Mortalidad materna: análisis médico forense / Maternal mortality: forensic medical analysis

Resumen:La Organización Mundial de la Salud (OMS) define la muerte relacionada al embarazo como el deceso de una mujer durante dicho embarazo, la labor de parto o en los cuarenta y dos días siguientes al nacimiento, independientemente de la duración o del lugar donde tuvo lugar. Esta definición incluye muertes por abortos o embarazos ectópicos pero excluye las causas incidentales. Aunque se considera que el embarazo es un proceso biológico normal, se asocia con cierta cantidad de cambios anatómicos o fisiológicos que incrementan el riesgo de muerte, especialmente en aquellas mujeres mayores de 35 años, afro americanas o con un control prenatal deficiente.Esta revisión pretende conceptualizar la mortalidad materna y definir sus principales causas y factores de riesgo, con especial énfasis en aspectos forenses

AbstractWorld Health Organitation defines the death related to pregnancy as the death of a woman during pregnancy, labor or in the next 42 days after the end of pregnancy state, regardless the duration or place where its taking place. This definition includes deaths from abortion or ectopic pregnancy but excludes those from incidental causes.Even though pregnancy is consider a normal biological process, it is associated with a certain amount of anatomic and physiological changes that increase the risk of death, especially in those woman over 35 years old, African American and those with a pour prenatal care.This review pretends to conceptualize maternal mortality, to define its main causes and risk factors, with special emphasis in forensic issues.

Inimputabilidad por trastornos mentales en el sistema legal / Criminal responsibility by mental disorders in the legal system

Resumen:El código penal costarricense admite la posibilidad de eximir de responsabilidad penal a los individuos que presentan algún trastorno mental en el momento del acto delictivo. La psiquiatría forense tiene como uno de usus fines determinar el grado de imputabilidad de todo sujeto a quien se le presuma afectado de enfermedad psíquica. La intervención es objetiva y esto se consigue a través de la entrevista y el examen del estado mental del sujeto. Durante el interrogatorio se evalúa la conciencia, la lucidez, el raciocinio, el jucio y la impulsividad. Se han determinado enfermedades que se excluyen de responsabilidad penal total o parcial como la esquizofrena, la paranoia en forma de delirio y la epilepsia en sus diferentes variables. Asimismo, se hace referencia al trastorno mental transitorio (TMT) que se da cuando el curso de la alteración implica un estado de recuperación de las facultades mentales superiores y el acusado puede retornar a una condición de normalidad psíquica.

Abstract:Costa Rica's penal code allows the possibility of exempting from criminal responsibility to individuals who have a mental disorder at the time of the criminal act. Forensic psychiatry aims to determine the degree of accountability of every person who is presumed will be affected by mental illness. The intervention is objective and this is achieved through the interview and mental exam. At the examination, the professional has to evaluate consciousness, lucidity, reasoning, judgment and impulsiveness. There are certain diseases that are excluded from total or partial criminal liability as different variables of schizophrenia, paranoia, delirium and epilepsy. In addition, referring to transient mental disorder (TMD), it occurs when the course of the alteration involves a recovery state of the mental faculties and the person can return to a normal mental condition.

Hepatotoxicidad por sustancias de origen botánico / Hepatotoxicity substances of botanical origin

Existe un interés creciente en prevenir la enfermedad y mejorar la salud, por lo que se han desarrolladosuplementos nutricionales percibidos por la población como inofensivos, sin embargo, las plantas son productorasde sustancias químicas que pueden inducir a daño hepático. Los suplementos usados para fisicoculturismo yreducción de peso son los productos naturales que más han reportado hepatotoxicidad en los últimos tiempos.El diagnóstico de la lesión hepática asociado a productos naturales debe hacerse de forma sistematizada ydebe incluir información sobre el inicio del consumo del producto natural, el periodo de tratamiento y el periodode latencia. Comúnmente, el cuadro clínico es agudo y los síntomas en su mayoría son inespecíficos. Se handefinido criterios de hepatotoxicidad a través de la medición de los niveles de la alanina aminotransferasa (ALT)y la fosfatasa alcalina (FA) y la relación entre estas dos variables. Con la cesación del agente implicado, lossignos clínicos generalmente ceden y se da una marcada disminución de los niveles de las enzimas hepáticas. Lapositividad de la reexposición no intencionada del producto es el gold standard para confirmar la hepatotoxicidadpor sustancias naturales. No existen hallazgos histológicos específicos de lesión hepática, por lo que la biopsiano forma parte de los algoritmos para diagnósitico. Con el fin de objetivizar la valoración de efectos adversos seutiliza la escala de CIOMS/RUCAM (Council for International Organizations of Medical Sciences/Roussel UclafCausality Assesment Method) que permite determinar la probabilidad de lesión hepática secundaria al producto.Además de la hepatotoxicidad directa producida por sustancias de origen botánico, se han descrito interaccionesentre medicamentos convencionales y los productos herbales, por lo que el médico tratante debe indagar sobreel uso de estos productos...

here is a growing interest in prevention of diseases and improvement of health. That is why nutritional supplementshave been developed and perceived by people as harmless, but plants produce chemical substances that can leadto liver damage. The supplements used for bodybuilding and weight reduction constituted the most common naturalproducts accounting for hepatotoxicity in last times. The diagnosis of liver injury associated to natural productsshould be done in a systematic way and should include information about the first use of the substance, the treatmentperiod and latency. Commonly, the clinic is an acute condition with nonspecific symptoms. The measurement oflevels of alanine aminotransferase (ALT), alkaline phosphatase (PA) and relationship between these variables serveas criteria of liver injury. With cessation of the agent involved, clinical signs usually yield and there is a markeddecrease in the liver biomarkers levels. Positive results for no intentional reexposure is the gold standard to confirmhepatotoxicity to natural substances. There are no specific histologic findings for liver damage, so biopsy cannotbe used for diagnosis. In order to objectify the adverse effects we use the CIOMS/RUCAM Scale (Council forInternational Organizations of Medical Sciences/ Roussel Uclaf Causality Assesment Method). In addition to thepotential for direct hepatotoxicity, some of the herbs may have interactions with certain prescription medications, sophysicians should ask for using natural products and prevention of concomitant use...

Abordaje del abuso sexual infantil: combatiendo la revictimizacion / Addressing child sexual abuse: fighting revictimization

Cuando el médico tiene poca experiencia o no suele enfrentarse a este tipo situaciones, el diagnóstico de abuso sexual es difícil y cuando es un niño o una niña es aún más complicado. En la dinámica de estos eventos intervienen diversos factores. Al evaluar al niño o niña afectada es indispensable evitar la revictimización, que al tomar lugar se convierte en una nueva agresión, para lograr lo anterior se requiere que sea un equipo interdisciplinario y con experiencia, el que lleve a cabo la evolución. Se debe evitar la duplicación de interrogatorios, entrevistas y exploración física. En los casos de abuso crónico, se puede prescindir del examen físico. La relación predominante en los casos de abuso es la de padre e hija y el tipo de agresión más frecuente es el tocamiento en casi el 90% de los casos. Premisa que nos lleva a considerar que es frecuente encontrar el área genito-anal totalmente indemne durante la exploración física. Las consecuencias de sucesos como estos dependerán del apoyo familiar, el grado de culpabilidad que se genere en el niño y del abordaje y las estrategias que se pongan en marcha para enfrentar la agresión.

When the doctor has little experience, the diagnosis of sexual abuse is difficult and when the victim is a child, is even more complicated. The dynamic of these events involved several factors. When assessing the affected youth it is essential to avoid re-victimization, which becomes a new aggression. In order to achieve this is required an interdisciplinary and experienced team to develop the analysis. Avoid duplication of interrogations, interviews and physical examination. In cases of chronic abuse, the physicians can dispense physical examination. The predominant relationship in cases of abuse is father and daughter and the most frequent type of aggression is touching, almost in 90% of cases. Reason why is not uncommon to get no abnormal findings in physical examination. The consequences of these kinds of events will depend on family support, the degree of culpability that is generated on the child and the approach and the implemented strategies to deal with aggression.

Escurrimiento oleoso anaranjado o «keriorrea», («orange oily anal leakage»): una nueva enfermedad ligada a cambios de hábito alimentario / Orange oily anal leakage: a new entity linked to dietary changes

Introducción Se acumula información relativa a casos clínicos de excepción, relacionados con la ingesta de determinados alimentos y con su forma de consumo, los que presentan un cuadro caracterizado por descarga anal, las más de las veces inadvertida, de líquido anaranjado oleoso que alarma a los pacientes. Método Se registran los antecedentes de una serie de casos recogidos de forma consecutiva, que presentan un cuadro clínico caracterizado por descarga masiva e involuntaria, sin sensación esfinteriana, de deposiciones de aspecto oleoso anaranjado después de ingerir pescado en la gran mayoría de los casos, de cocina japonesa. Resultados Se evaluaron 11 pacientes con el cuadro clínico mencionado. Cuatro mujeres y siete de ellos varones. Edad promedio de 47,3 años. Cuatro pacientes tenían estudio colonoscópico previo sin lesiones. La keriorrea se produciría por acumulación de «ésteres cerosos» no digeribles, presentes en algunos peces escolares, algunos de ellos incorporados recientemente a la ingesta cruda en forma de sashimi o mal llamados mero cocido. Estos aceites, al ser no absorbibles ni digeribles, se filtran insensiblemente desde el recto. También se postularía una disfunción esfinteriana secundaria a toxinas. En ocasiones se produce la misma sintomatología por consumo de estas especies en su forma cocida. El antecedente epidemiológico de ingesta previa de pescado de las características mencionadas, los datos clínicos y lo autolimitado del cuadro, permiten el diagnóstico sin necesidad de realizar mayores estudios. Conclusión Se describe y comunica una serie de casos, de enfermedad recientemente descrita, asociada a cambios de hábito alimentario, de curso benigno y autolimitado. Nos parece importante que este cuadro sea reconocido por los clínicos, para informar a los pacientes y manejar correctamente estos casos(AU)

Introduction Information is accumulating on exceptional cases of oily orange anal leakage, probably caused by certain foods and their form of consumption. The leakage is usually inadvertent and is worrisome for patients. Method Clinical data was gathered on a case series presenting with massive and inadvertent orange oily anal leakage, without sphincter sensation, causing the patients to feel alarmed. This condition usually occurs after eating fish, especially Japanese cuisine. Results Eleven patients were included (four women and seven men). The mean age was 47.3 years. Colonoscopy had previously been performed in four patients, with normal results. The symptoms, described as keriorrhea, were probably produced by accumulation of indigestible "wax esters", es Mero present in some oily fish, recently incorporated in raw fish dishes (sashimi) or as Japanese Mero sea bass. These oils, which cannot be absorbed or digested, accumulate in the rectum and may also filter spontaneously and induce toxin-related sphincter dysfunction. The same symptoms are sometimes produced after consumption of cooked versions of these species. The diagnosis is given by clinical data, prior ingestion of these types of fish and the self-limiting nature of the symptoms, without the need for further investigations. Conclusion We describe a case series of a recently described entity associated with dietary changes. This entity is benign and self-limiting. Clinicians should be familiar with the symptoms to inform patients correctly and avoid unnecessary laboratory studies(AU)

[Orange oily anal leakage: a new entity linked to dietary changes]. / Escurrimiento oleoso anaranjado o "keriorrea", ("orange oily anal leakage"): una nueva enfermedad ligada a cambios de hábito alimentario.

INTRODUCTION: Information is accumulating on exceptional cases of oily orange anal leakage, probably caused by certain foods and their form of consumption. The leakage is usually inadvertent and is worrisome for patients. METHOD: Clinical data was gathered on a case series presenting with massive and inadvertent orange oily anal leakage, without sphincter sensation, causing the patients to feel alarmed. This condition usually occurs after eating fish, especially Japanese cuisine. RESULTS: Eleven patients were included (four women and seven men). The mean age was 47.3 years. Colonoscopy had previously been performed in four patients, with normal results. The symptoms, described as keriorrhea, were probably produced by accumulation of indigestible "wax esters", es Mero present in some oily fish, recently incorporated in raw fish dishes (sashimi) or as Japanese Mero sea bass. These oils, which cannot be absorbed or digested, accumulate in the rectum and may also filter spontaneously and induce toxin-related sphincter dysfunction. The same symptoms are sometimes produced after consumption of cooked versions of these species. The diagnosis is given by clinical data, prior ingestion of these types of fish and the self-limiting nature of the symptoms, without the need for further investigations. CONCLUSION: We describe a case series of a recently described entity associated with dietary changes. This entity is benign and self-limiting. Clinicians should be familiar with the symptoms to inform patients correctly and avoid unnecessary laboratory studies.

Post-lumpectomy intracavitary retention and lymph node targeting of (99m)Tc-encapsulated liposomes in nude rats with breast cancer xenograft.

Liposomes are recognized drug delivery systems with tumor-targeting capability. In addition, therapeutic or diagnostic radionuclides can be efficiently loaded into liposomes. This study investigated the feasibility of utilizing radiotherapeutic liposomes as a new post-lumpectomy radiotherapy for early-stage breast cancer by determining the locoregional retention and systemic distribution of liposomes radiolabeled with technetium-99m ((99m)Tc) in an orthotopic MDA-MB-231 breast cancer xenograft nude rat model. To test this new brachytherapy approach, a positive surgical margin lumpectomy model was set up by surgically removing the xenograft and deliberately leaving a small tumor remnant in the surgical cavity. Neutral, anionic, and cationic surface-charged fluorescent liposomes of 100 and 400 nm diameter were manufactured and labeled with (99m)Tc-BMEDA. Locoregional retention and systemic distribution of (99m)Tc-liposomes injected into the post-lumpectomy cavity were determined using non-invasive nuclear imaging, ex vivo tissue gamma counting and fluorescent stereomicroscopic imaging. The results indicated that (99)Tc-liposomes were effectively retained in the surgical cavity (average retention was 55.7 ± 24.2% of injected dose for all rats at 44 h post-injection) and also accumulated in the tumor remnant (66.9 ± 100.4%/g for all rats). The majority of cleared (99m)Tc was metabolized quickly and excreted into feces and urine, exerting low radiation burden on vital organs. In certain animals (99m)Tc-liposomes significantly accumulated in the peripheral lymph nodes, especially 100 nm liposomes with anionic surface charge. The results suggest that post-lumpectomy intracavitary administration of therapeutic radionuclides delivered by 100-nm anionic liposome carrier is a potential therapy for the simultaneous treatment of the surgical cavity and the draining lymph nodes of early-stage breast cancer.

Interventional therapy of head and neck cancer with lipid nanoparticle-carried rhenium 186 radionuclide.

PURPOSE: Minimally invasive interventional cancer therapy with drug-carrying lipid nanoparticles (ie, liposomes) via convection-enhanced delivery by an infusion pump can increase intratumoral drug concentration and retention while facilitating broad distribution throughout solid tumors. The authors investigated the utility of liposome-carrying beta-emitting radionuclides to treat head and neck cancer by direct intratumoral infusion in nude rats. MATERIALS AND METHODS: Four groups of nude rats were subcutaneously inoculated with human tongue cancer cells. After tumors reached an average size of 1.6 cm(3), the treatment group received an intratumoral infusion of liposomal rhenium-186 ((186)Re) (185 MBq [5 mCi]/cm(3) tumor). Three control groups were intratumorally infused with unlabeled liposomes, unencapsulated (186)Re-perrhenate, or unencapsulated intermediate (186)Re compound ((186)Re-N,N-bis[2-mercaptoethyl]-N',N'-diethyl-ethylenediamine [BMEDA]). In vivo distribution of (186)Re activity was measured by planar gamma-camera imaging. Tumor therapy and toxicity were assessed by tumor size, body weight, and hematology. RESULTS: Average tumor volume in the (186)Re-liposome group on posttreatment day 14 decreased to 87.7% +/- 20.1%, whereas tumor volumes increased to 395.0%-514.4% on average in the other three groups (P< .001 vs (186)Re-liposome). The (186)Re-liposomes provided much higher intratumoral retention of (186)Re activity, resulting in an average tumor radiation absorbed dose of 526.3 Gy +/- 93.3, whereas (186)Re-perrhenate and (186)Re-BMEDA groups had only 3.3 Gy +/- 1.2 and 13.4 Gy +/- 9.2 tumor doses, respectively. No systemic toxicity was observed. CONCLUSIONS: Liposomal (186)Re effectively treated head and neck cancer with minimal side effects after convection-enhanced interventional delivery. These results suggest the potential of liposomal (186)Re for clinical application in interventional therapy of cancer.