RESUMEN
Introducción: La insuficiencia cardíaca (IC) tiene alta morbilidad y mortalidad. Su diagnóstico temprano en atención primaria de salud (APS) es un reto dada la baja especificidad de sus criterios clínicos y las limitaciones en acceso a técnicas diagnósticas. Objetivo: Analizar la prevalencia de IC, subtipos y pronóstico de pacientes con disnea y/o edema de extremidades inferiores que consultan en APS. Metodología: Se trata de un estudio prospectivo de 340 pacientes en APS, sin diagnóstico previo de IC. Se realizó una evaluación clínica, electrocardiograma, NT-proBNP "point-of-care", ecocardiografía con interpretación telemática por cardiólogos. Utilizando los algoritmos HFA-PEFF y H2FPEF se clasificaron los pacientes como :1) IC con fracción de eyección (FE) reducida (ICFER); 2) IC con FE preservada (ICFEP) y 3) pacientes sin diagnóstico de IC. Se efectuó un análisis de sobrevida de los diferentes grupos. Resultados: La prevalencia de ICFER fue 8%, ICFEP por HFA-PEFF 42% y por H2FPEF 8%. Los algoritmos sugieren efectuar un estudio complementario en el 47% con HFA-PEFF y 76% con H2FPEF (p<0.05). La sobrevida global a 36 meses fue 90±2% y cardiovascular 95±1%. Usando HFA-PEFF, los pacientes con IC tuvieron menor sobrevida que aquellos sin IC (HR 2.3, IC95% 1.14.9; p=0.029). No hubo diferencias de mortalidad con H2FPEF. Conclusiones: En pacientes de APS que consultan por disnea y/o edema de extremidades inferiores sometidos a evaluación con NT-proBNP y ecocardiografía, se observó una prevalencia de IC de hasta 50%, 8% de ICFER y 42% de ICFEP. La caracterización de IC utilizando HFA-PEFF está asociada al pronóstico vital.
Background: Heart failure (HF) is a condition associated with high morbidity and mortality. Its early diagnosis in primary health care (PHC) represents a substantial challenge, considering its non-specific clinical manifestations and the limitations on timely access to diagnostic techniques. Objective: To evaluate the prevalence of HF, characterize subtypes and determine the prognosis of patients consulting in PHC for dyspnea Edema of the lower extremities. Methods: Prospective study in 340 patients who consulted in PHC, without previous diagnosis of HF. Clinical evaluation, electrocardiogram, NT-proBNP point-ofcare and echocardiography with telematic interpretation by cardiologists were performed. Using the HFA-PEFF and H2FPEF algorithms patients were classified as: 1) HF with reduced ejection fraction (HFREF); 2) HF with preserved ejection fraction (HFPEF) and 3) No HF. Actuarial survival analyses were performed. Results: We observed a prevalence of HFREF of 8%, high probability of HFPEF by HFA-PEFF in 42% and by H2FPEF in 8%. Intermediate probability of HFPEF, requiring complementary study, was observed in 47% of patients with HFA-PEFF and 76% of patients with H2FPEF (p<0.05). Overall survival at 36 months was 90±2% and cardiovascular survival at 36 months was 95±1%. Using HFA-PEFF, patients with HF presented lower overall survival compared to patients with no HF (HR 2.3, 95%CI 1.1-4.9; p=0.029). We did not observe mortality differences with H2FPEF. Conclusions: In patients consulting for dyspnea and/or lower extremity edema at PHC and undergoing evaluation with NT-proBNP and echocardiography, we observed a HF prevalence of 50%. HF classification through HFA-PEFF was associated with lower survival rates.
Asunto(s)
Humanos , Masculino , Femenino , Anciano , Atención Primaria de Salud , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Pronóstico , Volumen Sistólico , Análisis de Supervivencia , Chile , Prevalencia , Péptido Natriurético Encefálico/análisis , Insuficiencia Cardíaca/clasificaciónRESUMEN
La biopsia endomiocárdica (BEM) es un procedimiento invasivo y una herramienta diagnóstica, que en el pasado se encontraba principalmente enfocado en el seguimiento del rechazo post trasplante cardíaco. Actualmente, juega un rol importante en el diagnostico de las miocardiopatías no isquémicas. Se realiza frecuentemente por un acceso venoso para acceder al ventrículo derecho. El rendimiento diagnóstico ha mejorado con el avance del análisis anatomo-patológico. El riesgo de complicaciones, cercana al 1%, de este procedimiento en centros con experiencia puede justificarse frente al beneficio potencial de un diagnóstico y pronóstico preciso.
Endomyocardial biopsy (EMB) is an invasive procedure and a diagnostic tool used mainly on the follow-up of post-heart transplant rejection in the past years. Currently, it has an important role in the diagnosis of non-ischemic cardiomyopathies. EMB is frequently performed through a venous access to enter the right ventricle. Diagnostic performance has improved with advances in pathology analysis. Its complications risk, close to 1% in high-volume interventional centers, can be justified considering the potential benefit of an accurate diagnosis and prognosis.
RESUMEN
COVID-19 disease is associated with a significant number of opportunistic infections, including invasive fungal infections such as mucormycosis. The prevalence of the latter is rare, estimated to be between 0.005 and 1.7 per million inhabitants. Risk factors include hematological diseases, Diabetes Mellitus with poor metabolic control, solid organ transplantation, neutropenia, and prolonged administration of systemic corticosteroids. We report two males aged 60 and 75 years with pulmonary and tracheobronchial invasive mucormycosis, respectively. Both patients had a deficient metabolic control of their diabetes as a predisposing risk factor added to severe COVID-19 infection. High suspicion and early diagnosis are essential for prompt treatment, especially considering the associated high morbidity and mortality of this fungal infection.
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Humanos , Masculino , Persona de Mediana Edad , Anciano , Infecciones Oportunistas/complicaciones , Infecciones Oportunistas/diagnóstico , COVID-19/complicaciones , Mucormicosis/complicaciones , Mucormicosis/diagnóstico , Diabetes MellitusRESUMEN
Chronic coronary syndromes are usually considered uncommon in young women, related to slower progression of atherosclerotic coronary artery disease, have atypical clinical presentations, and experience less diagnostic investigation. Non-atherosclerotic causes of coronary artery disease should be considered in young women experiencing angina. We report a 25-year-old woman who consulted for five months of moderate exertion angina. Physical examination revealed a right carotid bruit and asymmetrical upper extremity peripheral pulses. Initial work-up and imaging allowed to diagnose aortitis with bilateral coronary ostial stenosis secondary to Takayasu's arteritis. The patient experienced an apparent clinical response to initial medical therapy. However, follow-up evaluation revealed persistence of significant ischemia and requirement for myocardial revascularization. A percutaneous coronary intervention was performed.
Los síndromes coronaries crónicos son infrecuentes en mujeres jóvenes, quienes suelen presentar una lenta progresión de enfermedad coronaria aterosclerótica, tienen presentación clínica atípica y son menos sujetas a exploración diagnostica. Se deben considerar causas no ateroscleróticas de enfermedad coronaria en mujeres jóvenes con angina. Informamos una paciente de 25 años que consultó por cinco meses de angina con esfuerzos moderados. Al examen físico presentaba un soplo carotideo derecho y pulsos asimétricos de extremidades superiores. La exploración de laboratorio inicial y posterior evaluación multimodal permitió evidenciar la presencia de aortitis y estenosis de ambos ostium coronarios, concordante con el diagnóstico de una arteritis de Takayasu. Inició terapia medica con respuesta clínica aparentemente favorable. No obstante, la evaluación cardiológica no invasiva en el seguimiento permitió corroborar la persistencia de isquemia significativa y necesidad de revascularización miocárdica. Se realizó una intervención coronaria percutánea de ambos ostium, con una evolución favorable.
Asunto(s)
Humanos , Femenino , Adulto , Enfermedad de la Arteria Coronaria , Arteritis de Takayasu/complicaciones , Arteritis de Takayasu/diagnóstico por imagen , ArteriasRESUMEN
Resumen: Los aneurismas de seno de Valsalva son una malformación rara de observar en la práctica clínica. Se presentan a cualquier edad y pueden ser de origen congénito o adquirido. La importancia de su estudio radica en que potencialmente pueden complicarse con rotura y fistulización a otra estructura cardíaca o extracardíaca, con una alta mortalidad asociada. El diagnóstico muchas veces puede ser complejo, pero existen algunos elementos clínicos inespecíficos que pueden orientarnos en su detección y rápido manejo, lo que puede marcar una diferencia en el pronóstico del paciente. Se presenta el caso de un paciente de 49 años con un aneurisma de seno de Valsalva complicado y a continuación una breve revisión del tema.
Abstract: Aneurysms of the sinus of Valsalva are. They occur at any age, either as a congenital or an acquired malformation. They may rupture and form a fístula to other cardiac structures, with a high mortality rate. The clinical case of a 49 year-old patient with a ruptured sinus of Valsalva an a fístula to the right atrium is presented. A brief review of the subject is included.
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Humanos , Masculino , Persona de Mediana Edad , Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/diagnóstico por imagen , Rotura de la Aorta/complicaciones , Rotura de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/cirugía , Rotura de la Aorta/cirugía , Seno Aórtico/cirugía , Seno Aórtico/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Ecocardiografía TransesofágicaRESUMEN
BACKGROUND: Patients with a cardiovascular (CV) history may be at greater risk of becoming ill and die due to SARS-CoV-2. AIM: To assess the incidence of CV complications in COVID-19 patients, the type of complication, and their association with CV history. MATERIAL AND METHODS: The clinical course of 1,314 patients with COVID-19 admitted consecutively to critical care units of 10 Chilean hospitals was registered between April and August of 2020. RESULTS: The median age of patients was 59 years and 66% were men. One hundred-four (8%) had a CV history, namely heart failure (HF) in 53 (4.1%), coronary heart disease in 50 (3.8 %), and atrial fibrillation in 36 (2.7 %). There were CV complications in 359 patients (27.3%). The most common were venous thrombosis in 10.7% and arrhythmias in 10.5%, HF in 7.2%, type 2 acute myocardial infarction in 4.2%, arterial thrombosis in 2.0% and acute coronary syndrome (ACS) in 1.6%. When adjusted by age, sex and risk factors, only HF (Odds ratio (OR) = 7.16; 95% confidence intervals (CI), 3.96-12.92) and ACS (OR = 5.44; 95% CI, 1.50-19.82) were significantly associated with CV history. There was no association with arrhythmias, type 2 acute myocardial infarction, arterial or venous thrombosis. CONCLUSIONS: Patients with a history of CV disease are at greater risk of suffering HF and ACS when hospitalized due to COVID-19. Arrhythmias, type 2 AMI, and arterial or venous thrombosis occur with the same frequency in patients with or without CV history, suggesting that these complications depend on inflammatory phenomena related to the infection.
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Humanos , Masculino , Femenino , Persona de Mediana Edad , Trombosis de la Vena/etiología , Trombosis de la Vena/epidemiología , Síndrome Coronario Agudo , COVID-19/complicaciones , COVID-19/epidemiología , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/epidemiología , Infarto del Miocardio , Chile/epidemiología , SARS-CoV-2 , Hospitales , Unidades de Cuidados IntensivosRESUMEN
ABSTRACT Background The coronavirus disease (COVID-19) pandemic affected the prompt diagnosis and treatment of Acute myocardial infarction (AMI). Aim: To characterize the clinical profile of patients with AMI during the COVID-19 pandemic, comparing them with a historical cohort. Material and Methods: A case-control study of 96 patients with AMI transferred to a high-volume percutaneous coronary intervention (PCI) hospital between March and July 2020, and a historical cohort of 269 patients transferred during the same period in 2019. Results: When comparing patients transferred during the pandemic with those of the historical cohort, the former were younger (63 ± 12 vs 68 ± 12 years, p 12 hours from the onset of symptoms (44 vs 0%, p < 0.01), a higher median door-to-device time (4 vs 3 hours, p < 0.01), a higher use of primary percutaneous coronary intervention (97 vs 71%, p < 0.01), and higher frequencies of cardiogenic shock (20 vs 4%, p < 0.01) and mechanical complications (10% vs 2%, p < 0.01). Patients during COVID pandemic had a higher thirty-day overall (20 vs 1.4%, p < 0.01) and cardiovascular mortality (13 vs 1%, p < 0.01). During the outbreak, 40% of patients had positive COVID-19 status, which was a predictor for thirty-day overall mortality (Risk ratio 2.90; 95% confidence intervals 1.14-7.36). Conclusions: During the pandemic patients with AMI exhibited delays in consultations and treatment, higher morbidity, and increased mortality. COVID-19 positivity was associated to worse thirty-day overall survival.
Antecedentes: La pandemia COVID-19 afectó el tratamiento oportuno del infarto agudo de miocardio (IAM). Objetivo: Caracterizar el perfil clínico de pacientes con IAM durante la pandemia COVID-19 y compararlos con una cohorte histórica. Pacientes y Métodos: Estudio caso-control de 96 pacientes con IAM transferidos a un hospital de alto volumen de intervención coronaria percutánea (ICP) entre marzo julio de 2020 y una cohorte histórica de 269 pacientes transferidos en el mismo período de 2019 (n = 269). Resultados: Al comparar los pacientes transferidos durante pandemia y la cohorte histórica, los primeros eran más jóvenes (63 ± 12 y 68 ± 12 años respectivamente, p 12 h desde iniciados síntomas de IAM con elevación ST (44,4 y 0% respectivamente, p < 0,01), una mediana de tiempo puerta-guía mayor (4 y 3 horas respectivamente, p < 0,01), un mayor uso de ICP primaria (97 y 71% respectivamente, p < 0,01), mayor frecuencia de shock cardiogénico (19,8 y 4,1% respectivamente, p < 0.01) y complicaciones mecánicas (10,4 y 1,7% respectivamente, p < 0,01). A treinta días, los primeros tuvieron mayor mortalidad general (19,8 y 1,4% respectivamente p < 0.01) y cardiovascular (12,5 y 1,4% respectivamente, p < 0,01). Durante la pandemia, 40% de los pacientes presentó positividad para COVID-19, siendo un factor predictivo de mortalidad general (razón de riesgo 2,90; intervalos de confianza 95% 1,14-7,36). Conclusiones: Durante la pandemia, hubo retrasos en tiempos de consulta y tratamiento y mayor morbimortalidad del IAM. La positividad de COVID-19 se asoció a peor sobrevida general a treinta días.
Asunto(s)
Humanos , Angioplastia Coronaria con Balón , Intervención Coronaria Percutánea , COVID-19 , Infarto del Miocardio/terapia , Infarto del Miocardio/epidemiología , Pronóstico , Reperfusión , Estudios de Casos y Controles , Resultado del Tratamiento , Electrocardiografía , Pandemias , SARS-CoV-2RESUMEN
ABSTRACT Background: Cardiogenic shock (CS) is uncommon in the cardiac catheterization laboratory (CCL) among patients undergoing coronary angiography. Periprocedural CS is more frequent in high-risk patients and in technically demanding procedures. Aim: To describe the clinical outcomes of patients who underwent peripheral venoarterial extracorporeal membrane oxygenation (pVA-ECMO) for CS associated with interventional cardiology procedures. Material and Methods: Review of clinical records of seven patients treated between January 2014 and October 2018. Results: pVA-ECMO was implanted within 6 hours of the interventional cardiology procedure. All patients had coronary artery disease and one of them also had symptomatic severe aortic stenosis. One patient entered the CCL in cardiac arrest. Percutaneous coronary intervention (PCI) was performed in all patients; four patients underwent an emergency procedure and five patients experienced PCI complications. One patient undergoing transcatheter aortic valve replacement suffered acute severe aortic regurgitation. An intra-aortic balloon pump was inserted at the CCL in five patients. Six patients experienced cardiac arrest. Mean SAVE score was -4.3 and baseline lactate 55 mg/dl. pVA-ECMO mean duration was 5 ± 4 days. Survival after both hospital discharge and 12 months of follow-up was 85.7% Regarding vascular access complications, we observed one access site hematoma and one episode of cannulation site bleeding requiring surgical repair. Conclusions: pVA-ECMO should be considered in patients with periprocedural CS as a bridge to recovery. Its use was associated with improved clinical outcomes in this series.
Antecedentes: El shock cardiogénico (SC) es infrecuente en el laboratorio de cateterismo cardíaco (LCC) entre pacientes que son sometidos a coronariografía. El SC peri-procedimiento es más frecuente en pacientes de alto riesgo y en procedimientos técnicamente complejos. Objetivos: Describir los resultados clínicos de pacientes que fueron conectados a oxigenación con membrana extracorpórea veno-arterial periférica (ECMO-VAp) por SC peri-procedimiento de cardiología intervencional. Material y Métodos: Revisión de fichas clínicas de siete pacientes tratados en nuestro centro desde enero de 2014 a octubre de 2018. Resultados: ECMO-VAp fue utilizado dentro de las primeras 6 horas del procedimiento. Todos los pacientes tenían enfermedad coronaria y uno de ellos tenía además estenosis aórtica severa. Un paciente ingresó al LCC en paro cardíaco. Una intervención coronaria percutánea (ICP) fue realizada en todos los pacientes; 4 se realizaron procedimientos de emergencia y 5 pacientes tuvieron complicaciones de la ICP. A un paciente se le realizó un reemplazo valvular aórtico percutáneo y desarrolló una insuficiencia valvular aórtica aguda severa. Se instaló un balón de contrapulsación en el LCC en 5 pacientes. Seis pacientes tuvieron un paro cardiorrespiratorio. El valor del score de SAVE fue de -4,3 y el lactato basal 55 mg/dL. La duración media del ECMO-VAp fue 5 ± 4 días. La sobrevida al alta y a los 12 meses fue 85,7%. Como complicaciones del sitio de acceso vascular se observaron 1 hematoma y un episodio de sangrado que requirió reparación quirúrgica. Conclusiones: ECMO-VAp debería ser considerado en pacientes con SC peri-procedimiento como un puente a recuperación; su utilización estuvo asociada con mejoría de resultados clínicos en esta serie.
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Humanos , Choque Cardiogénico , Oxigenación por Membrana Extracorpórea , Intervención Coronaria Percutánea , Reemplazo de la Válvula Aórtica Transcatéter , Choque Cardiogénico/terapia , Oxigenación por Membrana Extracorpórea/efectos adversos , Resultado del Tratamiento , Intervención Coronaria Percutánea/efectos adversosRESUMEN
BACKGROUND: Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is common. Cardiac magnetic resonance (CMR) and intravascular imaging (IVI) may be useful for establishing its etiology. AIM: To describe a population with MINOCA and its multi-image assessment using IVI or CMR. MATERIAL AND METHODS: Review of medical records, imaging and functional studies of patients with MINOCA treated in three different clinical centers between 2015 and 2019. RESULTS: Twenty-eight patients with MINOCA and IVI were included. Seventy eight percent were women, 46% had hypertension, 32% smoked and 32% had dyslipidemia. At wall motion assessment, 46% presented apical ballooning pattern. In 36% of patients IVI identified lesions that explained the cause of MINOCA, namely plaque disruption (PD) in 18%, spontaneous coronary dissection in 11% and a thrombus without PD in 7%. Forty-six percent of patients had uncomplicated atherosclerotic plaques, and 36% had no pathological findings. CMR was performed in 50% of patients, identifying in all a diagnostic pattern. In nine cases it was compatible with stress cardiomyopathy, three cases had a myocarditis and two cases had transmural infarctions. PD and transmural late gadolinium enhancement were observed in 23% of patients with apical ballooning. Patients with a pattern of myocarditis did not have acute pathological findings at IVI. After a mean follow-up of 16.4±11.4 months, 3 patients with PD died. CONCLUSIONS: Among patients with MINOCA, there was a predominance of female gender with low cardiovascular risk factor load. The multi-image assessment allowed greater precision for etiological diagnosis of MINOCA. Apical ballooning was not pathognomonic for stress cardiomyopathy. PD was associated with mortality.
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Humanos , Masculino , Femenino , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Infarto del Miocardio/etiología , Infarto del Miocardio/diagnóstico por imagen , Angiografía Coronaria , Medios de Contraste , GadolinioRESUMEN
Background: Pharmacological treatment improves survival in patients with heart failure with reduced ejection fraction. The use of sacubutril/valsartan and ivabradine has been recently approved and incorporated in the latest guidelines. Aim: To identify candidates eligible for these therapies among patients treated in a heart failure clinic, considering the inclusion criteria for the PARADIGM-HF and SHIFT trials. Material and Methods: Cross-sectional study on 158 patients aged 62 ± 11 years (67% male) with heart failure and reduced ejection fraction, with at least three months of follow-up and without decompensation. The percentage of patients complying for the inclusion criteria for the PARADIGM-HF y SHIFT trials was determined. Results: In 37%, the etiology of heart failure was ischemic, 49% were in functional class I, their ejection fraction was 33 ± 11% and their median Pro-brain natriuretic peptide was 800 pg/mL. Ninety five percent were treated with vasodilators, 97% with beta-blockers and 82% with aldosterone antagonists. Using PARADIGM-HF and SHIFT criteria, 11 patients (7%) were eligible for sacubitril / valsartan and 21 patients (13.3%) for ivabradine. Among the main causes of non-eligibility for sacubitril / valsartan were being functional class I (48.7%) and not achieving a stable dose of enalapril ≥ 20 mg / day or losartan ≥ 100 mg / day (24.7%). In the case of ivabradine, apart from those in functional class I, the absence of sinus rhythm and a heart rate < 70 / min when receiving a maximal tolerated dose of beta-blockers, were present in 22%. Conclusions: A low percentage of our patients were eligible for these therapies. Among the causes that explain these results were clinical stability, a high percentage of patients in functional class I and being in a disease modifying treatment.
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Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Tetrazoles/administración & dosificación , Fármacos Cardiovasculares/administración & dosificación , Antagonistas de Receptores de Angiotensina/administración & dosificación , Ivabradina/administración & dosificación , Aminobutiratos/administración & dosificación , Insuficiencia Cardíaca/tratamiento farmacológico , Estudios Transversales , Selección de Paciente , Relación Dosis-Respuesta a Droga , Combinación de Medicamentos , Insuficiencia Cardíaca/fisiopatologíaRESUMEN
El cáncer de próstata es el segundo cáncer más prevalente en hombres en el mundo. Corresponde a la segunda causa de muerte por cáncer en hombres en Chile y EE.UU. convirtiéndose de esta manera en un problema de salud pública relevante. Hemos visto una serie de modificaciones a las recomendaciones de tamizaje del cáncer de próstata. Esta revisión tiene por objetivo resumir los principales acontecimientos en cuanto a recomendaciones sobre screening. La USPSTF ha realizado recomendaciones y variaciones a estas, siendo la última publicada en abril 2017. En Chile el screening no está incluido dentro de un programa ministerial y las últimas recomendaciones son del 2010. El uso y abuso del APE conlleva un stress emocional y eventuales complicaciones al paciente. Parece razonable, entonces, plantear un algoritmo basado no sólo en un parámetro predeterminado para definir si un paciente debe realizarse una biopsia o no, sino que incorporar al paciente en una toma de decisión informada.(AU)
Prostate cancer is the second cancer diagnosed in men in the world. It corresponds to the second cause of cancer death in men in Chile and the United States, thus becoming a relevant public health problem. We've seen a number of changes in prostate cancer screening recommendations. This review aims to summarize the main events regarding recommendations on screening. The USPSTF has made recommendations and variations to these subject, the last one being published in April 2017. In Chile, screening is not included in a ministerial program and the latest recommendations date from 2010. The use and abuse of the PSA brings emotional stress, as well as risks to the patient. It seems reasonable to propose an algorithm based not only on a parameter to define whether a patient requires a biopsy or not, but to incorporate the patient into an informed decision-making.(AU)
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Masculino , Neoplasias de la Próstata , Tamizaje Masivo , Antígeno Prostático EspecíficoRESUMEN
Fungal peritonitis is a major complication of peritoneal dialysis associated with high mortality. Most survivors have a high rate of abandonment of peritoneal dialysis. We report a case of fungal peritonitis due to an unusual agent. An 83 year-old woman, with a history of type 2 diabetes mellitus and multiple episodes of bacterial peritonitis associated to technical flaws in the implementation of automated peritoneal dialysis, was admitted due to abdominal pain and cloudy peritoneal fluid. Rhodotorula mucilaginosa was identified in the peritoneal fluid by MALDI-TOF. She was treated with catheter removal and oral posaconazole for 14 days showing clinical resolution and non-recurrence.
La peritonitis fúngica es una complicación mayor de la diálisis peritoneal, con una alta mortalidad asociada y la mayoría de los sobrevivientes presentan una alta tasa de abandono de diálisis peritoneal como terapia de reemplazo renal. Se presenta un caso de peritonitis fúngica por un agente infrecuente. Mujer de 83 años, diabética con múltiples episodios de peritonitis bacteriana asociada a fallas técnicas en la ejecución de diálisis peritoneal automatizada, ingresa por cuadro clínico de dolor abdominal y líquido peritoneal turbio. Se confirmó la presencia de Rhodotorula mucilaginosa en líquido peritoneal mediante MALDI-TOF. Fue tratada con retiro del catéter y posaconazol oral por 14 días, presentando una evolución favorable.
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Humanos , Femenino , Anciano de 80 o más Años , Peritonitis/microbiología , Rhodotorula/aislamiento & purificación , Diálisis Peritoneal/efectos adversos , Fiebre Mediterránea Familiar/terapia , Factores de Tiempo , Triazoles/uso terapéutico , Diálisis Peritoneal/métodos , Infecciones Relacionadas con Catéteres/microbiología , Infecciones Relacionadas con Catéteres/terapia , Antifúngicos/uso terapéuticoRESUMEN
Background: Consumption of illicit drugs (ID) has been associated with an increased risk of acute myocardial infarction (AMI). There is limited national evidence about the impact of substance use over the clinical presentation, management and outcomes of AMI patients. Aim: To describe the prevalence of ID consumption in patients within the Chilean Registry of Myocardial Infarction (GEMI), comparing clinical characteristics, management and outcome according to consumption status. Material and Methods: We reviewed data from the GEMI registry between 2001 and 2013, identifying 18,048 patients with AMI. The sample was stratified according to presence or absence of previous ID consumption, comparing different demographic and clinical variables between groups. Results: Two hundred eighty five patients (1.6%) had history of ID consumption (cocaine in 66%, cannabis in 35% and central nervous system stimulants in 24.0%). Compared with non-users, ID consumers were younger, predominantly male and had a lower prevalence of cardiovascular risk factors, except for tobacco smoking (86.3% and 42.5% respectively, p < 0.01). Among consumers, there was a higher percentage of ST segment elevation (85.2% and 67.8% respectively, p < 0.01) and anterior wall AMI (59.9 and 49.5% respectively, p = 0.01). Additionally, they had a higher rate of primary angioplasty (48.8% and 25.5% respectively, p < 0.01). There was no difference in hospital mortality between groups when stratified by age. Conclusions: A low percentage of patients with AMI had a previous history of ID consumption in our national setting. These patients were younger and had a greater frequency of ST segment elevation AMI, which probably determined a more invasive management.
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Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Drogas Ilícitas/efectos adversos , Infarto del Miocardio/inducido químicamente , Cannabis/efectos adversos , Chile/epidemiología , Prevalencia , Estudios Transversales , Factores de Riesgo , Cocaína/efectos adversos , Infarto del Miocardio/mortalidadRESUMEN
Introduction and aims: Despite general availability of HAART in Chile, admissions of HIV/AIDS patients to Intensive-Intermediate Care Units (IICU) are still happening, and a characterization of patient's profile, mortality and potentially avoidable admissions is necessary. Methods: Observational retrospective study in one general hospital in Chile of HIV/AIDS patients admitted to IICU during 9 years. Results: During 2005-2013, 32 patients were admitted to IICU, with 87,5% in AIDS stage, only 53,1% knew his/her condition, 43,8% were receiving HAART and 16.6% chemoprophylaxis for opportunistic infections, A CD4 count < 200/µL was registered in 75,9% of patients. Most admissions were driven by infectious conditions (84,4%) and 48,1% developed septic shock, IICU hospitalizations were motivated by respiratory failure, neurologic compromise, sepsis or a mixture of them (87,5%), By univariate analysis, admissions by respiratory failure were associated to no HAART, oral candidiasis or CD4 < 250/µL (p < 0.01). Eight patients died during their first hospitalization (25%) and other 5 in the following month after discharge. Death during hospitalization was significantly associated to vasoactive drug use ≥ 7 days (OR 16.5; IC95 2.1-128 p < 0.01). In multivariate analysis, APACHE score ≥ 18 was associated with death during hospitalization of after discharge (OR 3,3 IC95 1,1-10; p < 0,05), Four patients (12,5%) had potentially avoidable admissions. Conclusions: Despite HAART availability in Chile, hospitalizations of patients with HIV/AIDS are still happening, affecting those that either are unaware of his/her condition, are not receiving HAART and/or chemoprophylaxis. These admissions generate premature deaths and happen even after discharge in severely ill patients.
Antecedentes y Objetivos: A pesar de la disponibilidad de la terapia viral de gran actividad (TARGA) en Chile el ingreso de pacientes con infección por VIH/SIDA a la Unidad de Pacientes Críticos (UPC) siguen ocurriendo. Se necesita mayor información en Chile sobre el perfil de estos pacientes, su mortalidad y el porcentaje de ingresos evitables. Método: Estudio observacional retrospectivo de pacientes adultos que ingresaron a la UPC en un hospital general durante 9 años. Resultados: En el período 2005-2013 se identificaron 32 pacientes que ingresaron a UPC. El 87,5% estaba en etapa SIDA al ingreso, 53,1% sabía su diagnóstico, sólo 43,8% recibía terapia TARGA y 16,6% quimioprofilaxis. Un 75,9% tenía un recuento CD4 < 200/µL. La mayoría de los ingresos fue por una causa infecciosa (84,4%) y 48,1% presentaron shock séptico. Por sistemas, los ingresos a UPC fueron liderados por falla respiratoria, compromiso neurológico, sepsis o una mezcla de ellos (87,5%). Por análisis univariado, el ingreso por falla respiratoria se asoció a ausencia de HAART, candidiasis oral o un recuento CD4 < 250/µL (p < 0,01). Ocho pacientes fallecieron en la primera hospitalización (25%) y otros cinco en los meses siguientes al alta. El desenlace fatal en el hospital estuvo significativamente asociado al uso de fármacos vasoactivos por ≥ 7 días (OR 16,5; IC 95 2,1-128 p < 0,01). En el análisis multivariado, un score APACHE ≥ 18 se asoció en forma independiente a fallecimiento en el hospital o post alta (OR 3,3 IC 95 1,1-10; p < 0,05). Cuatro pacientes (12,5%), tuvieron hospitalizaciones potencialmente evitables. Conclusiones: Las hospitalizaciones de pacientes con infección VIH a UPC siguen ocurriendo a pesar de la disponibilidad de TARGA en Chile, afectando a pacientes que desconocen su condición, no están en tratamiento o con profilaxis. Estos ingresos generan muertes prematuras, las que ocurren incluso después del alta en los pacientes más graves.
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Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Terapia Antirretroviral Altamente Activa , Infecciones por VIH/tratamiento farmacológico , Unidades de Cuidados Intensivos/estadística & datos numéricos , Chile/epidemiología , Países en Desarrollo , Infecciones por VIH/mortalidad , Mortalidad Hospitalaria , Hospitales Generales , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores de TiempoRESUMEN
Background: Intracoronary delivery of autologous bone marrow mononuclear cells is an interesting therapeutic promise for patients with heart failure of different etiologies. Aim: To evaluate the long-term safety and efficacy of this therapy in patients with dilated cardiomyopathy of different etiologies under optimal medical treatment. Patients and Methods: Prospective, open-label, controlled clinical trial. Of 23 consecutive patients, 12 were assigned to autologous bone marrow mononuclear cell intracoronary transplantation, receiving a mean dose of 8.19 ± 4.43 x 10(6) CD34+ cells. Mortality, cardiovascular readmissions and cancer incidence rate, changes in functional capacity, quality of life questionnaires and echocardiographic measures from baseline, were assessed at long-term follow-up (37.7 ± 9.7 months) in patients receiving or not the cells. Results: No significant differences were observed in mortality, cardiovascular readmissions or cancer incidence rate amongst groups. An improvement in functional class and quality of life questionnaires in the transplanted group was observed (p < 0.01). The treated group showed a non-significant increase in left ventricular ejection fraction at long-term follow-up (from 26.75 ± 4.85% to 34.90 ± 8.57%, p = 0.059 compared to baseline). There were no changes in left ventricular volumes. We observed no improvement of these variables in the control group. Conclusions: Intracoronary transplantation of autologous bone marrow mononuclear cells is feasible and safe in patients with dilated cardiomyopathy of diverse etiologies. This therapy was associated to persistent improvements in functional class and quality of life. There was also a non-significant long-term improvement of left ventricular function.
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Femenino , Humanos , Masculino , Persona de Mediana Edad , Trasplante de Médula Ósea/métodos , Cardiomiopatía Dilatada/cirugía , Trasplante de Médula Ósea/mortalidad , Volumen Cardíaco/fisiología , Cardiomiopatía Dilatada/mortalidad , Cardiomiopatía Dilatada , Estudios de Seguimiento , Readmisión del Paciente/estadística & datos numéricos , Estudios Prospectivos , Calidad de Vida , Volumen Sistólico/fisiología , Encuestas y Cuestionarios , Factores de Tiempo , Trasplante Autólogo , Resultado del Tratamiento , Función Ventricular/fisiologíaRESUMEN
Available medical therapy is unable to completely prevent or revert the pathological cardiac remodeling secondary to ischemia or other injuries, which is responsible for the development of heart failure. Regenerative medicine through stem cells had an explosive development in the cardiovascular area during the past decade. Stem cells possess the capacity to regenerate, repair or substitute damaged tissue, allowing the reestablishment of its function. Stem cells can also modulate apoptosis, angiogenesis, fibrosis and inflammation, favoring the endogenous regenerative process initiated by the damaged tissue. These capacities have been corroborated in several animal models of cardiovascular diseases with positive results. In humans, therapies with bone marrow mononuclear stem cells, mesenchymal stem cells and cardiac stem cells are safe. Most randomized clinical trials in patients with myocardial infarction or cardiomyopathies of different etiologies have reported benefits on ventricular function, quality of life and even over mortality of treated patients. This article reviews the state of art of stem cell therapy in cardiovascular diseases, focusing on the most common cellular types used in patients with acute myocardial infarction and chronic cardiomyopathies of different etiologies.
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Humanos , Enfermedades Cardiovasculares/cirugía , Trasplante de Células Madre/métodos , Transdiferenciación Celular , Enfermedad Crónica , Cardiopatías/cirugía , Células Madre Multipotentes/fisiología , Células Madre Multipotentes/trasplante , Infarto del Miocardio/cirugíaRESUMEN
In recent years, much attention has focused on the role of aldosterone and mineralocorticoid receptors (MRs) in the pathophysiology of hypertension and cardiovascular disease. Patients with primary aldosteronism, in whom angiotensin II levels are low, have a higher incidence of cardiovascular complications than patients with essential hypertension. The Randomized Aldactone Evaluation Study (RALES) demonstrated that adding a non-specific MR antagonist, spironolactone, to a standard therapy that included angiotensin-converting enzyme (ACE) inhibitors, loop diuretics, and digoxin, significantly reduced morbidity and mortality in patients with moderate to severe heart failure. Similarly, the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) showed that the addition of a selective MR antagonist (ARM), eplerenone, to an optimal medical therapy reduces morbidity and mortality among patients with acute myocardial infarction complicated by left ventricular dysfunction and heart failure. These data suggest that aldosterone induces cardiac injury through activation of MRs and support the notion that MR blockade has beneficial effects on aldosterone-dependent cardiac injury, through mechanisms that cannot be simply explained by hemodynamic changes. Although, MRA are highly effective in patients with heart failure, the risk of hyperkalemia should not be overlooked. Serious hyperkalemia events were reported in some MRA clinical trials; however these risks can be mitigated through appropriate patient selection, dose selection, patient education, monitoring, and follow-up.
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Humanos , Enfermedades Cardiovasculares/tratamiento farmacológico , Antagonistas de Receptores de Mineralocorticoides/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Hipertensión/tratamiento farmacológico , Infarto del Miocardio/tratamiento farmacológico , Disfunción Ventricular Izquierda/tratamiento farmacológicoRESUMEN
Introducción: Estudios recientes indican que el trasplante intracoronario de células mononucleares de médula ósea (BMCs) autólogas, mejoran la fracción de eyección (FEVI) y otros marcadores clínicos en pacientes con insuficiencia cardíaca (IC). Objetivo: Evaluar la seguridad y eficacia de la administración intracoronaria de BMCs autólogas, en pacientes con insuficiencia cardíaca (IC) en fase dilatada, de diferente etiología y en óptimas condiciones de tratamiento médico. Método: De 23 pacientes consecutivos que cumplieron con los criterios de inclusión, 12 fueron asignados a trasplante intracoronario de BMCs autólogas, recibiendo una dosis media de 8.19+/-4.43 x 10(6) células CD34+ (Grupo trasplantado). Los pacientes restantes sólo recibieron terapia estándar (Grupo control). Todos los pacientes fueron evaluados mediante Electrocardiograma, Ecocardiografía, Holter ECG, RMN Cardíaca, Test de esfuerzo, Potenciales Ventriculares Tardíos, Variabilidad de Frecuencia Cardíaca y evaluación clínica a los 0, 3, 6 y 12 meses. La capacidad funcional (CF) fue evaluada clínicamente y por cuestionarios de calidad de vida. Elanálisis estadístico fue realizado mediante Test Anova, y test de Bonferroni. Resultados: El grupo trasplantado presentó un aumento significativo de la FEVI a los 6 meses (26.75+/-4.85 vs 37.82+/-6.97 por ciento, p=0.001) mejoría que se mantuvo a los 12 meses (26.75+/-4.85 vs 37.27+/-7.51 por ciento, p=0.002). Hubo una mejora significativa de la CF en el grupo trasplantado a los 6 y 12 meses (p<0.001). No hubo cambios significativos en los volúmenes de ventrículo izquierdo, así como en las restantes variables estudiadas. En el grupo control no observamos cambios de estas variables. No hubo complicaciones en relación al trasplante de BMCs. Conclusión: En pacientes con IC severa y baja FEVI, el trasplante intracoronario de células BMCs au-tólogas, se asoció a una mejoría significativa de la FEVI y la CF, a los 6 y 12 meses. Adicionalmente, no observamos ...
Background: Recent studies indicate that intra-coronary delivery of autologous bone marrow mono-nuclear cells (BMCs) improves the ejection fraction (LVEF) and other clinical markers in patients with heart failure (HF). Aim: To evaluate the safety and efficacy of intraco-ronary delivery of autologous BMCs in patients with HF in dilated phase under optimal medical treatment. Method: Of 23 consecutive patients who met the inclusion criteria, 12 were assigned to autologous BMCs intracoronary transplantation, receiving a mean dose of 8.19+/-4.43 x 106 CD34+ cells (BMCs group). The remaining patients received only standard therapy (control group). All patients were evaluated by Electrocardiogram, Echocardiography, Holter Monitoring, Cardiac Magnetic Resonance Imaging, Stress Testing, Ventricular Late potetials, Heart Rate Variability, and regular clinical examination at baseline and at follow-up (3, 6 and 12 months). Repeated measures ANOVA and Bonferroni testing were used for statistic analysis. Results: The BMCs group presented a significant increase in EF at sixth months (26.75+/-4.85 vs. 37.82+/-6.97 per cent, p=0.001) and 12 months post-transplant (26.75+/-4.85 vs. 37.27+/-7.51 per cent, p=0.002). There was a significant improvement in functional (NYHA) in the transplanted group at 6 and 12 months (p<0.001). There were no significant changes concerning left ventricular volumes, heart rate variability and exercise stress testing. We observed no improvement of these variables in the control group. There were no complications related to the BMCs transplant. Conclusions: Intracoronary infusion of auto-logous BMCs, in addition to standard therapy, was associated with significant improvement of left ventricular function at 12 months in patients with HF. We observed no complications relative to the procedure.
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Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Trasplante de Médula Ósea , Insuficiencia Cardíaca/terapia , Función Ventricular , Análisis de Varianza , Cardiomiopatía Dilatada/fisiopatología , Estudios de Seguimiento , Método Simple CiegoRESUMEN
Muchos modelos predictivos de recidiva para cáncer de próstata (CaP) post prostatectomía radical (PR)son difíciles de aplicar y la tendencia es a encontrar modelos que consideren datos clínicos y patológicosde fácil y rápida obtención. El grupo de trabajo del Johns Hopkins Hospital desarrolló una ecuación deriesgo validada para identificar pacientes de alto riesgo de recidiva precoz de CaP (etapa clínica T1c),después de PR.Realizamos una revisión retrospectiva de pacientes sometidos a PR retropúbica por CaP etapa clínica T1,con un seguimiento mínimo de 6 meses. En estos pacientes aplicamos la ecuación Rw.De un total de 190 pacientes sometidos a PR en los últimos 7 años, encontramos 60 pacientes analizablesen etapa T1c. El promedio de seguimiento fue de 25,4 meses. Al aplicar la ecuación Rw encontramos unasensibilidad de 29 porciento, especificidad de 98 porciento, VPP de 83 porciento y VPN de 78 porciento. En nuestra serie la ecuación RWtiene una pobre sensibilidad pero una buena especificidad.