelago

Numerosos estudios demuestran que el cáncer de piel ha aumentado su incidencia en las últimas décadas a nivel nacional. El Archipiélago Juan Fernández, se encuentra a 674 km. del continente. Se estudió el 44,5 por ciento de sus habitantes (334 personas), no encontrándose lesiones malignas, pero con una tasa de incidencia de lesiones premalignas de 7,5 por ciento, destacando un alto porcentaje de hombres (68 por ciento) de edad avanzada (84 por ciento) y de actividad laboral pescadores (82,3 por ciento). Se concluye que existe una tasa importante de lesiones premalignas correlacionadas con los principales factores de riesgo para desarrollar un cáncer de piel.

Several studies show that skin cancer has increased its incidence en recent decades at national level. Juan Fernández Archipielago, is 674 km from the continent. 44,5 percent of the inhabitants (334 people) were studied and no malignant lesions were found, but a 7,5 percent incidence rate of premalignant lesions was observed showing a higher percentage of males (84 percent) and fishermen (82,3 percent). It is concluded that there is a significant rate of premalignant lesions correlated with the principal risk factors to develop skin cancer.

Manifestaciones alérgicas en el primer año de vida / Allergic manifestations in the first year of life in a an upper middle and upper socioeconomic group of children

There is a lack of information in our country regarding allergies among infants. Objective: Measure the frequency of allergic reactions among children of an upper middle and upper socioeconomic group in Santiago, during their first year of life. Method: Chart information and telephone follow up every 3 months for a period of 12 months. Results: 7.2% of the children presented symptoms suggestive of allergies, and represented the "candidate group". At 12 months, all cases were reviewed, and 3.4% were thought to be probably allergic (48% of candidates). In all cases, the stimulus was thought to be cow's milk. Most frequent were digestive symptoms (88%), while three children had serious illness which included skin, respiratory and digestive symptoms. Treatment included maintenance of nursing when posible, and withdrawal of cow's milk from the diet, with success in all cases. Conclusion: The frequency of allergic type manifestations obtained by phone along the first year of life nearly doubled the number of diagnoses at 12 m of age. Figures obtained in the segment of population assessed were lower than those reported in other countries, mainly in Europe.

En nuestro país falta información sobre las manifestaciones de alergia en lactantes. Objetivo: Medir la frecuencia de manifestaciones alérgicas durante el primer año de vida en una cohorte de nivel socioeconómico medio y alto, nacida de Santiago. Metodología: Seguimiento de cohorte mediante llamadas telefónicas cada tres meses, durante 12 meses e información de fichas de médicos tratantes. Resultados: 7,2% reportaron síntomas potencialmente alérgicos y representaron al "grupo candidato". A los 12 meses, la evaluación caso a caso llevó a considerar que en 3,4% de la cohorte el diagnóstico más probable era alergia (48% de los candidatos); en todos los casos la proteína ofensora fue de leche de vaca. Las manifestaciones digestivas fueron las más frecuentemente informadas (88% de los casos). Tres niños tuvieron manifestaciones graves que incluían piel, aparato respiratorio y digestivo. El tratamiento mantuvo el amamantamiento cuando fue posible y retiró la leche de vaca de la dieta materna. Este tratamiento fue exitoso en todos los casos. Conclusión: La frecuencia de manifestaciones tipo alérgico a lo largo del año fue alrededor del doble de los casos considerados probablemente alérgicos a los 12 meses. Las frecuencias encontradas en el segmento de la población chilena evaluada fueron menores que la informada en otros países, especialmente europeos.

[Leptin-melanocortin system, body weight regulation and obesity]. / Sistema leptina-melanocortinas en la regulación de la ingesta y el peso corporal.

Obesity is a multifactorial disease that is rarely associated to single gene defects. However, due to their direct cause-effect relationships, those genetic defects that cause some forms of monogenic obesity are relevant in the study of mechanisms that contribute to increased energy intake and body fat accumulation. Most of the genes that have been shown to cause monogenic obesity are related to the leptin-melanocortin system. The functionality of this system has been elucidated through natural mutations (Agouti, ob and db) in mice and knock-out models. Mutations related to human monogenic obesity have been described in leptin, leptin receptor, proopiomelanocortin, prohormone convertase 1 or melanocortin receptor 4 genes. Therapy with human recombinant leptin in patients with genetic deficiency of the hormone is an effective medical treatment of obesity, although only applicable to very few families. The use of leptin-melanocortin agonists, drugs to avoid leptin resistance or combinations of treatments with leptin and other satiating peptides are currently being investigated for multifacotiral human obesity.

Sistema leptina-melanocortinas en la regulación de la ingesta y el peso corporal / Leptin-melanocortin system, body weight regulation and obesity

Obesity is a multifactorial disease that is rarely associated to single gene defects. However, due to their direct cause-effect relationships, those genetic defects that cause some forms of monogenic obesity are relevant in the study of mechanisms that contribute to increased energy intake and body fat accumulation. Most of the genes that have been shown to cause monogenic obesity are related to the leptin-melanocortin system. The functionality of this system has been elucidated through natural mutations (Agouti, ob and db) in mice and knock-out models. Mutations related to human monogenic obesity have been described in leptin, leptin receptor, proopiomelanocortin, prohormone convertase 1 or melanocortin receptor 4 genes. Therapy with human recombinant leptin in patients with genetic deficiency of the hormone is an effective medical treatment of obesity, although only applicable to very few families. The use of leptin-melanocortin agonists, drugs to avoid leptin resistance or combinations of treatments with leptin and other satiating peptides are currently being investigated for multifacotiral human obesity (Rev Méd Chile 2009; 137:1225-34).