RESUMO
Background: Immunomodulatory drugs (IMD), Interferon β1a, β1 b and glatiramer acetate are available in the Chilean public health system since June 2008 for patients with relapsing-remitting multiple sclerosis (RR-MS). Diagnostic confirmation and programmed follow up of these patients is carried out at a public national reference center. Aim: To describe the epidemiological and clinical features of 314 patients evaluated in this center between 2008 and 2012. Patients and Methods: Review of clinical records, to obtain information about demographic background, medical history, expanded disability status scale of Kurtzke (EDSS), multiple sclerosis functional composite (MSfic), intensity fatigue scale of Krupp, Raos Brief Repeatable Battery of Neuropsychological Tests (BNR-R) and anxious-depressive manifestations using Hamilton and Beck questionnaires. Results: The ages of patients ranged from 12 to 63 years and 67% were women. The initial symptoms were sensory disturbances in 20%, motor alterations in 18% and optical neuritis in 16%. In 9% of patients, the disease began with several manifestations. The EDSS was 4 or less in 73% of patients and cognitive impairment was observed in 34%. Treatment failure during the first and second years, occurred in 23 and 26% of patients, respectively. Male gender, age under 40 and brainstem malfunction at the onset of disease, were predictive of treatment failure during the second year. Conclusions: The features of these patients are very similar to those reported abroad.
Assuntos
Adolescente , Adulto , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Transtornos Cognitivos/etiologia , Depressão/etiologia , Esclerose Múltipla Recidivante-Remitente/complicações , Chile , Progressão da Doença , Fatores Imunológicos/uso terapêutico , Esclerose Múltipla Recidivante-Remitente/tratamento farmacológico , Esclerose Múltipla Recidivante-Remitente/psicologia , Testes Neuropsicológicos , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
Background: The detection of cognitive changes (CC) and psychiatric disorders in relapsing remitting multiple sclerosis (MS-RR) contributes to patient clinical monitoring. Aim: To assess the frequency and characteristics of CC and psychiatric disorders in Chilean patients with MS-RR, before starting immunomodulatory treatment. Patients and Methods: Retrospective review of data that was obtained following a standard assessment protocol. It consisted in the application of the Expanded Disability Status Scale of Kurtzke (EDSS), Multiple Sclerosis Functional Composite (MSFC), fatigue intensity scale of Krupp, brief repeatable battery of neuropsychological Rao (BRN-R) and Hamilton's depression and anxiety questionnaires. Results: We evaluated 129 patients aged between 12 and 60 years of age (69% women). Ninetyfour percent of patients had eight or more years of schooling. The average EDSS score was 2.83. CC were detected in 62% of participants, in at least one subtest of the BRN-R. The main changes were verbal memory and speed in the processing information. The frequency of cognitive impairment (CI), defined as at least two BRN-R subtests altered, was 36%. The figures decreased to 17% when significant major depression or associated fatigue were excluded. Depressive symptoms were observed in 58% and anxiety in 76.7%. Conclusions: The results are consistent with those described in the literature. The type of instruments used in the investigation of CC and the definition of CI in MS should be standardized.
Assuntos
Adolescente , Adulto , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Transtornos Cognitivos/epidemiologia , Fatores Imunológicos/uso terapêutico , Esclerose Múltipla Recidivante-Remitente/psicologia , Testes Neuropsicológicos , Ansiedade/epidemiologia , Estudos de Casos e Controles , Chile/epidemiologia , Transtornos Cognitivos/diagnóstico , Depressão/epidemiologia , Esclerose Múltipla Recidivante-Remitente/tratamento farmacológico , Estudos RetrospectivosRESUMO
In this "point of view" or special article, it has been reviewed the main bibliographic antecedents related to the entity denominated as chronic cerebrospinal venous insufficiency (CCSVI), which formulation has been stated by Zamboni et col, from the Vascular Diseases Center of the University of Ferrara-Italy, who have assigned it a pathogenic role or of aggravation one in Multiple Sclerosis (MS), what has led them to propose and carry out endovascular balloon angioplasty or venous stent in MS patients as a treatment. The bibliographic review at this stage of the knowledge of CCSVI does not let us to conclude whether this hypothetical entity has any role in the development or aggravation of MS. On the other hand, we agree with most of the clinicians and neuroimaging MS researchers because of the absence of arguments to indicate, support or propose envovascular "therapeutic" procedures for MS. To advance in the knowledge of CCSVI and the eventual relation with MS it is required some multicentric controlled studies carefully led and clinical and methodological rigorous procedures approved by committee of ethic in very well informed patients invited to participate in protocols of formal investigation who should be protected by complementary pertinent insurances and responsibilities connected to the investigation expenses.
En este artículo especial de la modalidad "puntos de vista", se revisan los antecedentes bibliográficos principales relacionados a la entidad denominada "Insuficiencia venosa crónica cerebro medular (IVCCM)" cuya formulación ha sido planteada por Zamboni y col, del Centro de Enfermedades Vasculares de la Universidad de Ferrara-Italia quienes le han adjudicado un rol patogénico o de agravación en la Esclerosis Múltiple (EM), que les ha llevado a proponer y realizar procedimientos de angioplastía mediante balón endovascular o stent venoso en pacientes con EM. La revisión de la bibliografía, en esta etapa del conocimiento de la IVCCM, no permite concluir si esta hipotética entidad tiene algún rol en el desarrollo o agravación de la EM. Por otro lado, concordamos con la mayoría de los clínicos e imagenólogos dedicados al estudio y tratamiento de la EM, en la ausencia de argumentos para indicar, alentar o propiciar procedimientos "terapéuticos" endovasculares para la EM. Para avanzar, en el conocimiento de la IVCCM y de eventual relación con la EM, se requieren estudios multicéntricos cuidadosamente conducidos, clínica y metodológicamente rigurosos, aprobados por comités de ética, en pacientes que sean invitados informadamente a participar en protocolos de investigación formales, que cuenten con las protecciones de seguros complementarios pertinentes y responsabilidades del gasto a costas de los investigadores.
Assuntos
Humanos , Angioplastia com Balão , Doenças do Sistema Nervoso Central/terapia , Esclerose Múltipla/terapia , Insuficiência Venosa/terapia , Stents , Doença Crônica , Doenças do Sistema Nervoso Central/fisiopatologia , Esclerose Múltipla/fisiopatologia , Insuficiência Venosa/fisiopatologiaRESUMO
Background: The only accepted treatment for acute ischemic stroke is thrombolysis with recombinant tissue plasminogen activator (t-PA). It was implemented in Chile in 1996, although its use was mainly restricted in Chile to private clinics. Recently, at year 2009, we have implemented this treatment in a public hospital. Aim: To describe the results of treatment of acute ischemic stroke with t-PA in a public hospital in Chile. Material and Methods: Prospective analysis of all eligible patients with acute ischemic stroke that were admitted within 4 hours of its onset and had no contraindications for thrombolysis. Results: In an eight months period, a total of 19 intravenous thrombolyses were performed in 12 males and seven females aged 28 to 79 years old. The mean lapse between onset of symptoms and onset of thrombolysis was 190 ± 57 min. Results were favorable, according to Rankin and National Institute of Health Stroke scales. Ninety days after treatment, 63 percent of patients had minimal or absent disability, 26 percent had moderate disability and only one (5 percent) had severe disability. One patient had a clinically not significant intracranial hemorrhage and one patient died six days after thrombolysis. Conclusions: These results indicate that thrombolysis can be successfully implemented in Chilean public hospitals. The limitations for its use in this setting are mostly administrative.
Assuntos
Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fibrinolíticos/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/uso terapêutico , Chile , Protocolos Clínicos , Hospitais Públicos , Estudos Prospectivos , Proteínas Recombinantes/uso terapêutico , Reprodutibilidade dos Testes , Resultado do TratamentoRESUMO
Multiple Sclerosis (MS) is a chronic disease of the central nervous system. It is manifested in the young adult who presents at the beginning alternation between transient neurological dysfunction and normality, followed by a progressive level of disability. MS affects the quality of life in the young adults in their full productive and creative age limiting not only in their personal lives but also affects to the whole society in terms of "dreams and life projects". Besides, this illness also influences the family group who has to assume progressively the help and care for the patient. In healthcare aspect MS implies intensive and progressive resources. In Chile, although we don't have epidemiological studies that indicate which is the MS prevalence it exist a projection that states 14 per 100.000 inhabitants. Considering a population of 16.5 million of inhabitants our expectative of patients with MS is of 2310 cases in our country. The MS immunomodulating injectable disease-modifying therapies are of high cost and were not available in a regular way in the state health care system of Chile (FONASA) that attends the 70 percent of the population; the other 30 percent has different private health insurances. In 2008 the ministry of health decided to initiate and pilot (exploratory) program which had a great meaning and impact concerning to start offering immunomodulating therapies to relapsing remitting MS, for patients belonging to FONASA system. The pilot program was thought with a double mission, on the one hand to achieve that a very limited group of MS patients belonging to FONASA system (80 cases) from all over the country had access to immunomodulating injectable disease-modifying therapies of high cost in a regular way. The second objective was to obtain clinical and epidemiological information which let us to evaluate the clinical and administrative obstacles generated by the incorporation of this treatment in the public health...
Introducción El presente documento corresponde al informe del primer año de trabajo operativo del "Programa piloto de tratamiento con inmunomoduladores, para pacientes beneficiarios de Fonasa1, que padecen esclerosis múltiple (EM)", elaborado por el equipo del centro de referencia nacional, para este programa, con sede en el Servicio de Neurología del Complejo Asistencial Barros Luco (CABL) del SSMS2. Dado su origen no incluye antecedentes del proceso de gestión ni toma de decisiones del nivel Minsal3 o Fonasa. Este trabajo, no es ni aspira ser: un ensayo clínico, una guía de práctica clínica, una revisión bibliográfica, ni una puesta al día sobre el tratamiento de la Esclerosis Múltiple (EM), es simplemente el informe anual de un centro de referencia, para una tarea específica, a la autoridad ministerial competente. El informe incluye algunos antecedentes generales y referencias presentadas como "notas al pie", sólo para contextualizar la información presentada4. La EM es una enfermedad crónica del SNC, de origen incierto, inmunológicamente mediada, bien definida en sus características inmunopatogénicas, patológicas, imagenológicas y clínicas. Se expresa en el adulto joven, quien presenta inicialmente alternancia entre disfunción neurológica transitoria y normalidad y cuya progresión determina múltiples efectos discapacitantes. La EM afecta la calidad de vida de adultos jóvenes en plena edad productiva y creativa limitando tanto los "sueños y proyectos de vida" como el desarrollo laboral, social y afectivo. Además trasciende al grupo familiar, cuando deben asumir la asistencia del paciente. En lo sanitario, la EM, genera uso intensivo y progresivo de recursos. Las terapias inmunomoduladores para la EM, que tienen la posibilidad de detener o reducir la evolución de la modalidad recurrente remitente de la EM, no se encontraban disponibles en forma regular en el sector público de salud de nuestro país, por esto el presente programa piloto...
Assuntos
Humanos , Masculino , Feminino , Esclerose Múltipla/tratamento farmacológico , Fatores Imunológicos/uso terapêutico , Programas Nacionais de Saúde , Setor Público , Chile , Seguro Saúde , Interferon beta/uso terapêutico , Seleção de Pacientes , Projetos Piloto , Peptídeos/uso terapêuticoRESUMO
Presentamos el caso clínico de un paciente que consultó por un síndrome cerebeloso y diplopía, asociados a pérdida de peso de 10 kilos en 6 meses y adenopatías múltiples. El estudio imagenológico cerebral demostró la presencia de lesiones de aspecto granulomatoso a nivel cerebeloso y mesencefálico, sin alteración citoquímica del líquido cefalorraquídeo. Las baciloscopias de orina y de la biopsia ganglionar fueron positivas y permitieron el diagnóstico de tuberculosis (TBC) sistémica. La serología para VIH resultó positiva en sangre con un recuento de linfocitos CD4 de 590 cel/mm3, clasificándose el caso como SIDA etapa Cl. El paciente fue tratado con el esquema antituberculoso según norma nacional, con buena respuesta clínica e imagenológica. La presentación de tuberculomas infratentoriales sin meningitis, como primera causa de pesquisa de TBC y SIDA no es habitual, de allí nuestro interés por comunicar el caso.
We present a clinical case of a patient who consulted for a cerebelous syndrome and diplopia associated to 10 kg weight loss in six months and multiple adenopathies. Cerebral imagenology study evidenced the presence of granulamatous masses at the cerebellum and midbrain level, there were no cerebrospinal fluid abnormalities. Systemic tuberculosis (TB) diagnosis was done based in finding of acid-fast bacilli positive staining in urine and lymph node biopsy. HIV infection was documented by ELISA serology. CD4 cell count was 590 cell/mm3, classifying the case a AIDS Cl stage. TB was treated according to national guidelines leading to good clinical and imagenology evolution. The clinical case scenario of infratentorial tuberculomas without meningitis as a first manifestation of TB and AIDS is unusual, generating our interest in reporting this case.
Assuntos
Adulto , Humanos , Masculino , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Antituberculosos/uso terapêutico , Doenças Cerebelares/microbiologia , Tuberculoma Intracraniano/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Doenças Cerebelares/diagnóstico , Doenças Cerebelares/tratamento farmacológico , Imageamento por Ressonância Magnética , Tomografia Computadorizada por Raios X , Tuberculoma Intracraniano/tratamento farmacológicoRESUMO
To introduce innovation in clinical practice is a difficult task. Although there is no universal recipe, education of involved actors has been identified as a key factor, including managers, health care workers, patients, and community. Managers in charge of developing and implementing new clinical guidelines bear great responsibility, and need formal education on the appraisal of evidence and the analysis of available resources, to ensure the quality of the product that will be delivered. Although continuous education and training is widely perceived as valuable activities, people need to be encouraged to participate in them. Incentives for fostering participation are needed, and they should be carefully planned. The contents of the training programs should be tailored to the different audiences and they should be delivered in attractive manner, in small groups, using modern interactive educational technology.
Assuntos
Humanos , Guia de Prática Clínica , Acidente Vascular Cerebral , Atenção à Saúde , Educação Médica , TutoriaRESUMO
Neurocysticercosis (NCC) is the most common parasitic disease of the central nervous system. Several drugs, such as drugs against tapeworms, praziquantel or albendazole associated to corticosteroids, have been tested for the treatment of this condition. Although some have claimed the reduction or involution of cystic or granulomatous lesions, there is no consensus about the efficacy of these treatments. The natural evolution of the disease is not clear and this hampers the assessment of treatment effects. Moreover, there are no good imaging or clinical indicators that can predict the progression or spontaneous resolution of lesions, specially at the meningeal or ventricular compartment. Therefore, evidence based medicine does not have a definitive answer about the treatment, neither of seizures, the most common manifestation of NCC, or the varied and complex meningeal and ventricular involvement. This review includes experts opinions to give the clinician some clues for decision making in the treatment of NCC.
Assuntos
Animais , Humanos , Albendazol/uso terapêutico , Anti-Helmínticos/uso terapêutico , Neurocisticercose/tratamento farmacológico , Praziquantel/uso terapêutico , Vacinas Bacterianas/uso terapêutico , Medicina Baseada em Evidências , Neurocisticercose/prevenção & controle , Taenia/efeitos dos fármacos , Taenia/crescimento & desenvolvimento , Taenia/imunologia , Resultado do TratamentoRESUMO
This journal is 58 years old with a publishing identity, style, and quality that has been increasingly recognized throughout Latin America and is indexed in Lilacs, Scielo, and Latindex. Our journal has applied for indexation in the Index Medicus of the USA National Library of Medicine, but unfortunately it has been not selected. Sociedad de Neurología Psiquatría y Neurocirugía (Sonepsyn) and Revista Chilena de Neuro-Psiquiatría should use this answer as an opportunity to consider deeply the journal we have, the one we want, and need, and then to decide whether to continue with the attempt to be indexed and if we are indeed in a position to reach this goal. If we should choose to reapply for indexation in Index Medicus, this will require backing in terms of financing and policy, prioritization and dedication from the next Sonepsyn Board of Directors, professionalization of the publishing committee and of the support team: secretary, abstract translator, proofreader, web page handler, medical illustration specialist, and above all, the contributions from researchers and authors to publish their best papers with us and to cite regularly the papers published in this journal. If we choose not to make indexation in the Index Medicus a primary goal, we need to move into a more pragmatic view in deciding what kind of journal we want and need, one that is not necessarily less responsible, transcendental, or useful.
Assuntos
Indexação e Redação de Resumos , Políticas Editoriais , MEDLARS , Neurologia , Publicação Periódica , PsiquiatriaRESUMO
El diagnóstico precoz de la infección por Aspergillus del Sistema Nervioso Central (SNC) es un gran desafío, donde la sospecha clínica fundamentada es clave por la alta letalidad de la entidad aún con tratamiento oportuno. La importante dificultad diagnostica es favorecida por algunas características de la entidad: baja incidencia, compromiso de individuos inmunocomprometidos que presentan múltiples infecciones, manifestaciones neurológicas clínicas e imagenológicas inespecíficas y métodos diagnósticos etiológicos de resultados tardíos. Presentamos el caso de un paciente diabético y alcohólico, con aspergilosis meningovascular precedida en 8 meses por un foco fúngico pulmonar. La presentación clínica fue a la manera de una meningoencefalitis subaguda con: cefalea, vértigo, compromiso de lenguaje, hemiparesia, alteración de conciencia y crisis convulsiva. Se trato con Anfotericina B con recuperación clínica completa. En este artículo revisamos algunos aspectos del compromiso por Aspergillus del SNC: mecanismos patogénicos, formas clínicas, factores de riesgo, principales métodos diagnósticos y alternativas de tratamiento.
Assuntos
Masculino , Adulto , Humanos , Aspergilose/diagnóstico , Aspergilose/patologia , Aspergilose/terapia , Antifúngicos/uso terapêutico , Aspergillus/isolamento & purificação , Aspergilose/etiologia , Líquido Cefalorraquidiano/microbiologia , Mananas , Meningoencefalite/etiologia , Fatores de Risco , Síndromes de Imunodeficiência/complicações , Vasculite do Sistema Nervoso Central/complicaçõesRESUMO
Constant improvements in published material, sufficient circulation of the material, and balanced financial management are key factors to the survival of a biomedical journal. The natural tendency to seek publishing in journals listed in the Science Citation Index (SCI) and Index Medicus (IM) in order to have greater readership acts as a vicious circle on the impact factor (IF) of any publication not listed in these Indexes. The reasons behind the choices of the readings selected and the references cited by the researchers who publish in the journals with the best IFs, whose preferences vouch for the quality of the rest, are complex, arbitrary, and are occasionally the result of simply reciprocity and convenience instead of technical merit. The SCI places clear restrictions on the developing world (including Latin America), favoring journals written in English and published in the U.S.A. and the U.K. In addition, the elite scientific journals publish research that does not necessarily represent the interests of the countries of origin. Latin American papers account for 1.6 - 1.8 percent of the total number of publications in the journals listed in the SCI. Therefore, it is crucial that Latin American databases be developed and consolidated, such as the LILACS (Latin American and Caribbean Literature on Health Sciences), ScIELO (Scientific Electronic Library Online) and Latindex (a regional on-line information system for scientific magazines from Latin America, the Caribbean, Spain, and Portugal.).
Assuntos
BibliometriaRESUMO
This article is an invitation to reflect on what is termed Complementary and Alternative Medicine (CAM) and its potential impact on the way we normally practice Western-style medicine. CAM is defined, and its relation with traditional medicine (TM) is discussed. Features are mentioned that could provide a core identity for this heterogeneous group of practices that the West includes in CAM/TM. Data is presented on the extent to which CAM/TM is practiced in the world, who uses it, for what illnesses, and why they opt for this type of health care. Trends in terms of safety and effectiveness are discussed, as well as the evidence from tests supporting these practices. Finally, possible challenges are presented both for those who practice traditional Western medicine and for CAM/TM practitioners. As the former, we must break away from the taboo, the prejudice, the ignorance, and the indifference with which we view non-conventional forms and practices. The challenge for the latter is to develop supervisory and qualification mechanisms at least among peer practitioners, provide practice records with indications and contraindications, and furnish solid proof of safety and effectiveness using universal standards for the practices and products used. Progress in these areas could lead toward tolerance, respect, and the ties necessary to achieve a stronger integrated or convergent type of medicine that focuses on the individual and respects his or her culture, needs, lacks, ailments, beliefs, and choices.
Assuntos
Medicina Tradicional , Terapias Complementares/classificação , Terapias Complementares/tendênciasRESUMO
The profuse offer of biomedical publications, the early obsolescence of some contents, and the increasing complexity of scientific advances, make it necessary to develop instruments and strategies that will help the reader select material according to quality, relevance, and accuracy. Review articles have evolved from spontaneous narration to systematic revision, guided by evidence-based medicine. The rigorous methodology used in systematic revisions when it comes to searching for and analyzing information has created a positive and increasing impact on the way biomedical information is processed, leading to the creation of journals that specialize on systematic revisions, as well as regular intervals for work analysis in ôJournal Clubsõ. Inspired by this search for instruments to help the reader, we open a new section for the analysis of journal articles. Our goals for this ôPaper Clubõ section, are in tune with those of journals specializing in systematic reviews: to learn about articles that are relevant, as well as methodically strong, in a clear and succinct manner, that is focused towards the application in clinical practice. However, in contrast the ôindustrial likeõ character of systematic revisions, we are looking for a more flexible space where we can revalue the expertÆs opinion and explore the continuous advances in the biomedical field from diverse analytical viewpoints.
Assuntos
RevisãoRESUMO
En el marco del proceso periódico de Acreditación de Programas y Centros para la Formación de Especialistas, regulados por la Asociación de Facultades de Medicina de Chile (ASOFAMECH), se realizó a fines del 2002 el proceso ordinario para la especialidad de neurología. Para este fin la Comisión Nacional de Acreditación de la ASOFAMECH, convocó a los profesores directores de tres de los cinco centros formadores en proceso de reacreditación. En au-sencia de referentes locales para la especialidad, la comisión de neurología al concluir su mi-sión, propuso a ASOFAMECH un conjunto de criterios mínimos para la finalidad mencionada. Este documento considera: perfil del neurólogo egresado del programa. Características de un centro responsable de un programa de formación: organización, recursos humanos, recursos organizacionales, producción científica y docente, número de pacientes anuales atendidos en las diversas modalidades de atención, por el servicio y hospital. Se delinea un programa general, considerando asignaturas básicas, metodología de enseñanza, actividades formativas, evaluación y formas de supervisión y tutoría. Finalmente, se establece una productividad clínica y académica, a lograr por el becado durante el proceso de especialización. Los autores están conscientes que algunos de los aspectos propuestos, no son considerados o cumplidos, en el grado requerido por los centros actualmente acreditados. Sin embargo, su aceptación permitiría a cada centro, la implementación de una estrategia de desarrollo, para lograr paulatinamente el cumplimiento de los criterios mínimos de acreditación, antes de la próxima acreditación. Los autores, presentan este documento, para su discusión, complemen-tación, validación y eventual uso como instrumento de autoevaluación.
Assuntos
Educação de Pós-Graduação em Medicina/métodos , Educação de Pós-Graduação em Medicina/tendências , Neurologia/educação , Acreditação , MedicinaRESUMO
Presentamos un caso de CADASIL (acrónimo inglés de arteriopatía cerebral autosómica dominante con infartos subcorticales y leucoencefalopatía), que corresponde al primero de una serie de 4 casos diagnosticados en nuestro servicio desde 1998, con correlato clínico, imageno-lógico y de ultrapatología muscular (microscopia electrónica). Se trata de una paciente mujer con historia de dos crisis isquémicas cerebrales transitorias a los 29 años, sin factores de riesgo tradicionales para patología cerebrovascular, que luego de 7 años desarrolló síntomas de tipo depresivos, asociados a un cuadro de retraimiento sicomotor y parkinsonismo de carácter progresivo y sin respuesta a terapia farmacológica convencional. En su estudio, la resonancia nuclear magnética de cerebro mostró extensas alteraciones en sustancia blanca a nivel fronto-occipital, bilaterales, hiperintensas en T2 e hipointensas en T1, cuya señal no se reforzó con gadolinio, sin efecto de masa, asociadas a leucoaraiosis, compatibles con el diagnóstico de CADASIL. El estudio de una biopsia muscular mediante microscopia electrónica, confirmó una arteriopatia con depósito de material granular osmiofílico en los vasos sanguíneos, tipo CADASIL. No encontramos antecedentes de cuadros demenciales ni cerebrovasculares sintomáticos en otros parientes de la paciente, madre, padre, tíos, abuelos, por lo que es probable que se trate de un cuadro esporádico. No realizamos estudio genético ni biopsico de los parientes asintomáticos. Las características de la paciente ilustran cuando sospechar el diagnóstico de CADASIL, aún frente a un caso aparentemente esporádico.
Assuntos
Humanos , Adulto , Feminino , Demência por Múltiplos Infartos/diagnóstico , Demência VascularRESUMO
Con motivo de incorporar la declaración de conflicto de interés en nuestra revista, el comité editorial presenta un Panel sobre el tema. En éste, se define conflicto de interés en términos generales y editoriales, así como se analizan otros escenarios de la práctica médica con potenciales conflictos de intereses. Se evalua el sentido de las declaraciones explícitas de conflicto de interés, como expresión de preventiva transparencia, clave del control comunitario del problema. Finalmente se evaluan casos y ejemplos de subnotificación de intereses y el impacto del conocimiento de los conflictos de intereses en los usuarios de la información biomédica. De la información presentada en el panel es posible concluir que: el conflicto de interés existe, el aludirlo es inevitable, el pensar controlarlo con facilidad es ingenuo. El generar instrumentos que sirvan para transparentar relaciones y vínculos que son naturales en nuestro quehacer, es necesario. Muchos de los que declaran sus conflictos de interés tienen vínculos sanos. En un escenario de declaraciones explícitas los vínculos no declarados por ese solo hecho resultan potencialmente sospechosos. El acuerdo y consenso conceptual en un tema tarda en cambiar conductas, pero el paso inicial es impostergable. La responsabilidad de pensar en el sesgo, como manera sistemática de análisis de un artículo, es una responsabilidad indelegable, incluso en aquellos artículos que cuentan con gran soporte corporativo profesional o de sociedades científicas. Finalmente el abstraerse de las pautas del International Committee of Medical Journal Editors, es editorialmente imprudente e insular.
Assuntos
Humanos , Conflito de Interesses , Ética Médica , Relações Médico-Paciente , Formulação de PolíticasRESUMO
Background: Plasmapheresis can be useful in myasthenia gravis, Guillain BarrÚ syndrome and chronic demyelinating inflamatory polyradiculoneuritis. Aim: To report our experience with plasmapheresis in patients with neurological diseases. Material and methods: Retrospective review of plasmapheresis procedures done between 1995 and 2001, in a public hospital. Indications criteria, clinical results and technical yield were analyzed. Results: One hundred fifty nine procedures were reviewed. One hundred forty (88 percent) were indicated for neurological diseases (44 percent for Guillain BarrÚ syndrome and 29 percent for myasthenia gravis). Clinical improvement or eventual complications were avoided in 70 percent of patients with Guillain BarrÚ syndrome and 100 percent of patients with myasthenia gravis. Hypotension in 10 percent and paresthesias in 7 percent were observed. All complications were successfully controlled with crystalloid or fresh plasma infusions or citrate management. In 11 cases, the procedure was interrupted due to obstruction of the venous access, that was peripheral in eight of these. The most common difficulties of the procedure were delay in performing it in 50 percent of patients and insufficient exchange volumes in 30 percent. Conclusions: Plasmapheresis was safe and useful in patients with myasthenia gravis and Guillain BarrÚ syndrome. The drawbacks of the procedure are its costs and requirement of special equipment (Rev MÚd Chile 2004; 132: 295-8).