Tratamiento multidisciplinario de aneurisma aórtico con anatomía hostil / Multidisciplinary treatment of aortic aneurism with hostile anatomy

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A novel biweekly schedule with cisplatin and gemcitabine in advanced non-small cell lung cancer.

A new schedule with cisplatin and gemcitabine administered biweekly was prospectively evaluated in stage IIIB or IV non-small cell lung cancer. We report the interim analysis of the safety and efficacy with the first 23 patients included. The mean age was 60. Thirteen patients (56.5%) were stage IIIB and 10 (43.5%) were stage IV The overall response rate was 47.8%: 69.2% for stage IIIB and 20% for stage IV The median survival among the 23 patients was 33 weeks and 1-year survival was 39%: 53.8% for stage IIIB and 20% for stage IV Seventy-seven cycles (154 administrations) were given. The mean number of cycles/patient was 3.3 (range: 1 to 6). Of the 154 administrations, 26 were delayed 1 week for recovery from toxicity. The dose intensity (Hryniuk criteria) was 94% of the planned dose. There was one toxic death with grade 4 thrombocytopenia and grade 4 esophagitis. In two patients, grade 3-4 vascular toxicity was observed, with distal arterial ischemic changes in the lower extremities. There were three (3.9%) episodes of grade 2 neutropenia, one (1.7%) of grade 3 and another one of grade 4. No cases of febrile neutropenia were seen. Predominant nonhematologic toxicities were asthenia and nausea/vomiting. This schedule of cisplatin and gemcitabine has a good therapeutic index and, as it is active, enrollment is ongoing to complete the second part of the study.

Identification of an extracellular plasmin binding protein from nephritogenic streptococci.

Examination of the extracellular products of nephritis(+) and nephritis(-) group A streptococci revealed the presence of a 46-kD protein secreted by nephritogenic strains that binds to human plasmin. Immunological data revealed that this protein, called nephritis plasmin binding protein (NPBP), is not related to group A streptokinase nor to a recently described streptococcal dehydrogenase protein. The binding of human plasmin to this protein can be blocked by epsilon-amino caproic acid, indicating the importance of lysine groups in the binding process. Mutanolysin extracts of cell walls from these nephritogenic strains probed with anti-NPBP antibody were negative for cell wall-bound NPBP. Serological data with acute poststreptococcal glomerulonephritis (APSGN) and acute rheumatic fever sera indicated that the protein reacts preferentially with APSGN sera. Amino acid sequence analysis and immunological reactivity suggest NPBP is the streptococcal pyrogenic exotoxin B precursor, also previously described as zymogen (streptococcal proteinase precursor). The secretion of both group A streptokinase and a secreted plasmin binding protein in the same nephritogenic strain raises an intriguing hypothesis of the mechanisms of action of this protein in APSGN.

Neumopatías en el nivel primario de atención / Neumopathies in primary care level

Se analiza la cantidad de consultas por neumopatías (neumonias, bronconeumonias, neumonitis y un grupo que se registra como neumopatía) de menores de 15 años ocurridas entre 1989 y 1991 en un consultorio del área Norte de Santiago. Se encontró que de las 65.574 consultas otorgadas, un 2,4% correspondieron a neumopatías. Casi dos tercios son bronconeumonias, 17,2% neumonía y 6,5% neumonitis, el resto no tenía diagnóstico específico. La incidencia para los tres años es de 31,3 por mil. No se observó diferencia por sexo aunque sí por edad. Es un problema frecuente entre los lactantes de 6 a 11 meses (26,5%) y de 12 a 23 meses (16,8%) el que disminuye con la edad. El riesgo es de 105,2% en menores de 2 años, 35,1% en los niños de edad preescolar y sólo 9,5% en los de edad escolar. Es una patología con variación estacional. Aumenta entre Mayo y Agosto y alcanza su máxima frecuencia en el mes de Julio (23,0%), disminuyendo a medida que se acerca el verano. En relación al total de consultas mensuales, las neumopatías varían entre 1,77% y 0,95% en el período de Diciembre a Junio, alcanza el máximo de 6,1% en Julio. Entre Agosto y Noviembre la proporción varía alrededor de 3%. El comportamiento de estas neumopatías sugiere especial preocupación por los menores de dos años, y un reforzamiento de atención de Mayo a Agosto

Bile duct abnormalities in the acquired immune deficiency syndrome.

Pathological changes in the liver have been described in patients with acquired immune deficiency syndrome; however, lesions of the bile ducts have not been noted. We report 2 patients with intrahepatic bile duct abnormalities, one having sclerosing cholangitis of the large ducts. We discuss the possibility that these changes are secondary to opportunistic infection or are induced more directly by immunologic mechanisms.

Comparison of dietary protein with an oral, branched chain-enriched amino acid supplement in chronic portal-systemic encephalopathy: a randomized controlled trial.

A randomized study was conducted in 37 hospitalized patients at six cooperating hospitals in which protein-intolerant cirrhotic patients were fed increasing amounts of either dietary protein or a branched-chain enriched amino acid solution (BCAA) until they attained an intake of 80 gm protein per day or equivalent or until they developed stage 2 encephalopathy. All patients initially received 20 gm of dietary protein for 1 week, after which 20 gm of protein or BCAA were added weekly. Nitrogen balance improved from negative to positive in all patients in whom it was measured and increased equally in both groups. Seven of the 20 patients in the protein group and 1 of 17 in the BCAA group developed encephalopathy of stage 2 or greater (p less than 0.05). Changes in each component of the portal-systemic encephalopathy syndrome were compared, and differences were statistically significant for mental status grade (p less than 0.01), asterixis (p less than 0.05), Portal-systemic encephalopathy index (p less than 0.01), but insignificant for Number Connection Test, EEG or ammonia. Plasma amino acid profiles showed an increase in BCAA in the study group. Thus, oral BCAA supplements appear to induce positive nitrogen balance to approximately the same degree as an equivalent amount of dietary protein without inducing encephalopathy as frequently.

Hepatic abscess due to Yersinia enterocolitica without bacteremia.

A 71-yr-old diabetic patient was evaluated because of right upper quadrant pain. He was found to have a large hepatic abscess secondary to Yersinia enterocolitica infection. He lacked clinical evidence of bacteremia or gastrointestinal infection. It is postulated that Yersinia enterocolitica reached the liver through the portal system from an inapparent intestinal infection. This is the first reported case of a liver abscess secondary to Yersinia enterocolitica without evidence of systemic infection.

Whipple's disease, successful response to sulfamethoxazole-trimethoprim.

Because of allergy to penicillin and intolerance to tetracycline, a 47-year old man, known to have Whipple's disease, was treated with sulfamethoxazole-trimethoprim, one tablet two times a day for six months. The patient has remained in remission one year after medication was discontinued. Sulfamethoxazole-trimethoprim may be the treatment of choice for Whipple's disease.

Asymptomatic primary biliary cirrhosis.

Ten asymptomatic patients with biochemical, immunologic, and histologic features of primary biliary cirrhosis are described. Their liver disease was first suggested by an elevated alkaline phosphatase level upon routine biochemical screening tests. Increasing awareness of this disease has led to its increased detection in asymptomatic patients. It is this group of asymptomatic patients from whom we will learn more about the natural history of primary biliary cirrhosis.

Factitial bleeding: successful management with psychotherapy.

A young female nurse presented with unusual upper and lower-gastrointestinal bleeding, shown to be factitial. Following detection, she was successfully confronted and treated with psychotherapy. A plan for successful management of the Munchausen syndrome is discussed.

Rod-shaped organism in the liver of a patient with Whipple's disease.

Histological review of a liver biopsy from a patient with known Whipple's disease revealed a prominence of Kupffer cells containing PAS-positive granules. Electron microscopy revealed rod-shaped organisms in the Kupffer cells but the presence of these structures were not associated with overt liver injury. This is thought to be the first reported demonstration of these bacillary bodies in this location.

Peyronie's disease and sclerosing cholangitis in a patient with ulcerative colitis.

A 51-year-old patient with a 30-year history of ulcerative colitis developed sclerosing cholangitis and later Peyronie's disease. The occurrence of these diseases in the same patient supports the view of an immunological origin of these associated disorders.

Erythromycin ethylsuccinate-induced cholestasis.

A 52-year-old Caucasian female developed abdominal pain, fever, and jaundice after erythromycin ethylsuccinate administration. Similar symptoms followed the administration of the same drug 5 mo earlier. It is believed that this is the first published case of erythromycin ethylsuccinate-induced cholestasis.

Alcohol and liver disease.

It has recently been shown that alcohol may produce liver damage even in the presence of adequate nutrition. Absolute intake, regardless of the type of alcoholic beverage consumed, appears to be the important determinant of whether liver damage will occur. The spectrum of liver injury produced by alcohol includes fatty liver, hepatitis, and cirrhosis. Liver biopsy is necessary for confirmation and to determine prognosis. Therapy includes abstinence, supportive care and nutritional replacement.

Extrahepatic malignancy in chronic liver disease: report of six cases.

Six patients are described with chronic liver disease, 3 with primary biliary cirrhosis and 3 with chronic active hepatitis, all of whom developed malignant disease in organs other than the liver. Two malignancies were mixed histiocytic-lymphocytic lymphomas. All patients had received corticosteroid or azathioprine therapy. Specific lymphocyte counts and immunoglobulin and antibody determinations failed to reveal a consistent pattern of abnormality to recognize the patient at risk. Several diseases in which the immune responsiveness is disturbed seem to have this potentiality in common, especially if therapy that further alters immunological reactivity is given.

Intrahepatic cholestasis after griseofulvin administration.

The occurrence of cholestatic jaundice in a patient receiving griseofulvin is described. The clinical manifestations, laboratory features, and pathological lesion of drug-induced hepatotoxicity are discussed. Complete recovery followed the discontinuation of drug administration. The potential hepatotoxicity of griseofulvin and the importance of close monitoring of liver function studies in patients receiving this drug are emphasized.

Renal response to secretin.

The effect of Jorpes secretin on the urinary volume, pH, and excretion of sodium, potassium, chloride, bicarbonate, titratable acidity, ammonia and phosphate was studied in five healthy male volunteers with and without simultaneous aspiration of duodenal fluids. A three- to fourfold increase in urinary volume and sodium excretion occurred within the first 30 min after secretin injection and this was accompanied by a significant rise in urinary pH in each instance. Urinary bicarbonate excretion increased from 55 plus or minus 13 to 395 plus or minus 33 mueq/30 min after secretin injection. Aspiration of alkaline duodenal contents was accompanied by an even greater postsecretin increase in urinary bicarbonate excretion. No significant changes in arterial pH or blood gases were detected throughout the study. These observations are compatible with a direct effect of secretin upon the renal tubular reabsorption of water, bicarbonate, and other ions, and could account for the transient alterations in urinary pH occurring in response to a meal.