Dolor y medicina complementaria y acupuntura / Pain and complementary medicine and acupuncture

El objetivo de este artículo es entregar información documentada sobre la situación actual de la Medicina Complementaria y la Acupuntura en Chile, su definición, reglamentación, mecanismos de acción y evidencia. Busca orientar sobre el uso de estas herramientas terapéuticas que son cada vez más solicitadas en el país.

Effectiveness of a training course on the quality assurance of chest radiography in the Philippines.

SETTING: Socio-economically underprivileged areas in urban settings in the Philippines. OBJECTIVE: To determine the effectiveness of a training course in quality chest radiography (CXR). METHODS: A descriptive, observational intervention study in which a questionnaire was administered to X-ray facility staff before training, and CXRs were reviewed before and after a training course for radiological technologists in Manila and Quezon City in the Philippines from 2009 to 2010. Course participants submitted six CXRs, each taken before and after training. Two senior radiological technologists blinded to the CXR profiles assessed the CXRs independently, using an assessment sheet developed by the Tuberculosis Coalition for Technical Assistance. RESULTS: Forty radiological technologists from 10 facilities in Manila City and nine in Quezon City participated in the training. A total of 36 participants submitted the required set of CXRs. The assessment indicated that the training effectively improved the quality of CXRs in terms of identification marking (Wilcoxon matched-pairs signed-rank sum test, P = 0.00), contrast (P = 0.00), sharpness (P = 0.01), artefacts (P = 0.00), and the total score of the factors (P = 0.00). CONCLUSION: The significant improvement in the total score of assessment factors strongly suggests a positive impact of the training course on improving the quality of CXRs.

Tuberculosis Diagnostic Committees' contribution to the National TB Program in Manila and Quezon Cities.

SETTING: The Philippines Tuberculosis Diagnostic Committees (TBDCs) were created to improve the quality of diagnosis of sputum smear-negative chest radiography suggestive of pulmonary tuberculosis (sn-PTB). OBJECTIVE: To determine current TBDC activities, obstacles and possible solutions for improvements in the quality of diagnosis of sn-PTB in Manila City and Quezon City. DESIGN: A descriptive review of TBDC Masterlist records and interviews with TBDC members using a semi-structured questionnaire. RESULTS: A record review of nine of 10 TBDCs was conducted, with interviews of 33 of the 49 current members. During the second and third quarters of 2009, respectively 1142 and 1563 sn-PTB cases were evaluated by the TBDCs in both cities. Of these, 53% in Manila City and 65% in Quezon City were classified as active TB patients. There were significant variations in the percentage of patients recommended for anti-tuberculosis treatment by the TBDC. The participation of its members is based on their expressed commitment to program sustainability. CONCLUSION: TBDC activities contribute to TB control in the Philippines by ensuring the judicious use of resources. Further research to assess the contributions of TBDCs in reducing diagnostic and treatment delays, and factors affecting the sustainability of the TBDCs, is recommended.

Traumatic phacocele.

We report a case of traumatic phacocele in a 42-year-old patient with a history of congenital glaucoma and bilateral goniotomies as an infant. Her left eye had little vision and poorly controlled intraocular pressure but was comfortable until her presentation after blunt trauma. Phacocele or subconjunctival dislocation of the crystalline lens is a rare consequence of blunt trauma, particularly in a patient whose only previous ocular surgery was goniotomy more than 40 years ago.

Osseous manifestations of bacillary angiomatosis.

We report a case of bacillary angiomatosis in a 32-year-old HIV-positive black Haitian male. Radiologic and pathologic features are presented.

Rapid oral desensitization for sulfonamides in patients with the acquired immunodeficiency syndrome.

BACKGROUND: A prospective case series was undertaken in a university teaching hospital. OBJECTIVE: To evaluate the safety and efficacy of two oral desensitization procedures for sulfonamides in patients with the acquired immunodeficiency syndrome (AIDS). METHODS: A rapid oral desensitization protocol to sulfadiazine (2.5 hours) or trimethoprim-sulfamethoxazole (8 hours) was used. Increasing volumes of either drug were given orally every 15 minutes until 1 g of sulfadiazine or 1443.3 mg of trimethoprim-sulfamethoxazole was reached. RESULTS: Nine of 13 (69%) patients were able to tolerate sulfadiazine for a period of 10 to 730 days (mean: 184 days). This was achieved in eight patients after the first attempt, in one after the second attempt. Five patients failed after the first attempts with or without premedications. Two of these five failed despite two attempts. Two patients relapsed 21 days after responding to rapid desensitization. Three patients underwent a successful 5 to 6-day slow desensitization protocol with premedications with high dose corticosteroids and antihistamines despite failures after two attempts with rapid desensitization in two of these patients and relapse in one. CONCLUSIONS: Overall, 11 of 13 (85%) patients were successfully desensitized to sulfonamides using both rapid and slow methods. No life-threatening reactions occurred. Premedications with oral antihistamines and corticosteroids may be needed to control and prevent early occurrences of rash or pruritus during desensitization. In those who fail rapid desensitization, the slow method with premedications is an alternative.

Utilidad clínica del diagnóstico serológico de TBC por un test de ELISA / Clinical useful of the serological diagnosis of TBC by an ELISA test

La tuberculosis es una enfermedad de alta prevalencia. Sería de gran utilidad disponer de un método serológico principalmente en los casos que son positivos sólo por cultivo que demora 30 a 60 días. El inconveniente de la serología radica en la interpretación de los resultados, por lo que se requiere una cuidadosa evaluación de la utilidad clínica del test en un área determinada. Con el objetivo de implementar y determinar la utilidad clínica del diagnóstico serológico de TBC, se estudiaron los sueros de 101 pacientes divididos en 4 grupos; grupo 1: 26 controles sanos, grupo 2: 25 pacientes con patología pulmonar no TBC, grupo 3: 27 tuberculosos baciloscopia (+) y grupo 4: 2 tuberculosos sólo cultivo (+). Se determinó IgG, IgM y IgA anti antígeno A60 por un ELISA indirecto cenocial. Se calculó para cada suero la sumatoria de las 3 clases de inmunoglobulinas y se estableció un punto de corte de 0,45 absorvancia. La sensibilidad para grupo 4 fue de 78 por ciento y la específidad para grupo 2 fue de 88 por ciento. Con estos resultados la aplicación del test como screening de TBC resulta no recomendable con un alto número de falsos (+) que lleva a tratamientos prolongados e innecesarios. En cambio, el test sería de gran utilidad si se emplea en pacientes hospitalizados, en los que se descarten patologías de diagnóstico diferencial de TBC (cáncer, neumonías, cavitarias, etc). A medida que se va descartando otras patologías, (probabilidad pre-test) va aumentando con lo cual el valor predictivo positivo del examen mejora significativamente: si la probabilidad pre-test es 0,3, el valor predictivo positivo es de 74 por ciento y si la probabilidad pre-test es de 0,7, el valor predictivo positivo aumenta a 94 por ciento. En conclusión, el test de ELISA anti-antígeno A60 sería de gran utilidad como otro elemento de apoyo en pacientes con alta probabilidad clínica de TBC y microbiología negativa

Cranial neuropathy heralding otherwise occult AIDS-related large cell lymphoma.

Three HIV-infected patients developed cranial neuropathy as the initial manifestation of an AIDS-related large cell lymphoma. All were homosexual men known to be HIV seropositive for 3 to 4.5 years. At the time of presentation for neurological disease, the CD4 T-lymphocyte count was < 400 cells/mm3 in each. Initial manifestations were retro-orbital headache and oculomotor nerve palsy in two and an abducens nerve palsy in the other. Repeatedly negative CSF cytologies and recovery of the cranial neuropathy obscured the diagnosis. These patients illustrate that cranial neuropathy with HIV infection may herald the presence of an occult large cell lymphoma. Spontaneous or corticosteroid-associated improvement of the cranial neuropathy, absence of abnormalities on brain imaging studies, and negative CSF cytologies do not exclude this diagnosis. We suggest that a diligent and repeated search for lymphoma be considered in HIV-infected patients presenting with cranial neuropathy, including repeated CSF examinations, MRI of brain and spine (T1 and T2) with and without gadolinium enhancement, chest and abdominal CT scans, and bone marrow biopsy.

[Protein and energy requirements in patients with severe head injury]. / Requerimientos caloricos y proteicos en pacientes con traumatismoencefalocraneano severo.

The aim of the present study was to assess the effect of severe head injury over resting energy expenditure and nitrogen losses. Eight patients with severe head trauma (mean Glasgow scale of 4.9 +/- 1.6), subjected to emergency craniotomy were studied; four patients had septic complications and none received steroids. Energy expenditure was measured using indirect calorimetry and nitrogen losses were assessed measuring 24 h urea nitrogen excretion on days 1, 4, 7 and 10 of the postoperative period. Twelve healthy males composed the control group. Measured energy expenditure in patients, evaluated in 22 occasions, was 35 +/- 9.8 Kcal/kg/day or 145 +/- 41% of the estimation according to Harris-Benedict equations, compared to 22.0 +/- 4.6 Kcal/kg/day or 89.9 +/- 17.5% in the control group (p < 0.001). 24 h urinary urea nitrogen excretion in patients was 18 +/- 12 g/day (range 5.2-46.9) and the catabolic index was 7.4 +/- 13.5. It is concluded that, due to the great individual variability in measured energy expenditure in these patients and their hypercatabolism, indirect calorimetry and nitrogen balance studies become useful tools to perform an adequate nutritional support.

An outbreak of tuberculosis caused by multiple-drug-resistant tubercle bacilli among patients with HIV infection.

OBJECTIVE: To evaluate a nosocomial outbreak of tuberculosis caused by multiple-drug-resistant bacilli among patients with tuberculosis and HIV infection. DESIGN: A case-control study. PATIENTS: Patients with HIV infection and culture-proven tuberculosis. MEASUREMENTS: Patient characteristics, date of diagnoses of HIV infection and disease, date of diagnosis of tuberculosis, Mycobacterium tuberculosis susceptibility results, and medical center contact. RESULTS: Sixty-two patients who had tuberculosis caused by multiple-drug-resistant bacilli (cases) and 55 patients who had tuberculosis caused by susceptible or single-drug-resistant bacilli (controls) were identified. Controls were more likely to be black (odds ratio, 0.4; 95% CI, 0.2 to 0.9) or Haitian (odds ratio, 0.2; CI, 0.1 to 0.6) compared with cases, who were more likely to be homosexual men (odds ratio, 2.9; CI, 1.3 to 6.4). Forty-four cases (71%) had previous contact with an HIV clinic compared with 15 controls (27%) (P less than 0.0001). Cases were more likely to have had AIDS (odds ratio, 7.7; CI, 1.5 to 53.7), to have been hospitalized on an HIV ward (odds ratio, 8.3; CI, 2.3 to 29.7), to have been seen in an HIV clinic (odds ratio, 7.8; CI, 3.4 to 18.1), to have received intravenous therapy in an HIV clinic (odds ratio, 13.0; CI, 4.6 to 37.0), or to have received inhalation pentamidine in an HIV clinic before a diagnosis of tuberculosis was made. Multiple logistic regression analysis showed that a diagnosis of AIDS (odds ratio, 11.2; CI, 3.1 to 40.6) and HIV clinic visits (odds ratio, 13.0; CI, 2.7 to 63.7) before a diagnosis of tuberculosis were significantly associated with tuberculosis caused by multiple-drug-resistant bacilli. Using susceptibility patterns and appointment dates, we found that 22 cases had previous contact with a person who had tuberculosis caused by multiple-drug-resistant bacilli in the HIV clinic. CONCLUSIONS: Nosocomial transmission of M. tuberculosis from other HIV-infected patients with tuberculosis caused by multiple-drug-resistant bacilli can occur. These findings have serious public health implications and demand strict adherence to acid-fast bacilli isolation precautions.

Clinical presentation and outcome of patients with HIV infection and tuberculosis caused by multiple-drug-resistant bacilli.

OBJECTIVE: To determine the clinical manifestations of patients with human immunodeficiency virus (HIV) infection and tuberculosis caused by multiple-drug-resistant bacilli compared with those with single-drug-resistant or susceptible bacilli. DESIGN: Descriptive, case-control, and cohort studies. SETTING: A large urban teaching hospital. PATIENTS: Sixty-two patients with tuberculosis caused by multiple-drug-resistant bacilli (cases) and 55 patients with tuberculosis caused by single-drug-resistant or susceptible bacilli (controls). MEASUREMENTS: Characteristics of clinical presentation, radiographs, pathologic abnormalities, antituberculosis treatment, and clinical course. RESULTS: Twenty cases (32%) had concomitant pulmonary and extrapulmonary disease at presentation compared with 9 controls (16%; odds ratio, 2.4; 95% CI, 1.0 to 5.9). More cases had alveolar infiltrates (76%; odds ratio, 3.6; CI, 1.2 to 11.4), interstitial infiltrates with a reticular pattern (67%; odds ratio, 7.8; CI, 1.0 to 83.5), and cavitations (18%; odds ratio, 6.6; CI, 0.8 to 315.3) on initial chest radiographs compared with controls (49%, 19%, and 3%, respectively). Pathologic specimens from cases showed extensive necrosis, poor granuloma formation, marked inflammatory changes with a predominance of neutrophils, and abundant acid-fast bacilli. Twenty-five cases received two or more effective antituberculosis drugs for more than 2 months. Only 2 cases had three consecutive negative cultures for Mycobacterium tuberculosis; one patient died within 1 day of the last negative culture, and the other had positive cultures 496 days later. The remaining 23 cases had persistently or intermittently positive cultures despite therapy. The clinical course of these cases suggested overwhelming miliary tuberculosis with involvement of the lungs (77%), pleura (15%), stool (34%), meninges (13%), bone marrow (16%), blood (10%), lymph nodes (10%), and skin (8%). The median survival time was 2.1 months for cases compared with 14.6 months for controls (P = 0.001, log-rank test). CONCLUSIONS: Tuberculosis caused by multiple-drug-resistant bacilli in patients with HIV infection is associated with widely disseminated disease, poor treatment response with an inability to eradicate the organism, and substantial mortality.

Infección postoperatoria en neurocirugía / Postoperatory infection in neurosurgery

Se revisan 120 casos de infecciones postoperatorias de 4.348 intervenciones quirúrgicas entre los años 1986 y junio de 1988. De éstos 2.764 fueron operaciones de neurocirugía electiva con 87 infecciones y 1.584 intervenciones quirúrgicas de urgencia con 33 infecciones postoperatorias. Un 45% correspondieron a infección de la herida operatoria, 33% a infección del sistema derivativo de líquido cefalorraquídeo, 10% a empiema subdural, 10% a meningitis y 2% a absceso cerebral. Se aisló germen en el 86% de los casos. Los más frecuentes fueron el estafilococo epidermidis y estafilococo aureus. No se demostró un aumento de la incidencia de infección postoperatoria por la edad del paciente, corticoides preoperatorios, tratamiento anticonvulsivante, uso de microscopio operatorio, cirugía de urgencia y uso de metilmetacrilato. Existe un aumento de la incidencia de infecciones en relación con la fístula de LCR, concomitancia de infección intercurrente, abertura de los senos paranasales, uso de drenaje postoperatorio, instalación de sistema derivativo de LCR, cirugía transesfenoidal y por craneosinostosis (P<0,001). Se demostró que las infecciones postoperatorias aumentan en forma significativa la duración y el costo de la hospitalización postoperatoria

Prevalencia de seropositividad al VIH en pacientes tuberculosis activos de la Región Metropolitana / Prevalence of HIV seropositivity among patients with active tuberculosis in Santiago de Chile

La detección sistemática de casos de SIDA se ha dirigido hacia grupos de riesgo: homosexuales, drogadictos endovenosos y promiscuos sexuales. La alta frecuencia de morbilidad por tuberculosis que presentan los pacientes con SIDA hace elegibles a los enfermos de tuberculosis para buscar seropositividad al VIH. La prevalencia de tuberculosis activa en la Región Metropolitana es de más de 1000 casos los que fueron estudiados con estudio serológico para el VIH. Para ello se les tomó una muestra de sangre en las Centrales de Tratamiento de tuberculosis de los 6 Servicios de Salud de la Región Metropolitana entre los días 16 de agosto y 1 de septiembre de 1989. Se examinaron 1159 muestras de sangre provenientes de igual número de pacientes con tuberculosis activa en tratamiento. Se obtuvieron 4 muestras positivas y 1 indeterminada. Además, otras 5 muestras dieron el resultado del test de ELISA que estaba repetidamente en el límite de la negatividad. Estos pacientes fueron seguidos con nuevas muestras. Los casos detectados se incorporaron a los programas de enfermedades de transmisión sexual de los Servicios de Salud

Nosocomial transmission of tuberculosis from unsuspected disease.

Tuberculosis remains an occupational hazard for hospital employees. A case of acute generalized tuberculosis occurring in a patient with a malignancy who had received corticosteroids was undetected during life and during a gross autopsy examination. Histologic examination of tissue performed one month later was necessary to establish the diagnosis. Of susceptible hospital staff members who were exposed to the index case, infection developed in nine of 56 (16 percent) compared with three of 333 (0.9 percent) unexposed personnel with similar risk but no known exposure (p less than 0.001). This was a 17.8-fold increase in the infection rate for the exposed group. Three employees infected had evidence of active disease: two had pleural effusions and one had cavitary pulmonary infiltrates; six were asymptomatic. The high rate of infection was associated with inadequate air ventilation and exposure to uncontained infectious aerosol. Preventive therapy with isoniazid, high-change-ventilating systems, ultraviolet radiation, and primary barrier systems are recommended methods to reduce the infection risk.

Bases microanatómicas para los accesos quirúrgicos a la región pineal / Microanatomical bases for surgical ways to the pineal region

Se estudia la microanatomía y se comparan los diferentes accesos quirúrgicos a la región pineal en 25 cerebros no fijados e inyectadas las arterias y venas con resina coloreada. Los accesos infratentorial supracerebeloso y transtentorial sub-occipital se efectúan por debajo del sistema venoso profundo. El acceso infratentorial es útil en las lesiones localizadas en el vermis, lámina cuadrigémina con mínima extensión a la parte posterior del tercer ventrículo, fisura cerebelo mesencefálica y cisternas ambiens. El acceso transtentorial estaría indicado en las lesiones ubicadas en la lámina cuadrigémina con extensión ipsilateral al vermis, fisura cerebelo mesencefálico y cisterna ambiens con mínima extensión a la parte posterior del tercer ventrículo. En el acceso transcalloso es necesario dividir el cuerpo calloso o el splenium y la desección se efectúa entre las venas cerebrales internas y basales de Rosenthal. Es útil en las lesiones localizadas por encima del sistema venoso profundo con extensión hacia la parte posterior de tercer ventrículo y la lámina cuadrigémina y que no se extiende hacia la fosa posterior o las cisternas ambiens. El acceso transventricular es útil para las lesiones con extensión lateral e hidrocefalia importante

Cryptococcal peritonitis. Report of a case and review of the literature.

Cryptococcus neoformans is a rare cause of peritonitis; only four cases have been reported in the literature. A 63-year-old man in whom isolation of C. neoformans from ascitic fluid provided the initial clue to disseminated cryptococcosis is described. Review of this case and those previously reported reveals striking association between cryptococcal peritonitis and hepatic disease.