Trauma, disociación y verguenza. Un tratamiento de adicción / Trauma, dissociation and shame. An addiction treatment

El proceso de recuperación de una adicción requiere transitar por un profundo cambio de la manera en que una persona se relaciona consigo mismo y con los demás. En este trabajo se describe parte de un proceso terapéutico que muestra la manera en que se ponen en juego la subjetividad del paciente y su terapeuta. Se trata de un paciente de 35 años, dependiente a cocaína. En el contexto de su rehabilitación, se descubrió que el paciente había engañado en forma sistemática a su familia y al equipo terapéutico. En realidad, no había estado abstinente, sino que mantenía un constante consumo. Por diversas razones, el sistema de tratamiento falló en cumplir con los exámenes de orina propios de una rehabilitación. Luego del destape de la verdad, el paciente reacciona con indiferencia y agresividad. El terapeuta se molesta con la conducta del paciente, lo confronta y se produce un impasse entre ambos. El eje de análisis del caso son los sentimientos de vergüenza del paciente y su terapeuta. Se relaciona la vergüenza con el trauma relacional del paciente. Se discute acerca de dos enactments, relacionándolos con la vergüenza disociada. Se analiza el caso en el contexto de la alta exigencia impuesta en los tratamientos de adicciones.

The addiction recovery process needs to go through a qualitative change in the way a patient relates to others and himself.In this report, a therapeutic process is described, showing the way both patient´s and therapist´s subjectivity interact. The case is about a 35 years old man, addicted to cocaine. The patient kept assisting to treatment sessions, in the context of an addiction program. A collaborative relationship with his individual therapist was developed, validating its contribution and mutual understanding. Nevertheless, things changed when it was discovered that the patient had lied during 3 months. Despite the fact he had asserted he had been abstinent, he had been consuming cocaine 3-4 times a week. Due to different reasons, the treatment system failed at practicing weekly urine screening. After the hidden consumption was opened, Joseph reacts both indifferently and aggressively. The therapist feels annoyed and confronts the patient. A therapeutic impasse is generated.The center of this case analysis is both patient´s and therapist´s shame. This feeling is related to patient´s relational trauma. Two enactments are discussed, understanding them as signs of dissociated shame, addict/patient dissociation and validated/cared self dissociation. A context of high therapeutic expectation amongst addiction treatments is also considered.

Técnica combinada de LEC con ureteroscopía flexible en cálculo de gran tamaño en cáliz inferior / ESWL technique combined with Flexible ureteroscopy in big lower calyx stones

El tratamiento del cálculo del caliz inferior es controversial. Los resultados del tratamiento de los cálculos caliciarios mayores de 1 cm especialmente en el cáliz inferior son no óptimos con la Litotripsia extracorpórea . Debido al avance en los ureteroscopios flexibles es que iniciamos una experiencia para obtener pacientes libres de cálculos residuales. Se presentan 15 pacientes con cálculos mayores de 1 cm. que fueron operados en una sola sesión aplicando primero Litotripsia extracorpórea hasta fragmentar el cálculo y luego extraer los fragmentos residuales con ureteroscopio flexible. En 14 de 15 pacientes el control demostró ausencia de caculos residuales. Esta experiencia demuestra la eficacia de la combinación de ambos métodos sin complicaciones. Debe evaluarse la relación costo beneficio de esta técnica en el objetivo de dejar a los pacientes libres de cálculos.

Treatment of lower caliz’ Stone is controversial. Greater than 1 cm and especially in the low caliz witht he extracorporeal lithotripsy is bad. Because of advances in flexible ureteroscopes is to begin an experience for patients with big stones in the low caliz. We present 15 patients with stones larger than 1 cm who were operated in a single session using extracorporeal lithotripsy to fragment first calculating and then extract the residual fragments with ureteroscoip flexible. In 14 of 15 patients showed Stone free. This report demonstrates the effectiveness of the combination of both methods without complications. Must evaluate the cost benefit of this technique in order to make patients stone free.

Cristaluria en una población pediátrica del estado carabobo, venezuela / Cristaluria in a pediatric population of carabobo state, venezuela

En la orina la presencia de cristales tiene poco significado clínico, aunque su correcta identificación es de utilidad en pediatría pues, proporciona información para el diagnóstico de padecimientos sistémicos, enfermedades de las vías urinarias y posibles errores congénitos del metabolismo. A fin de evaluar la influencia del género, grupo etario, condición socioeconómica y el estado nutricional antropométrico sobre la prevalencia de cristaluria, se evaluaron 381 niños aparentemente sanos, edad 1 a 18 años, atendidos en tres de los ambulatorios del Municipio Guacara, Estado Carabobo. Se determinó estado nutricional antropométrico mediante peso/edad, talla/edad, peso/talla, área grasa y área muscular en lactantes, preescolares y escolares; índice de masa corporal para adolescentes; nivel socioeconómico medido por Graffar modificado. Análisis de orina al microscopio óptico (aumento 400x) Estadístico SPSS versión 10.0 significancia p<0,05. Del total de la población estudiada 49,1% presentó cristaluria, con prevalencia en preescolares y adolescentes (33,2% y 26,2% respectivamente), con predominio estadísticamente significativo en varones (57,8%). El cristal prevalerte fue el oxalato de calcio en 66,8%, con una relación estadísticamente significativa entre tipo de cristal, grupo etario y estrato socioeconómico. En el estado nutricional antropométrico se encontró 16,6% de desnutrición, predominio del estrato socioeconómico IV en todos los grupos etarios. Se concluye que la cristaluria encontrada en esta población pediátrica de nivel socioeconómico bajo, es independiente del estado nutricional antropométrico, aunque asociado a otros factores como grupo etario, género y estrato socioeconómico(AU)

In the urine the crystal presence has little clinical meaning; although its correct identification is of utility in pediatric, due to it provide information for the diagnosis of systemic sufferings, diseases of the urinary routes and possible congenital errors of the metabolism. In order to evaluate the influence of the gender, etario group, socioeconomic condition and the anthropometric nutritional state on the prevalence of cristaluria, 381 apparently healthy children were evaluated; age 1 to 18 years, taken care in three of the ambulatory of the Guacara Municipality, Carabobo State. Was determined anthropometric nutritional state by means of weight/age, carves/age, weight/ carves, greasy area and muscular area in suckling babies, preschool and school students; corporal mass index for adolescents; socioeconomic level measured by modified Graffar. Analysis of urine by optical microscope (400x). Statistical SPSS version 10.1 significance p<0.05. Of the total of studied population 49.1% presented cristaluria, with prevalence in preschool and adolescents (33.2% and 26.2% respectively), with statistically significant predominance in boys (57.8%). The crystal prevalent was the oxalate of calcium in 66.8%, with a statistically significant relation between type of crystal, etario group and socioeconomic layer. In the anthropometric nutritional state was 16,6% of undernourishment. Predominance of socioeconomic layer IV in all the etarios groups. We concludes that cristaluria found in this pediatric population of low socioeconomic level, is independent of the anthropometric nutritional state, although other factors like etario group, gender and socioeconomic level are associated(AU)

Detection of patients with functional dyspepsia using wavelet transform applied to their electrogastrogram

The aim of the present study was to develop a classifier able to discriminate between healthy controls and dyspeptic patients by analysis of their electrogastrograms. Fifty-six electrogastrograms were analyzed, corresponding to 42 dyspeptic patients and 14 healthy controls. The original signals were subsampled, filtered and divided into the pre-, post-, and prandial stages. A time-frequency transformation based on wavelets was used to extract the signal characteristics, and a special selection procedure based on correlation was used to reduce their number. The analysis was carried out by evaluating different neural network structures to classify the wavelet coefficients into two groups (healthy subjects and dyspeptic patients). The optimization process of the classifier led to a linear model. A dimension reduction that resulted in only 25 percent of uncorrelated electrogastrogram characteristics gave 24 inputs for the classifier. The prandial stage gave the most significant results. Under these conditions, the classifier achieved 78.6 percent sensitivity, 92.9 percent specificity, and an error of 17.9 ± 6 percent (with a 95 percent confidence level). These data show that it is possible to establish significant differences between patients and normal controls when time-frequency characteristics are extracted from an electrogastrogram, with an adequate component reduction, outperforming the results obtained with classical Fourier analysis. These findings can contribute to increasing our understanding of the pathophysiological mechanisms involved in functional dyspepsia and perhaps to improving the pharmacological treatment of functional dyspeptic patients.

Situación socieconómica: diagnóstico nutricional antropométrico y dietario en niños y adolescentes de Valencia-Venezuela / Socioeconomic status: anthropometric nutritional diagnosis and dietary adequacy in children and adolescents of an area of Valencia-Venezuela

La capacidad de compra de alimentos derivada del nivel socioeconómico influye en calidad y cantidad de la dieta, pudiendo originar alteraciones nutricionales. Se planteó evaluar la asociación de indicadores socioeconómicos y antropométricos con la adecuación dietaria en niños de una zona de pobreza. Se estudiaron 257 niños menores de 18 años, de una Parroquia de Valencia, 2004. Se determinó estrato socioeconómico (ESE)(Graffar-Méndez), adecuación dietaria (recordatorios 24h, n=97) e indicadores antropométricos: P/E, T/E, P/T, circunferencia brazo, área grasa y muscular, pliegue tricipital e Índice de Masa Corporal). Análisis estadístico por distribución de frecuencia, Chi cuadrado y Pearson. Predominaron varones, escolares, estratos IV y V y una familia por vivienda. Hubo 36,6% de déficit, normalidad en 54,8% y 8,6% de exceso nutricional. Las adecuaciones calórica y proteica fueron aceptables, pero excesiva para fibra, 41,2% de déficit calórico y 45,3% en proteínas, 58,3% de los normales y en exceso tenían aporte calórico deficiente, y los desnutridos 46,5%. El exceso en consumo de fibra (49%) fue independiente del estrato y estado nutricional. La adecuación de fibra se relacionó con ingesta calórica y proteica, edad, talla y área muscular pero no hubo entre adecuación calórica y proteínas con ESE. Se concluye que hubo asociación importante entre el consumo dietario y estado nutricional pero la asociación es menor con el ESE. La evidencia no relacionó las alteraciones encontradas con la situación de pobreza. La evaluación del consumo de alimentos fue útil para complementar la información antropométrica y sociodemográfica; considerando la sub o sobreestimación del dato dietario.

Food purchase capacity is related to socioeconomic level, and it influences dietary quality and quantity. Changes on diet may cause alterations of nutritional status. In order to evaluate the association between socioeconomic and anthropometrics indicators to dietary adequacy in children from a poverty area, 257 children and adolescents randomly selected, from Valencia, Venezuela (2004) were assessed. Socioeconomic status was determined(SES, Graffar-Méndez), dietary adequacy (24h recalls, n=97) and anthropometrical indicators (W/A, H/A, W/H, arm circumference, fat and muscular area, tricipital skinfold and BMI) were measured. Statistical Analysis by frequency distribution, Chi² test and Pearson correlation was performed. Boys, school children; families in poverty(IV and V stratum) and one family/home were highly prevalent. Nutritional diagnosis consisted of: 36.6% of deficit, 54.8% of normality and 8.6% of excess. Mean caloric and protein intake and adequacy were acceptable, but fiber adequacy was excessive. 41.2% of subjects had inadequate energy intake and 45.3% inadequate protein intake. Energy intake was deficient in 58.3% of normal subjects and also in those in excess, and in 46.5% of undernourished children, 52.1% of the undernourished children had excessive adequacy for fiber. There was association between fiber adequacy to energy and protein intake, age; height and muscular area, but not between energy and protein intake to socioeconomic condition. It is concluded that there was an important association between dietary intake and nutritional status but only a weak relation to SES. Evaluation of dietary intake and adequacy is useful to complement anthropometric and socioeconomic information; but care has to be taken for the possibility of under or overestimation of data reported by the interviewed.

Asociación entre pobreza e infestación parasitaria intestinal en preescolares, escolares y adolescentes del sur de Valencia estado Carabobo-Venezuela / Association between poverty and intestinal parasitism in pre-school, elementary school children and adolescents from south of Valencia state of Carabobo Venezuela

Condiciones de vida deficientes, contaminación fecal de agua, de alimentos y del suelo favorecen la transmisión de parásitos intestinales. Para establecer asociación entre pobreza e infestación parasitaria se evaluaron aspectos socio-sanitarios (composición familiar, estrato social, vivienda), ambientales (agua, excretas) y coproparasitológicos (examen directo y kato) en 257 sujetos (2 a 18 años), de Valencia Estado Carabobo. Se encontró: Predominio de escolares en estrato IV, de estructura monofamiliar y de 5 personas por grupo; 48,2 por ciento de infestación, alta prevalencia en escolares (mono (57,3 por ciento) y poliparasitismo (52,6 por ciento). Los protozoarios fueron más prevalentes en el estrato IV (63,9 por ciento) y los helmintos en el estrato V (64,3 por ciento). No se encontró asociación estadísticamente significativa entre estrato socioeconómico por el método de Graffar- Méndez Castellano y parasitosis, pero sí entre parasitosis y ausencia de cloacas, agua no tratada, baño intradomiciliario, ausencia de piso y número de personas por familia. Predominio de protozoarios en familias de hasta 5 personas (56,6 por ciento) y helmintos en familias con mas de de cinco personas (78,6 por ciento). Asociación significativa entre Blastocystis hominis, Entamoeba coli y Ascaris lumbricoides y familias de más de 5 personas. Hubo estrecha aociación entre parasitosis y condiciones socio-sanitarias, ambientales y conductuales, lo que favorece la morbilidad en este grupo poblacional, perpetuando el ciclo de pobreza e infestación parasitaria.

Poor living conditions, fecal contamination of food, water and soil are factors that contribute to intestinal parasites transmission. In order to stablish association between poverty and parasitary infectation, socio-sanitary (family structure, social stratum, housing), environmental (water and excreta disposition) and coproparasitological (direct and kato examination) aspects were evaluated, in 257 subjects (2-18 years old), from Valencia, Carabobo State. Findings were: High prevalence of school children, of stratum IV, of monofamiliar structure, with five persons per group. Parasite infestation was found in 48.2 percent of children, more prevalent in school children, with mono (53.7 percent) and poliparasitism (52.6 percent). Protozoa forms were more prevalent in stratum IV (63.9 percent) and helminthes forms in stratum V (64.3 percent). There was not statistically significant association between socioeconomic strata assessed by Graffar-M‚ndez Castellano method and parasitic infestation, but between parasitic infestation and sociosanitary conditions (absence of sewers, non-treated water, intradomiciliary bath, absence of floor and number of people by family), statistically significant association was present. Predominance of protozoa in subjects from small families groups (less than five persons) was 56.6 percent while in children from large families groups (higher than five persons), prevalence of helminthes was 78.6 percent. Significant association was found between Blastocystis hominis, Entamoeba coli and Ascaris lumbricoides and large families groups. It is concluded that a strong and significant association was found between parasite infestations and socio-sanitary, environmental and cultural conditions, situation that favours a high morbidity rate, which perpetuates the interactions cycle of poverty and parasite infestations.

Infecciones por candida en neonatología / Candida infections in neonatology

Introducción: La infecciones nosocomiales por hongos han aumentado significativamente en los últimos veinte años, y entre estas, las infecciones por Candida constituyen una causa emergente en unidades de neonatología. Objetivos: Caracterizar el perfil clínico-microbiológico de los recién nacidos ingresados a una unidad de neonatología que desarrollaron una infección por Candida. Pacientes y Método: Estudio retrospectivo tipo caso control en un período de 10 años (1994 a 2004). Por cada caso se seleccionaron dos controles de similar edad gestacional que no hayan presentado infección a Candida. Resultados: Se identificaron 14 casos con infecciones por Candida. Comparados con los controles (n = 28) los recién nacidos con infecciones por Candida tuvieron significativamente (p < 0,05) mayor: estadía hospitalaria, proporción de ventilación mecánica, uso de alimentación parenteral - antibióticos, intervenciones quirúrgicas y mortalidad. En el grupo con infecciones por Candida; nueve se presentaron en recién nacidos a término o cerca del término, la especie más frecuentemente aislada fue Candida albicans en ocho casos y en seis casos Candida no albicans siendo el principal sitio de aislamiento el territorio sanguíneo. La mortalidad en esta serie fue de 28% (4/14). Conclusiones: En nuestra unidad, las Infecciones por Candida predominaron en recién nacidos a término y se confirma la emergencia de Candida no albicans como causantes de infecciones nosocomiales por hongos. Se requiere optimalizar el diagnóstico precoz y la búsqueda de la diseminación a distancia de estas infecciones.

Nosocomial fungal infections have significantly increased over the past 2 decades. Candida species are recognized as leading nosocomial pathogens in neonatal intensive care unit. Objective: To describe the clinical and microbiological profile of Candida infections in a neonatal intensive care unit. Method: Retrospective case-control study in a period of 10 years (1994-2004), performed in all newborns admitted to our unit. Each case was compared with 2 control neonates who did not have fungal infection. Results: 14 cases of Candida infections were identified. Compared with match controls (n = 28), newborns with Candida infections had significantly (p < 0,05) longer hospitalizations and duration of mechanical ventilation, use of parenteral nutrition and broad spectrum antibiotics, along with surgical interventions and mortality. In the group with fungal infections, 9 were term or near-term newborns, mean age at onset was 21 days and Candida albicans was recovered from 8 of 14 cases. Blood was the main source for positive cultures (8/14), fungal dissemination was rare and 28% died (4/14). Conclusions: Candida infections predominate in term and near-term newborns and Candida no albicans have become common agents of nosocomial fungal infections in our unit. Improvement of diagnosis and multiple organ evaluation are further required.

Prótesis testicular en pacientes orquiectomizados por cáncer testicular. ¿se justifica como insumo del plan nacional de salud Auge Ges? / Testicular prostheses in patient after orchidectomy for testicular cancer: justified as devices of the AUGE-GES’s health national law?

La pérdida de un testículo es un trauma físico y psicológico, en particular si la causa es por cáncer. En Chile desde julio de 2005 rige la Ley Nº 19.966, AUGE GES en Salud, y el cáncer testicular del adulto está incluido, pero no contempla la prótesis testicular. Fue esta la motivación para realizar este trabajo y objetivar si es un punto importante del tratamiento del cáncer de testículo. Material y Métodos: Se realizó una entrevista personal a 60 pacientes orquiectomizados por cáncer testicular, entregándoles un cuestionario dividido en preguntas antes y después de la orquiectomía ampliada, y si aceptan o rechazan la prótesis testicular y sus razones. Las respuestas se tabularon en una base de datos Microsoft Access. Se aplicó análisis estadístico con método de Fisher' Irving. Resultados: La mediana de edad fue 31 años (17-57). El 66,7 por ciento refirió no tener problemas de ser monórquicos; el 28,3 por ciento relató complejo de mostrarse desnudo y el 5 por ciento indicó incomodidad física. El 58,3 por ciento se operaría nuevamente para instalar la prótesis testicular y de éstos el 88,5 por ciento lo haría por estética. El 93,3 por ciento hubiese aceptado la instalación de prótesis al momento de la orquiectomía. No existió diferencia al comparar grupo de solteros y casados, ni grupo etario. Discusión: La repercusión psicológica es algo muy difícil de objetivar, sobre todo en una sociedad machista. Al momento de preguntar si se operarían varios de los pacientes cambian su respuesta y muestran su malestar de ser monórquicos. Es muy importante el hecho de contar con la prótesis al momento de la orquiectomía para optimizar los tiempos y disminuir los costos físicos y psicológicos de una nueva cirugía. Conclusiones: Dado que la Ley 19.966 de Salud, establece las prestaciones de carácter promocional, preventivo, curativo, de rehabilitación y paliativo, y que en el caso del cáncer testicular no cuenta con la prótesis dentro del Listado de Prestaciones Específicas, no se estaría cumpliendo con el carácter de rehabilitación garantizado por la Ley mencionada. Es por esta razón, y en base a los resultados obtenidos en este estudio, que se justifica plenamente que la prótesis testicular fuese parte del Plan AUGE GES.

Bone aluminum uptake in uremic rats receiving intraperitoneal iron.

To assess the effect of concomitant iron and aluminum loads on bone aluminum accumulation and on the response to the deferoxamine test in rats with the same aluminum surcharge, Wistar rats with chronic renal failure were divided into three groups: iron-overloaded rats (N = 6) (intraperitoneal iron); iron-depleted rats (N = 6) (blood withdrawal two to three times per week); control rats (N = 4) (no manipulation). All groups received intraperitoneal aluminum simultaneously. After 6 wk, a deferoxamine challenge test was performed. Thereafter, bone aluminum and iron were measured. The iron-overloaded rats showed higher bone iron content (iron overloaded: 147.7+/-55.4 microg/g; iron depleted: 7.9+/-1.0, and controls 13.3+/-9.9 microg/g, p < 0.010) and lower bone aluminum content (iron overloaded: 14.2+/-4.0 microg/g; iron depleted: 70.9+/-35.1 microg/g; controls: 72.7+/-28.3 microg/g p < 0.005). No differences were found between the iron-depleted and control rats. After the deferoxamine infusion, the iron-depleted rats tended to have higher serum aluminum increments (p = NS) and higher urinary aluminum excretion (p < 0.012, p < 0.020) than control rats despite similar amounts of aluminum in bone of the two groups. Aluminum bone accumulation was minor if iron and aluminum loads were given concomitantly. The iron depletion influenced the results of the deferoxamine challenge test in rats with similar bone aluminum burden.

[Antiretroviral therapy. Announcement of the Advisory Committee of the Chilean Society of Infectology on AIDS]. / Terapia anti retroviral. Pronunciamiento del Comité Consultivo de SIDA de la Sociedad Chilena de Infectología.

There are treatments to induce the long term suppression of viral replication and that delays the progression of HIV disease. To be effective, these treatments require the uninterrupted use of a combination of drugs (ideally three), patients must be highly compliant, must be instituted in early stages of the disease and drugs must be used for prolonged periods and given by specialists. These treatments are indicated in all symptomatic patients and in those with early immunologic deterioration or high viral load. Recent infection and acute primary retroviral infections should also be considered for treatment. The treatment sponsored and financed by the ministry of health for its beneficiaries is insufficient at this time, since it is received by a minority of eligible patients due to budgetary reasons, and only two drugs are given which is considered such optimal by most experts. The committee considers that the responsibility for financing, providing and delivering these treatments in proper combination and dosages exceeds the duty of the Ministry of Health and should include all the involved parties. However, the state and its official institutions have a special responsibility to provide with adequate treatments to the poorer segments of our population. They also should promote, supervise and control the proper access of the rest of the population to efficient treatments. The committee also considers that the efforts to prevent new infections must not be neglected and that individuals under successful treatment should not consider themselves as non infectious.

[Resistance of human immunodeficiency virus (HIV) to zidovudine. Genotypic analysis in strains isolated from Chilean patients]. / Resistencia del virus de inmunodeficiencia humano (VIH) a zidovudina (AZT): análisis genotípico en cepas aisladas de pacientes chilenos.

BACKGROUND: Resistance of HIV to AZT is the result of mutations in the pol gene that codifies the enzyme reverse transcriptase. AIM: To assess the resistance to antiretroviral drugs in Chilean patients infected with HIV. MATERIAL AND METHODS: The presence of mutations was searched in 22 patients infected with HIV. The emergence or persistence of these mutations was studied in sequential samples of 19 patients. The presence of the mutation that confers resistance to didanosine (DDI) was studied in those subjects exposed to the drug. Polymerase chain reaction techniques were used to analyze mutations in codons 41, 70 and 215 of the pol gene (resistance to AZT) and the mutation in codon 71 (resistance to DDI). RESULTS: On admission, none of the patients without previous exposure to AZT had drug resistance mutations. Seven of 12 patients (58.3%) that had received AZT had mutations in codon 215. In two, they were associated to a mutation in codon 41 and in two, a mutation in codon 70. After a mean follow up of 14 months, 13 of 15 patients (86%) that received AZT had viral strains genotypically resistant to the drug. In nine of these, the resistance was associated with disease progression. None of the 10 patients that received DDI had the mutation in codon 74 that confers resistance to the drug. However, in one of these patients, that never received AZT, a virus with a mutation in codon 215 was detected. CONCLUSIONS: A high percentage of patients that have received monotherapy with AZT have genotypic resistance to the drug. This resistance is associated with clinical and immunological derangement in 70% of these subjects.

Are there any differences in the parathyroid response in the different types of renal osteodystrophy?

With the purpose of studying the curve of parathyroid response to variations of serum calcium during dialysis, we studied 20 patients on haemodialysis: 10 women and 10 men, with different forms of bone disease diagnosed by bone biopsy (adynamic bone disease, mild hyperparathyroidism, severe hyperparathyroidism). In all patients, we performed parathyroid stimulation by 4 h dialysis with 1 mEq/l of Ca2+ in the dialysate, and an inhibition test in another dialysis session with 4 mEq/l of Ca2+, with a 48 h interval. Ca2+ and intact parathyroid hormone (iPTH) were measured prior to dialysis and every hour subsequently, to obtain a Ca2+-iPTH for each patient. The analysis of the curves was made using Brown's four-parameter model. Stimulation and inhibition levels were similar in all groups, but basal iPTH and the response profiles obtained varied in the different histological groups. Basal, maximal and minimal iPTH were lower in adynamic forms than in the other two groups (P<0.04), and basal calcium was higher than basal calcium of severe hyperparathyroidism, expressing a basal inhibition status. In severe hyperparathyroidism, basal calcium was lower than the set-point, showing a permanent stimulation, and the slope was higher than in other groups, showing more sensitivity to serum calcium variations. The set-point of severe hyperparathyroidism was significantly higher than the set-point of mild and adynamic forms. In conclusion, the functional parathyroid study showed a different response in the different forms of renal osteodystrophy.

Can we use 99mTc-MIBI in functional studies of the parathyroid gland?

The usefulness of technetium-99m-sestamibi (99mTc-MIBI) in patients with secondary hyperparathyroidism on haemodialysis was assessed. We studied 33 patients with parathyroid scintigraphy with i.v. (99mTc-MIBI). Static images in a scintillation camera were taken at 15 and 120 min after the injection. With P x Ca<80, we performed an inhibition test with calcitriol i.v. 2 microg, three times a week, for 2 weeks. The MIBI study and assessment of intact parathyroid hormone (iPTH) were performed before (baseline study) and after inhibition. A 'focal positive study' corresponded to one or more areas of abnormal hypercaptation in relation to surrounding thyroid tissue seen in early images and persisting in later images, and a 'negative study' did not correspond to the previous image. In the baseline study, iPTH in the positive MIBI group was significantly greater than in the negative group. Eight positive MIBI patients had a bone biopsy; six corresponded to severe osteitis fibrosa and two to mild osteitis fibrosa. In the negative MIBI group, four of the six patients who had bone biopsy had mild forms of osteitis fibrosa (Fisher=0.03); the other two had low turnover forms. A positive inhibition test was defined when the basal uptake disappeared after calcitriol administration. In these patients, we observed a significant decrease of iPTH, not observed in the negative inhibition test. In 10 patients who had been parathyroidectomized, those with alpha positive basal MIBI result had a nodular parathyroid hyperplasia. We conclude that a scintigraphic parathyroid study with 99mTc-MIBI showed a good correlation with functional parathyroid status. With the same inhibition test, only some glands were inhibited, suggesting that this could be the expression of different vitamin D receptor densities in inhibited glands and/or a different kind of proliferation in those glands. This test would be of value in functional studies when a therapeutic decision must be made.

[Natural history of human immunodeficiency virus infection in a cohort of Chilean patients]. / Historia natural de la infección por virus de inmunodeficiencia humano en una cohorte de pacientes chilenos.

We characterized clinical manifestations and the risk to develop AIDS in a cohort of 32 patients infected with human immunodeficiency virus without AIDS A multivariate analysis was performed to determine association between the progression of infection and control variables (socioeconomic level, age, sex and sexual preferences) and causal variables (psycho-social changes, significant clinical events, stress scoring and sexual activity). The cumulative AIDS incidence, defined as a CD4 lymphocyte count below 200 cells/cm3 was 50% at 6.5 years and 82% at 8 years. Using clinical criteria to define AIDS, 50% developed the disease at 8 years of follow up. Among studied factors, only age (faster progression at higher age) and time of evolution were associated with progression in stages before AIDS, the most frequent diseases were acute diarrhea, sexual transmission diseases, oral candidiasis, sinusitis and varicella zoster infections. The reduction; of CD4 lymphocytes-below 200 cells/cm3 always preceded the symptoms of the disease. Two patients have remained more than eight years without clinical or immunological deterioration.

PIP: Clinical manifestations and the risk of developing AIDS were studied in a cohort of 32 HIV-seropositive patients referred by their treating physicians to the Center for Medical Investigation of the Catholic University of Chile. The only exclusion criteria were a CD4 lymphocyte count below 400 or marked symptoms of AIDS. The study design included an examination at entry and every 6 months thereafter for a maximum follow up of 3 years. A multivariate analysis was conducted to determine the relation between disease progression and control and causal variables. The subjects were 8 women averaging 38 years old and 24 men averaging 33 years. Most were middle class and had higher education. 46% of the men became sexually active before age 15 and 42% were homosexual. HIV transmission was sexual in 28 subjects, through intravenous drug use in 2, and by unknown route in 2. The subjects had been infected for an average of 4.3 years at entry into the study. Of the 30 whose date of infection was known, 16 developed AIDS during the study according to the criterion of CD4 lymphocyte count below 200, and 8 of these developed markers of AIDS. 50% of patients developed AIDS 6.5 years after infection and 82% 8 years after. Using clinical criteria, 50% of patients had developed AIDS 8 years after infection. Multivariate analysis showed only subject's age at infection (faster progression at higher ages) and length of time since infection to be related to the risk of developing AIDS. No association was observed between development of the disease and sex, sexual orientation, use of alcohol or drugs, smoking, history of sexually transmitted diseases, number of sexual partners, or frequency of sexual relations. The most frequently observed pathologies before the stage of AIDS were acute diarrhea, sexually transmitted diseases, oral candidiasis, sinusitis, and varicela zoster infections. In the patients who progressed to AIDS, the decline of the CD4 lymphocyte count below 200 always preceded other symptoms. Two patients showed no significant decline in CD4 lymphocyte count or clinical manifestations of AIDS more than 8 years after infection.

Influence of iron status in the response to the deferoxamine test.

The study presented here was carried out to evaluate the possible relationship between serum iron and iron transferrin saturation with the response to the deferoxamine test in 86 chronic renal failure patients undergoing hemodialysis. The deferoxamine test was performed as a diagnostic tool for aluminum intoxication. Basal serum aluminum levels correlated with: (1) serum aluminum levels after the infusion of deferoxamine (r = 0.45; P < 0.05); (2) serum iron levels (r = -0.26; P < 0.05), and; (3) iron transferrin saturation (r = -0.33; P < 0.05). The increase in serum aluminum levels after deferoxamine administration (DAI) showed a negative relationship with serum iron levels (r = -0.23; P < 0.05) and iron transferrin saturation (r = -0.26; P < 0.05). The correlations improved when analysis of this study included only those patients with high serum iron levels or high iron transferrin saturation (r = -0.55). Patients with low probability of having aluminum overload (serum iron levels < 40 micrograms/L and DAI < 150 micrograms/L) had significantly higher values of serum iron, iron transferrin saturation, and serum ferritin levels compared with those patients with a high probability of having aluminum overload (serum aluminum levels > 40 micrograms/L and DAI > 150 micrograms/L). The study presented here suggests that patients who have indicators of iron repletion would tend to have lower increases in serum aluminum levels after the challenge with deferoxamine and presumably a higher incidence of false negative results with the deferoxamine test. These findings indicate that iron measurements must be always taken into account when interpreting the deferoxamine test.

The 'CheA' and 'CheY' domains of Myxococcus xanthus FrzE function independently in vitro as an autokinase and a phosphate acceptor, respectively.

FrzE is a chemotaxis protein in Myxococcus xanthus which has sequence homology to two different chemotaxis proteins of enteric bacteria, CheA (autokinase) and CheY (phosphate acceptor) [Proc. Natl. Acad. Sci. USA 87 (1990) 5898-5902]. It was also shown that a recombinant FrzE protein was autophosphorylated when incubated in the presence of ATP and Mn2+ [J. Bacteriol. 172 (1990) 6661-6668]. In this study, we further investigated the biochemical properties of FrzE. Two recombinant proteins were produced: one containing only the 'CheA' domain of FrzE and the second only the 'CheY' domain. The CheA domain polypeptide contained the autokinase activity which was absent from the CheY domain polypeptide. The phosphorylated CheA domain polypeptide as well as the intact FrzE protein were able to transfer phosphate groups to the CheY domain peptide. These results indicate that FrzE has structural as well as functional homologies to CheA and CheY in a single polypeptide.

Perfil de las denuncias por violencia intrafamiliar contra la mujer efectuadas en el hospital Gustavo Fricke / Denunciations profile of intrafamily violence against women at Hospital Gustavo Fricke

La violencia intrafamiliar es cualquier forma de abuso físico entre personas que tienen algún tipo de relación afectiva. El objetivo del presente trabajo fue describir a la mujer agredida denunciante, su agresor y las circunstancias de la agresión y de la denuncia. Se relizó un estudio retrospectivo de 250 casos de denuncias por violencia intrafamiliar contra la mujer, registradas por personal de Carabineros en la Unidad de Emergencia del Hospital G. Fricke de Viña del Mar, entre el 1º de Enero y el 31 de Junio de 1993. En cuanto a las mujeres denunciantes, tuvieron 29,0 años de edad como mediana y un 50,8 porciento estaban casadas. Su agresor fue de sexo masculino, en un 92,3 porciento con una mediana de edad de 37,7 años; un 73,4 porciento de ellos era o habiá sido la pareja de la victima. La agresión ocurrió en un 78,4 porciento al interior de una casa particular, produciéndose un peak entre las 21 y 24 horas (26,0 porciento) y en los sábados y domingos (42,8 porciento). Un 81,2 porciento de las lesiones fueron leves. En el 45,6 porciento de los casos, la denusncia se efectuó dentro de las primeras 4 horas después de la agresión. Efectuando una generalización, se concluye que el perfil de los casos de denuncias por violencia intrafamiliar contra la mujer es el siguiente: se trata de una mujer adulto-joven, agredida por un hombre, de edad algo mayor, su pareja. La agresión produce lesiones leves, ocurre en una casa particular, de noche, los fines de semana. La denuncia se efectúa a las pocas horas de ocurrida la agresión. Nuestros resultados son similares a los obtenidos en el único estudio efectuado en Chile hasta el momento (Guerra, 1992)

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