Relación médico paciente: la bioética y el cuidado en medicina / Physician Patient Relationship. Bioethics and Medical Care

A lo largo de la historia de la medicina, el médico ha desempeñado principalmente tareas de asistencia y consuelo. Entre los siglos XV y XVII se realiza un cambio en la concepción de la medicina que acompaña a la transformación del conocimiento, poner remedio se transforma muy rápidamente en poner un remedio, una medicina. En la actualidad, imbuidos del mismo espíritu, entendemos que apartar todo daño y maleficio significa apartar la enfermedad. La bioética nos propone acercarnos al médico y hallar conductas éticas en que se manifieste el hombre en su plenitud, íntegro, con capacidad de vivir su historia y proyectarse al porvenir, tal cual lo pedía Potter, su fundador. Esto muchas veces implica curar, reparar, extraer el daño, pero sobre todo obliga al médico a cumplir con su vocación más antigua: cuidar. Pero ¿cómo pensar el cuerpo de otra manera y la enfermedad de otra manera? Proyectar un mundo con el enfermo compartiendo un espacio con él, el cuidado de ese espacio común, de ese proyecto común. Esto es la medida no sólo del ejercicio de la humanidad del médico, sino de su ética. Debemos hablar de una ética del cuidado en medicina. Esto significa básicamente estar atentos a que el paciente es un otro que necesita de nosotros, que acude al médico a pedir ayuda; negársela, omitir acciones, o realizar acciones en beneficio de terceros, sería claramente optar por una conducta no ética, inmoral. Reflexionar frente al enfermo muriente y sobre todo al enfermo sufriente, se convierte en el mayor desafío para el médico. Practicar la ética del cuidado no es otra cosa que acompañar al enfermo en el camino hacia el futuro, sea este de vida o de muerte, teniendo presente lo que decía Erik Cassel "El médico pocas veces cura, algunas alivia, pero siempre debe consolar".

Along the medicine history the doctor has mainly performed tasks of assistance and consolation. Between the fifteenth and seventeenth centuries the evolving knowledge brought a change in the concepts of medicine. To assist patients very quickly starts to mean prescription of a medication. Today, imbued with the same spirit, we understand that removing a damage and spell means removing the disease. Bioethics teaches to find ethical behaviors in the doctors like men showing their integrity, ability to live with their history and projections into the future, as Potter, its founder, proposed. This often involves healing, repairing, removing the damage, but overall it requires that the doctors fulfill their oldest vocation: to care. But, how can the doctors think the body as well as the illness in a different way? By projecting a world with the patient, sharing the same space with him, taking care for the common space, the joint project. This is a measure not only of the doctors' humanitarian practice, but also of his ethics. We should speak of an ethics of medical care. This means to be basically attentive that the patient is a person who needs us, who comes to the doctor asking for help. If the help is denied, actions are not taken, or the actions are for the benefit of others, this would clearly mean an unethical, immoral conduct. The biggest challenge for the doctor is to meditate in front of a dying patient and especially a suffering patient. Practicing ethical of care is to accompany the patient on the road to the future, be it life or death, bearing in mind what Erik Cassel said "The doctor rarely cures, sometimes alleviates, but should always console".

Pulmón del soldador de arco / Arc welder's lung

La siderosis del soldador o neumoconiosis siderótica fue descripta por Doig y McLaughlin en 1936 como una enfermedad pulmonar causada por la inhalación crónica de polvo de hierro en soldadores de arco eléctrico. Presentamos un caso de siderosis del soldador asociada a aumento de los niveles de ferritina, sin hallazgo de depósito de hierro en otros órganos y sin causas evidentes de hemosiderosis secundaria.

Pneumoconiosis of electric arc welder or siderotic pneumoconiosis was described by Doig and McLaughlin in 1936 as a lung disease caused by chronic inhalation of iron fumes in electric arc welders. We present a case report of electric arc welder siderosis associated with high levels of ferritin, without findings of iron deposit in any other organ.

Radiological versus histopathological diagnosis of usual interstitial pneumonia in the clinical practice: does it have any survival difference?

BACKGROUND: Recent studies have shown that quantification of specific histopathologic features found in usual interstitial pneumonia (UIP) are useful in defining a prognosis, suggesting the need of biopsy in all patients. OBJECTIVES: This study examines whether UIP-associated mortality is different in patients diagnosed by high-resolution computed tomography (HRCT) features considered definite of UIP and in patients with no definite radiological diagnosis that required histological confirmation of diagnoses. METHODS: Forty-five patients were included (30 males, mean age 65.3 +/- 10.7 years). Two groups of patients were identified: those with HRCT findings of definite UIP (n = 26) and those whose radiological diagnosis was not definite and required a surgical biopsy to confirm the presence of UIP (n = 19). Forced vital capacity, forced expiratory volume in 1 s and diffusing capacity for carbon monoxide were measured in all patients. All data were obtained from medical records, and the survival status was obtained by telephone or personal interview. All clinical parameters and HRCTs were obtained within 1 month before surgical lung biopsy. RESULTS: Median survival was not different across groups and was similar to that previously reported (35 months). Kaplan-Meier analysis did not show any difference in 5-year survival between both groups. CONCLUSIONS: In a clinical context in which the diagnosis of UIP can be obtained as a dynamic process that includes an integrated clinical, radiological and pathologic approach, a reliable diagnosis of UIP can be obtained based on a typical definite HRCT with no risk of including patients with a more benign disease and a more prolonged survival.

Granulomatosis de Wegener y tuberculosis: Una mala combinación / Wegener's granulomatosis and tuberculosis: A bad combination

La enfermedad de Wegener es una vasculitis de pequeños y medianos vasos asociada a anticuerpos anticitoplasma del neutrófilo (ANCA). Dentro de los órganos blancos, el pulmón se encuentra comprometido en el 85% de los casos. Numerosas entidades deben ser consideradas en el diagnóstico diferencial, entre ellas, la tuberculosis pulmonar. Presentamos el caso de un hombre de 54 años de edad, con diagnóstico en el año 1996 de enfermedad de Wegener, que comienza en agosto de 2007 con expectoración hemoptoica, disnea de esfuerzo progresiva y esputo con baciloscopia BAAR (+), por lo que inicia tratamiento antituberculoso. La baciloscopia no se constata en dos lavados broncoalveolares contemporáneos. Evoluciona con deterioro de la función renal, púrpura palpable y anticuerpos anticitoplasma del neutrófilo patrón citoplasmático (ANCA-c) positivo. Se interpreta reactivación de su enfermedad de base. Inicia tratamiento inmunosupresor y hemodiálisis y suspende tratamiento antituberculoso. Un mes después del alta se reinterna con cuadro similar al previo, con esputo seriado positivo para BAAR.

Wegener's disease is a vasculitis of small and medium-sized vessels associated with anti-neutrophil cytoplasm antibodies (ANCA). Within their target organs the lungs are involved in 85% of cases. Many entities are part of the differential diagnosis, including pulmonary tuberculosis. We present the case of a 54 years old man, diagnosed as Wegener's disease in 1996 which begins in August 2007 with cough, hemoptysis, progressive dyspnea on effort and serial sputum positive for AFB and then starts TB treatment. Subsequent bronchoalveolar fluids resulted negative for AFB. The patient evolved with impaired renal function, palpable purpura and positive anti-neutrophil cytoplasm antibodies cytoplasmic pattern (c-ANCA), interpreted as Wegener's disease relapse. He started hemodialysis and immunosuppressive therapy and tuberculosis treatment was stopped. One month after discharge was readmitted with a similar picture with serial sputum positive for AFB.

Factores predictores de la caída de la saturación de oxígeno durante la caminata de 6 minutos en la fibrosis pulmonar idiopática / Predictors factors of the fall of oxygen saturation during the six-minute walk test in idiopathic pulmonary fibrosis

La prueba de caminata de seis minutos (PC6m) es potencialmente útil en la fibrosis pulmonar idiopática (FPI), ya que proporciona información para el pronóstico. El objetivo de nuestro estudio fue determinar si las pruebas funcionales pulmonares en reposo pueden predecir la disminución de la saturación de oxígeno (SaO2) durante una prueba PC6m y si la distancia caminada se correlaciona con las pruebas funcionales pulmonares en reposo. Se incluyeron 53 pacientes con diagnóstico de FPI de acuerdo a la definición de la ATS/ERS a los que se les realizó espirometría, medición de volúmenes pulmonares, DLCO y PC6m. Los metros caminados en la PC6m no se correlacionaron con la edad (r = -0.154; p = 0.272), ni con la DLCO en % del valor predicho (r = 0.261, p =0.065), pero en cambio se correlacionaron con la SaO2 basal (r = 0.359; p = 0.007). Los pacientes que mostraron caída de la SaO2 no fueron diferentes de los que no mostraron desaturación en términos de presencia de disnea en el momento del diagnóstico ( 78 vs 66 % ; p=0.124), presencia de una TAC catalogada como neumonía intersticial usual definitiva (72% vs 80%; p = 0.52) o proporción de pacientes con CVF normal como % del valor predicho (59% vs 77%; p = 0.29) pero tuvieron diferencias estadísticamente significativas en la CVF (61.80 ±17.50 vs. 82.50 ±19.02; p = 0.003) y en la saturación basal (94.03 ±1.98 vs. 95.87 ± 2.17; p= 0.004). Como conclusión la caída de la SaO2 durante la PC6m no puede predecirse por los valores de la DLCO ni por las anomalías encontradas en la TAC de tórax pero se correlaciona con la disminución de la CVF. Este estudio enfatiza la importancia de evaluar la caída de la SaO2 en la FPI independientemente de la disnea o la DLCO.

The six-minute walk-test (6mWT) is potentially useful to define prognosis in patients with idiopathic pulmonary fibrosis (IPF). The objective of this study was to determine if resting pulmonary function tests (PFT) can predict the presence of decrease of oxygen saturation (SaO2) during a 6mWT and if the walked distance correlates with the resting PFT. Fifty-three patients with IPF were included according to the ATS/ERS consensus definition. Pulmonary function tests (including spirometry, lung volumes and diffusing lung capacity of carbon monoxide - DLCO) and a 6mWT were performed in all patients. The walked distance during a 6mWT did not correlate with age (r = -0.154; p = 0.272) or DLCO as % of predicted value (r = 0.261, p = 0.065), but it correlated with baseline SaO2 (r = 0.359; p = 0.007). No significant difference was found in patients who showed fall of oxygen saturation in comparison with those who did not in the proportion of the following variables: dyspnea at the moment of diagnosis (78 vs. 66%; p = 0.124), high resolution computed tomography (HRCT) showing definitive usual interstitial pneumonia (72% vs. 80%; p = 0.52) and normal FVC as % of predicted value (59 % vs. 77 %; p = 0.29). In contrast, there was a significant difference in FVC (61.80 ± 17.50 vs. 82.50 ± 19.02, p = 0.003) and in basal saturation (94.03 ± 1.98 vs. 95.87 ± 2.17, p = 0.004) between these two groups. The fall of SaO2 during the 6mWT cannot be predicted by clinical variables or HRCT findings but it does relate to the fall of FVC. This study shows the importance of performing the 6mWT independently of the presence of dyspnea or spirometry results.

Evolución funcional respiratoria en dos pacientes con enfisema y fibrosis pulmonar / Functional respiratory evolution in two patients with emphysema and pulmonary fibrosis

La combinación de enfisema y fibrosis pulmonar es una condición frecuentemente subdiagnosticada. Los estudios funcionales aislados pueden generar interpretaciones inadecuadas. No hemos hallado comunicaciones de casos que documenten la evolución espirométrica de estos pacientes. Se presentan dos casos de fibrosis y enfisema combinados que permiten observar la evolución funcional a largo plazo y comprender los valores espirométricos actuales en forma más precisa. Los hallazgos más relevantes son: 1) espirometría con discretas alteraciones funcionales en presencia de disnea marcada y, en un paciente, necesidad de oxigenoterapia crónica, 2) evolución funcional con seudonormalización del patrón espirométrico obstructivo inicial, posiblemente como consecuencia del desarrollo de fibrosis. Un defecto obstructivo leve en un paciente con diagnóstico de obstrucción crónica al flujo aéreo y marcado deterioro de su condición clínica y clase funcional debería alertar sobre la posibilidad de fibrosis pulmonar asociada. La tomografía y la disponibilidad de estudios funcionales previos permiten comprender esta condición.

Combined pulmonary fibrosis and emphysema (CPFE) is a frequently under-diagnosed condition. Isolated pulmonary function tests (PFT) can give rise to misinterpretations. We have found no reports on these patients’ spirometric progression. We describe two cases of CPFE, showing long-term functional evolution to have a more accurate understanding of current spirometric values. The most relevant findings are: 1) spirometry with discrete functional alterations in the presence of a marked dyspnea and the need, in one patient, for chronic oxygen therapy; and 2) functional evolution reflecting "pseudonormalisation" of the initial obstructive spirometric pattern, possibly as a result of fibrosis development. A mild obstructive defect in a patient with chronic airflow limitation and marked impairment of his/her clinical status and functional class should alert on the possibility of associated pulmonary fibrosis. A computed tomography (CT) and previous PFTs will allow a better understanding of this condition.

Patterns of pulmonary function in smoking and nonsmoking patients with progressive systemic sclerosis.

Pulmonary involvement is a prominent feature in systemic sclerosis and a significant cause of morbidity and mortality. A restrictive ventilatory defect is typical and static lung volumes are usually reduced in patients with ILDs. The possibility of obstruction of small airways in progressive systemic sclerosis (SSc) has been suggested by widespread bronchiolectasis and peribronchial fibrosis noted at necropsy. A total of 46 patients with a diagnosis of SSc were retrospectively included in this study. Patients were classified according to their smoking status (never smokers, n = 34 and ex or current smokers, n = 12). Patients were also compared on the basis of the presence or not of an obstructive pattern on spirometry. The purpose of this study was to establish if SSc patients who are smokers have a different pattern of pulmonary function involvement. Our hypothesis was that smoking habit was not the only cause of air trapping and that the existence of small airway involvement secondary to SSc itself cannot be excluded.

[Wegener's granulomatosis and tuberculosis. A bad combination]. / Granulomatosis de Wegener y tuberculosis. Una mala combinación.

Wegener's disease is a vasculitis of small and medium-sized vessels associated with anti-neutrophil cytoplasm antibodies (ANCA). Within their target organs the lungs are involved in 85% of cases. Many entities are part of the differential diagnosis, including pulmonary tuberculosis. We present the case of a 54 years old man, diagnosed as Wegener's disease in 1996 which begins in August 2007 with cough, hemoptysis, progressive dyspnea on effort and serial sputum positive for AFB and then starts TB treatment. Subsequent bronchoalveolar fluids resulted negative for AFB. The patient evolved with impaired renal function, palpable purpura and positive anti-neutrophil cytoplasm antibodies cytoplasmic pattern (c-ANCA), interpreted as Wegener's disease relapse. He started hemodialysis and immunosuppressive therapy and tuberculosis treatment was stopped. One month after discharge was readmitted with a similar picture with serial sputum positive for AFB.

Compromiso pulmonar en esclerosis sistémica / Lung involvement in systemic sclerosis

El objetivo del estudio fue determinar las características clínicas de los pacientes con esclerodermia y compromiso pulmonar y evaluar si existen factores clínicos predictores de mayor riesgo de enfermedad intersticial. Se estudiaron en forma retrospectiva 40 pacientes con esclerodermia. Fueron divididos en 2 grupos: capacidad de difusión del monóxido de carbono (DLCO) normal (n = 22) y DLCO disminuida (n = 18, 45%). Los pacientes con DLCO disminuida no fueron diferentes en edad (51.1 más o menos 13.5 vs. 53.5 más o menos 9.3 años, p = 0.5182), sexo (varones 13.6%, p = 0.6088 ), presencia de Raynaud (86.6% vs. 85%, p = 0.6272), síndrome de ojo seco (6.2% vs. 10.5%, p = 1.0000) prevalencia de enfermedad difusa (94.1% vs. 83.3%, p = 0.6026) o de dilatación esofágica. El tiempo de evolución de la enfermedad no fue diferente. La sensibilidad de la disnea para detectar una DLCO alterada fue 46.6% con una especificidad del 90% y la de la caída de la saturación de O2 (SaO2) del 71.4% y 80% respectivamente. Los pacientes con DLCO baja tuvieron mayor prevalencia de anticuerpos anti-Scl 70 positivos (5/9 vs. 0/11, p = 0.0081) y de incapacidad ventilatoria restrictiva aunque en 56.7% de los pacientes con DLCO disminuida la capacidad pulmonar total (CPT) era normal. La presencia de hipertensión pulmonar medida por ecocardiograma Doppler fue idéntica (11/13 vs. 10/11, p = 1.0000). Los pacientes con DLCO disminuida tuvieron una prevalencia muy superior de tomografía computada de tórax con evidencias de compromiso intersticial (82.3% vs. 5.8%, p menor o igual a 0.0001). En conclusión, nuestros datos sugieren que la disminución de la DLCO es un hallazgo, muy frecuentemente asociado a TAC de tórax con compromiso intersticial y que no hay variables clínicas que permitan predecir su anormalidad.

The objective of this study was to determine clinical predictors of interstitial lung disease in patients with systemic sclerosis (SSc) and pulmonary involvement as defined by presence of a decreased diffusing capacity for carbon monoxide (DLCO). Forty subjects with SSc were retrospectively evaluated. Patients were categorized according to their level of DLCO (less than or more than or equal to 80% of predicted). Sensitivity of dyspnea to detect a decreased DLCO was 46.6% and specificity 90%, whereas oxygen desaturation showed a sensitivity of 71.4% and a specificity of 80%. Patients with decreased DLCO (n = 18) were not different in age (51.1 more or less than 13.5 vs. 53.5 more or less than 9.3 y, p = 0.5182), sex (male 13.6%, p = 0.6088), prevalence of Raynaud (86.6% vs. 85%, p = 0.6272), sicca syndrome (6.2% vs. 10.5% p = 1.0000) diffuse cutaneous involvement (94.1% vs. 83.3%, p = 0.6026) or esophageal dilatation. The duration of symptoms since diagnosis was no different. Prevalence of pulmonary hypertension assessed by Doppler echocardiography or abnormal nailfold capillaroscopic findings were identical in both populations. Patients with low DLCO had a significatly higher prevalence of anti topoisomerase antibodies. (5/9 vs. 0/11, p = 0.0081) and restrictive lung disease. Patients with low DLCO showed a significantly higher prevalence of abnormal HRCT findings suggestive of ILD (82.3% vs. 5.8%, p less than or equal to 0.0001). We conclude that a low DLCO is a frequent finding in SSc patients, strongly associated with HRCT signs of ILD. We have not found clinical factors predictive for a low DLCO.