Fístula arteriovenosa post-TIPS, un reto diagnóstico: reporte de caso / Post-TIPS arteriovenous fistula, a diagnostic challenge: case report

La hipertensión portal es una de las principales complicaciones de la cirrosis. El papel de la derivación portosistémica transyugular intrahepática (TIPS, por sus siglas en inglés), ha ganado aceptación como tratamiento efectivo en la hipertensión portal. En los últimos años su técnica se ha ido perfeccionando, disminuyendo la morbimortalidad relacionada con este procedimiento. Describimos un caso de un paciente masculino con cirrosis Child-Pugh 8 y MELD 16, con antecedente de descompensación por sangrado variceal recurrente y trombosis parcial de la vena porta, con un gradiente de presión venosa hepática (GPVH) de 20 mmHg, por lo que es llevado a TIPS como profilaxis secundaria, con un gradiente final post-TIPS de 6 mmHg. Posterior al procedimiento, presentó evolución tórpida con deterioro de las pruebas de bioquímica hepática. Se realizó una angiografía demostrando permeabilidad del TIPS sin progresión de la trombosis portal, y hallazgos anormales inespecíficos de la arteria hepática. Se decidió realizar una arteriografía selectiva, demostrando un pseudoaneurisma de la rama derecha de la arteria hepática y una fístula arteriovenosa de la arteria hepática a las colaterales portales. Se realizó embolización selectiva de la fístula con evolución satisfactoria del paciente.

Portal hypertension is a life-threatening complication of cirrhosis. The role of transyugular intrahepatic portosystemic shunt (TIPS) has gained acceptance as an effective treatment for portal hypertension. In the past few years, its technique has been improved, decreasing the mortality related with the procedure. We describe a case of a male with Child-Pugh 8 and MELD 16 cirrhosis, with previous decompensation of recurrent variceal bleeding and partial thrombosis of the portal vein. TIPS was performed due to a hepatic venous pressure gradient (HVPG) of 20 mmHg. The final measure showed HVPG of 6 mmHg. After the procedure, he presented a torpid evolution with deterioration of liver function tests. An angiography was performed demonstrating patency of the TIPS without progression of portal thrombosis and nonspecific abnormal findings of the hepatic artery. Selective arteriography was performed and revealed a pseudoaneurysm of the right branch of the hepatic artery and an arteriovenous fistula (AVF) from the hepatic artery to portal collaterals. Embolization was performed to treat the fistula with satisfactory evolution of the patient.

Morbilidad materna extrema en mujeres peruanas atendidas en una institución especializada. 2012- 2016 / Extreme maternal morbidity in peruvian women attended at a specialized institution. 2012-2016

Introducción: La morbilidad materna extrema genera indicadores para evaluar y controlar el riesgo de muerte materna. Objetivo: Describir la morbilidad materna extrema en mujeres peruanas atendidas en una institución especializa de Perú, 2012-2016. Material y Método: Estudio observacional, descriptivo y transversal. Se incluyeron las pacientes atendidas en el Instituto Nacional Materno Perinatal de Perú, entre el 2012 y 2016. Los casos de morbilidad materna extrema fueron incluidos según criterios de la Federación Latinoamericana de Sociedades de Obstetricia y Ginecología. Se describieron características maternas y se evaluaron indicadores de resultado. Se aplicó estadística descriptiva e inferencial bajo intervalos de confianza al 95%, utilizando el programa Stata versión 14. Resultados: La población de estudio fue 1245 casos. La multiparidad estuvo presente en el 63,7% de casos, presentaron en promedio 4 controles prenatales y el 60% de los casos tuvo por lo menos una cesárea previa. La razón de morbilidad materna extrema varío entre 10,7 y 17,6 por cada 1,000 recién nacidos vivos, el Índice de Mortalidad fue 3%, la relación morbilidad materna extrema / muerte materna fue de 32,8 casos. Conclusiones: La prevalencia promedio de morbilidad materna extrema fue de 13 casos por cada mil nacidos vivos con tendencia al incrementó en los últimos tres años de estudio, siendo principalmente causado por trastornos hipertensivos, sepsis y hemorragias. Los índices de resultado de morbilidad materna extrema demuestran una mejora progresiva en la calidad de atención de las pacientes con una tendencia a la disminución de muerte materna.

Introduction: Extreme maternal morbidity generates indicators to assess and monitor the risk of maternal death. Objective: To describe the extreme maternal morbidity in Peruvian women attended in a specialized institution in Peru, 2012-2016. Material and Method: Observational, descriptive and transversal study. Patients attended at the National Maternal and Perinatal Institute, between 2012 and 2016 were included. Cases of extreme maternal morbidity were included according to criteria of the Latin American Federation of Obstetrics and Gynecology Societies. The study shows maternal characteristics and outcome indicators. Descriptive and inferential statistics were applied under 95% confidence intervals, using the Stata version 14. Results: The study population was 1245 cases. Multiparity was present in 63.7% of cases, presented on average 4 prenatal controls and 60% of cases had at least one previous cesarean section. The extreme maternal morbidity ratio varied between 10.7 and 17.6 per 1,000 live births, the mortality index was 3%, the extreme maternal morbidity / maternal mortality ratio was 32.8 cases. Conclusions: The average prevalence of extreme maternal morbidity was 13 cases per thousand live births with a tendency to increase in the last three years of the study, mainly due to hypertensive disorders, sepsis and hemorrhages. The outcome indexes of extreme maternal morbidity demonstrate a progressive improvement in the quality of care of patients with a tendency to decrease maternal death.

Gestión de información y epidemiología en el caso de la distribución espacial de personas mordidas por perros / Information management and epidemiology in the case of spatial distribution of people bitten by dogs

La gestión de información es importante para las instituciones de salud. Por eso, el objetivo de esta investigación fue identificar los productos de información obtenidos desde un sistema de información georreferenciado, utilizando como ejemplo la distribución espacial de las personas mordidas por perros en la ciudad de Temuco, para mostrar productos útiles para la toma de decisiones. Los productos de información asociados a su componente geográfico permitieron visualizar elementos ambientales que los productos clásicos como informes dificultan representar. Mediante un sistema de información georreferenciado e imágenes satelitales pudimos indicar que existen dos zonas de alta concentración de personas mordidas por perros: Pedro De Valdivia y Pueblo Nuevo, con el 36,8 y el 1,4 por ciento respectivamente. También pudimos evaluar los eventos de interés particulares en relación con las fuentes fijas de información y determinar los componentes ambientales involucrados. Por último, utilizando datos basados en un sistema de información georreferenciado, se generaron múltiples productos de información que serían dependientes de las necesidades de información requerida. Los sistemas de información georreferenciados son herramientas de gran ayuda en dar respuesta a las necesidades, cada vez más demandantes, por productos de información inmediatos, económicos y sencillos. Los productos obtenidos a través del sistema de información georreferenciado permiten a los epidemiólogos consolidar e integrar información, conocer la distribución y la densidad, así como realizar los análisis de acuerdo con las necesidades que los eventos de interés patológico requieren y que se resumen en el monitoreo, el control y su posible erradicación(AU)

Information management is important for health institutions. Therefore, as the objective, information products obtained from a georeferenced information system are examined, using as an example the spatial distribution of people bitten by dogs in the city of Temuco, to show useful products for decision making. Information products associated with its geographic component allow the visualization of environmental elements that classic products such as reports make difficult to represent. Using a geo-referenced information system and satellite images, we can indicate that there are two areas of high concentration of people bitten by dogs: Pedro De Valdivia and Pueblo Nuevo, with 36.8 percent and 1.4 percent respectively. We can also evaluate the events of particular interest associated with the fixed sources of information and determine the environmental components involved. Finally, using data based on a geo-referenced information system, multiple information products can be generated that will be dependent on the information needs required. Geo-referenced information systems are very helpful tools in responding to the increasingly demanding needs for immediate, economic and simple information products. The products obtained through georeferenced information systems allow epidemiologists to consolidate and to integrate information, to know the distribution and density, as well as to perform the analyses according to the needs required by the events of pathological interest and that are summarized by monitoring, control and possible eradication(AU)

Gestión de información y epidemiología en el caso de la distribución espacial de personas mordidas por perros / Information management and epidemiology in the case of spatial distribution of people bitten by dogs

La gestión de información es importante para las instituciones de salud. Por eso, el objetivo de esta investigación fue identificar los productos de información obtenidos desde un sistema de información georreferenciado, utilizando como ejemplo la distribución espacial de las personas mordidas por perros en la ciudad de Temuco, para mostrar productos útiles para la toma de decisiones. Los productos de información asociados a su componente geográfico permitieron visualizar elementos ambientales que los productos clásicos como informes dificultan representar. Mediante un sistema de información georreferenciado e imágenes satelitales pudimos indicar que existen dos zonas de alta concentración de personas mordidas por perros: Pedro De Valdivia y Pueblo Nuevo, con el 36,8 y el 1,4 por ciento respectivamente. También pudimos evaluar los eventos de interés particulares en relación con las fuentes fijas de información y determinar los componentes ambientales involucrados. Por último, utilizando datos basados en un sistema de información georreferenciado, se generaron múltiples productos de información que serían dependientes de las necesidades de información requerida. Los sistemas de información georreferenciados son herramientas de gran ayuda en dar respuesta a las necesidades, cada vez más demandantes, por productos de información inmediatos, económicos y sencillos. Los productos obtenidos a través del sistema de información georreferenciado permiten a los epidemiólogos consolidar e integrar información, conocer la distribución y la densidad, así como realizar los análisis de acuerdo con las necesidades que los eventos de interés patológico requieren y que se resumen en el monitoreo, el control y su posible erradicación(AU)

Information management is important for health institutions. Therefore, as the objective, information products obtained from a georeferenced information system are examined, using as an example the spatial distribution of people bitten by dogs in the city of Temuco, to show useful products for decision making. Information products associated with its geographic component allow the visualization of environmental elements that classic products such as reports make difficult to represent. Using a geo-referenced information system and satellite images, we can indicate that there are two areas of high concentration of people bitten by dogs: Pedro De Valdivia and Pueblo Nuevo, with 36.8 percent and 1.4 percent respectively. We can also evaluate the events of particular interest associated with the fixed sources of information and determine the environmental components involved. Finally, using data based on a geo-referenced information system, multiple information products can be generated that will be dependent on the information needs required. Geo-referenced information systems are very helpful tools in responding to the increasingly demanding needs for immediate, economic and simple information products. The products obtained through georeferenced information systems allow epidemiologists to consolidate and to integrate information, to know the distribution and density, as well as to perform the analyses according to the needs required by the events of pathological interest and that are summarized by monitoring, control and possible eradication(AU)

Hematoma hepático subcapsular en síndrome HELLP en un hospital de referencia de Lima / Subcapsular hepatic hematoma in HELLP syndrome in a Lima reference hospital

Objetivo. Determinar las características clínicas y manejo de casos de hematoma hepático subcapsular (HHS), como consecuencia de preeclampsia y síndrome HELLP durante los años 2004 al 2016. Diseño. Estudio descriptivo, retrospectivo, tipo serie de casos. Lugar. Instituto Nacional Materno Perinatal, Lima, Perú. Material. Historias clínicas de pacientes con HHS. Métodos. Se revisó los casos de HHS atendidos durante los años 2004 al 2016, identificados en forma retrospectiva. Con fines de comparación, se identificó también los casos de la literatura mundial en PubMed. Principales medidas de resultados. Incidencia, características clínicas, manejo y evolución. Resultados. Se encontró 31 casos de HHS, con incidencia de 1 en 6 000 a 9 000 partos. La edad promedio fue 34 años y 81 % multíparas. La forma de diagnóstico más frecuente fue la visión directa durante la cesárea (45%). El síntoma más frecuente fue dolor en abdomen superior (52%), cefalea (36%), estado de conciencia alterado (31 %) Y hematuria (48%). En 90% se practicó empaquetamiento hepático y en 10% observación y monitoreo. En 44% se colocó Bolsa de Bogotá en la primera intervención quirúrgica y en los últimos 2 años se utiliza el sistema VAC para evitar el síndrome comparta mental. El 74% de los casos sobrevivió y 26% falleció. El promedio de estancia hospitalaria fue de 23,2 días. Conclusiones. La incidencia de hematoma hepático subcapsular como consecuencia de preeclampsia y síndrome HELLP fue 1 en 6 000 a 9 000 partos. La hematuria fue un signo relevante y debiera ser motivo de estudio posterior. El 90% de empaquetamiento hepático tuvo diferencias estadísticas con lo reportado en la literatura mundial (p = 0,0025), debido probablemente a la tendencia en procedimientos conservadores. A pesar de solo usar manejo quirúrgico, la cifra de mortalidad fue similar a la reportada en la literatura mundial (26% versus 17%; p = 0,2702).

Objective: To determine the clinical characteristics and management of subcapsular hepatic hematoma (SHH) as a result of severe preeclampsia and HELLP syndrome in the period 2004-2016. Design: Descriptive, retrospective study, series of cases type. Setting: Instituto Nacional Materno Perinatal, Lima, Peru. Material: We reviewed the clinical charts of patients with SHH. Methods: The clinical charts of cases with SHH attended at our institution between 2004 and 2016 were reviewed. Search also included PubMed and the results were compared with those in the literature. Main outcome measures: Incidence, clinical features, diagnosis, management and results. Results: 31 cases of SHH were found, with an incidence of 1 in 6 000 to 9 000 births. The mean maternal age was 34 years and 80% were multiparous. Diagnosis was usually through direct visualization of the hepatic rupture during caesarean section (45%). The most frequent symptoms were upper abdominal pain (52%), headache (36%), alteration of consciousness (31 %) and hematuria (48%). Liver packing was performed in 90% of the cases; observation and monitoring, in 10%. In 44% of cases, a Bogotá bag was placed during the first surgery. During the last 2 years, we have recurred to vacuum-assisted closure to prevent compartment syndrome. 74% of cases survived and 26% died. The average hospital stay was 23.2 days. Conclusions: The incidence of subcapsular hepatic hematoma as a result of severe preeclampsia and HELLP syndrome was 1 in 6 000 to 9 000 births. Hematuria was a significant sign and should be studied further. Liver packing was performed in 90% of patients, a statistically significant higher rate than that reported in the literature (p=0.0025), maybe due to a preference for conservative management. Despite only performing surgical treatment, the mortality rate was similar to that reported in the literature (26% versus 17%; p=0.2702).

The desert tortoise trichotomy: Mexico hosts a third, new sister-species of tortoise in the Gopherus morafkai-G. agassizii group.

Desert tortoises (Testudines; Testudinidae; Gopherus agassizii group) have an extensive distribution throughout the Mojave, Colorado, and Sonoran desert regions. Not surprisingly, they exhibit a tremendous amount of ecological, behavioral, morphological and genetic variation. Gopherus agassizii was considered a single species for almost 150 years but recently the species was split into the nominate form and Morafka's desert tortoise, Gopherus morafkai, the latter occurring south and east of the Colorado River. Whereas a large body of literature focuses on tortoises in the United States, a dearth of investigations exists for Mexican animals. Notwithstanding, Mexican populations of desert tortoises in the southern part of the range of Gopherus morafkai are distinct, particularly where the tortoises occur in tropical thornscrub and tropical deciduous forest. Recent studies have shed light on the ecology, morphology and genetics of these southern 'desert' tortoises. All evidence warrants recognition of this clade as a distinctive taxon and herein we describe it as Gopherus evgoodei sp. n. The description of the new species significantly reduces and limits the distribution of Gopherus morafkai to desertscrub habitat only. By contrast, Gopherus evgoodei sp. n. occurs in thornscrub and tropical deciduous forests only and this leaves it with the smallest range of the three sister species. We present conservation implications for the newly described Gopherus evgoodei, which already faces impending threats.

Effect of malnutrition on the expression of cytokines involved in Th1 cell differentiation.

Malnutrition is a common cause of secondary immune deficiency and has been linked to an increased susceptibility to infection in humans. Malnutrition specifically affects T-cell-mediated immune responses. The aim of this study was to assess in lymphocytes from malnourished children the expression levels of IL-12, IL-18 and IL-21, molecules that induce the differentiation of T cells related to the immunological cellular response (Th1 response) and the production of cytokines related to the immunological cellular response (Th1 cytokines). We found that the expression levels of IL-12, IL-18 and IL-21 were significantly diminished in malnourished children compared to well-nourished children and were coincident with lower plasmatic levels of IL-2 and IFN-γ (Th1 cytokines). In this study, we show for the first time that the gene expression and intracellular production of cytokines responsible for Th1 cell differentiation (IL-12, IL-18 and IL-21) are diminished in malnourished children. As expected, this finding was related to lower plasmatic levels of IL-2 and IFN-γ. The decreased expression of Th1 cytokines observed in this study may contribute to the deterioration of the immunological Type 1 (cellular) response. We hypothesize that the decreased production of IL-12, IL-18 and IL-21 in malnourished children contributes to their inability to eradicate infections.

Lack of cytotoxic and genotoxic effects of Minthostachys verticillata essential oil: studies in vitro and in vivo.

Minthostachys verticillata (peperina) is an aromatic and medicinal plant with several uses and ethnobotanical properties. Numerous studies have demonstrated that its essential oil (Mv-EO) presents antimicrobial capacity and shows immunomodulating and anti-allergic properties in human cell lines. Thus, the goal of this study was to investigate the main chemical composition, analyzed by GC-FID, and the cyto-genotoxic effects of Mv-EO, using Vero cells, human PBMCs and mice bone marrow cells. The Mv-EO was rich in pulegone 60.5% and menthone 18.2%. Our results clearly show that Mv-EO is not cyto-genotoxic in vitro nor in vivo. It not induced cytotoxic effects, as indicated by trypan blue dye exclusion and NRU assays both in Vero cells and human PBMCs. In addition, Mv-EO (100-1000 µg/mL) not induced apoptotic effects on human PBMCs, as indicated by Hoechst staining and DNA fragmentation analysis by agarose gel electrophoresis. The in vivo assay showed that Mv-EO (25-500 mg/kg) not increased the frequency of micronucleus in bone marrow cells of mice. Further, the ratio of polychromatic/normochromatic erythrocytes was not modified. These findings suggest that Mv-EO appears to be safe as a therapeutic agent.

Apoptosis and mutagenicity induction by a characterized aqueous extract of Baccharis articulata (Lam.) Pers. (Asteraceae) on normal cells.

In a previous study we have demonstrated that cold aqueous extract of Baccharis articulata (Ba-CAE) induced the death of human peripheral blood mononuclear cells (PBMCs) and exerted low mutagenic effects on mice at 6h after administration. The aim of this work was to investigate whether the PBMCs death induced by Ba-CAE is due to apoptosis, and whether this extract exerts mutagenic effects on mice at 24 and 48h after administration. In addition, Ba-CAE was chemically characterized. PBMCs from healthy volunteers were exposed to extract (10, 20, 40, 80, 160, 320, 640 and 1280µg/mL) for 18-24h. Cell viability was determined by staining of trypan blue dye exclusion method. Apoptosis was determined by Hoechst 33258 staining, TUNEL, and DNA fragmentation analysis by agarose gel electrophoresis. BALB/c mice were injected with extract (1800, 900 and 450mg/kg) and sacrificed at 24 and 48h postinjection. Bone marrow samples were used to assess chromosome mutations by the micronucleus test. The extract induced PBMCs death by apoptosis and increased the frequency of micronuclei in bone marrow. The phytochemical study of Ba-CAE showed the presence of flavones as luteolin and acacetin, caffeoylquinic acids as chlorogenic acid, and tannins.

Study of antiviral and virucidal activities of aqueous extract of Baccharis articulata against Herpes suis virus.

Baccharis articulata is native of América and traditionally used for the treatment of digestive disorders and urinary infections. Cytotoxicity of aqueous extracts of B. articulata was investigated in Vero cells. As the maximal non cytotoxic concentration has been established, this concentration has been used to evaluate antiviral and virucidal activities against Herpes suis virus type 1, member of the same subfamily of Herpes simplex virus. Aqueous extracts of B. articulata exhibited more than 95% of virucidal activity. These findings support their potential application as a disinfectant or antiseptic with low toxicity and provide a valuable knowledge to ethnopharmacology properties of Baccharis articulata.

Contribuição da educação popular no atendimento fisioterapêutico domiciliar / Contribution of popular education in domiciliary physiotherapeutic attendance

O projeto de extensão Fisioterapia na Comunidade é desenvolvido no Bairro do Grotão, vinculado às unidades de saúde da família, em João Pessoa. Procura-se neste trabalho valorizar os saberes e práticas populares. A assistência fisioterapêutica domiciliar à luz da educação popular, ao mesmo tempo em que promove uma assistência à população desassistida, amplia nossa visão de saúde como processo educativo. A cada visita domiciliar, nos confrontamos com a realidade social das camadas populares e os problemas que estas pessoas enfrentam, repercutindo no seu estado de saúde, evidenciando para nós os condicionantes socioeconômicos do processo saúde-doença. Observa-se que, ao realizar atendimentos domiciliares com base nos princípios da educação popular, amplia-se a perspectiva de atuação do fisioterapeuta. Isso se deve ao fato de ser esta uma educação baseada no diálogo, que propõe a troca entre os saberes científico e popular, motivando a perspectiva de um compromisso à saúde junto à comunidade.

The extension project of Physiotherapy in the Community is developed in the neighborhood of Grotão linked to the family health units, in the city of João Pessoa. The aim of this work is to value popular knowledge and practices. The domiciliary physiotherapeutical assistance to the light of the popular education, at the same time that it promotes assistance to the unassisted population, extends our vision of health as an educational process. In each domiciliary visit we observed the social reality of the popular layers and the problems these people face, reflecting in its state of health, being evident for us the partner-economic conditionants of the process health-illness. This is observed that when carrying out domiciliary consultation on the basis of the principles of the popular education, it extents the perspective of the performance of the physiotherapist. This is so, because it is an education based on the dialogue, that proposes the exchange between scientific and popular knowledge, motivating the perspective of a commitment to the health together with the community.

[Contribution of popular education in domiciliary physiotherapeutic attendance]. / Contribuição da educação popular no atendimento fisioterapêutico domiciliar.

The extension project of Physiotherapy in the Community is developed in the neighborhood of Grotão linked to the family health units, in the city of João Pessoa. The aim of this work is to value popular knowledge and practices. The domiciliary physiotherapeutical assistance to the light of the popular education, at the same time that it promotes assistance to the unassisted population, extends our vision of health as an educational process. In each domiciliary visit we observed the social reality of the popular layers and the problems these people face, reflecting in its state of health, being evident for us the partner-economic conditionants of the process health-illness. This is observed that when carrying out domiciliary consultation on the basis of the principles of the popular education, it extents the perspective of the performance of the physiotherapist. This is so, because it is an education based on the dialogue, that proposes the exchange between scientific and popular knowledge, motivating the perspective of a commitment to the health together with the community.

High dosage of ascorbic acid and alpha-tocopherol is not useful for diminishing oxidative stress and DNA damage in healthy elderly adults.

AIM: To determine the useful dosage of ascorbic acid and alpha-tocopherol against oxidative stress and DNA damage in the elderly. METHODS: A double-blind controlled clinical assay carried out in a sample of 66 healthy subjects divided into three age-paired random groups with 22 subjects in each group. Group A received placebo and group B was administered 500 mg of ascorbic acid and 400 IU of alpha-tocopherol, whereas group C received 1,000 mg of ascorbic acid and 400 IU of alpha-tocopherol for a 6-month period. The following measurements were performed before and after the 6-month treatment period: thiobarbituric acid reactive substances (TBARS); total antioxidant status (TAS); superoxide dismutase (SOD), and glutation peroxidase (GPx) and DNA damage by comet assay. RESULTS: After 6 months, group B subjects exhibited an increase in SOD and GPx enzyme levels; however, this was not statistically significant (p > 0.05). Likewise, TBARS and TAS concentrations remained unchanged (p > 0.05). In addition, in group C the decrease in TBARS and increase in SOD, GPx, and TAS were not statistically significant (p > 0.05). Similarly, average DNA migration showed no significant differences with high-dosage ascorbic acid and alpha-tocopherol. CONCLUSION: These findings suggest that administration of 1,000 mg of ascorbic acid plus 400 IU of alpha-tocopherol for 6 months is not useful for diminishing oxidative stress and DNA damage in healthy elderly adults.

Toxina botulínica A e intervenção fisioterapêutica no tratamento do ombro doloroso pós acidente vascular cerebral: relato de caso / Botulinum toxin A and physiotherapy intervention in the treatment of the painful shoulder after stroke: case report

A síndrome do ombro doloroso é considerada um achado comum em pacientes que sofreram acidente vascular cerebral. Várias modalidades terapêuticas são apontadas para melhoria do quadro clínico dos pacientes. Neste relato, será apresentado um caso de síndrome do ombro doloroso, cujo tratamento consistiu no emprego de toxina botulínica A associada à fisioterapia. Após quatro meses de tratamento, houve melhorias significativas quanto à dor, espasticidade, amplitude de movimento e qualidade de vida, e isso sugere ser essa associação terapêutica uma ferramenta eficaz contra os efeitos incapacitantes relacionados a esta síndrome.

The syndrome of the painful shoulder is considered a common finding in patients who suffered stroke. Several therapeutic modalities are suggested for the improvement of the patients’ clinical condition. In this report, a case of syndrome of the painful shoulder will be discussed, whose treatment consisted of the use of botulinum toxin A associated to physiotherapy. After a four-month treatment, significant improvements occurred concerning pain, spasticity, range of motion and quality of life, suggesting that this therapeutic association is an efficient tool against the incapacitating effects related to this syndrome.

Salud, equidad y los objetivos de desarrollo del milenio / Health, equity, and the Millennium Development Goals

In September 2000 representatives of 189 countries met for the Millennium Summit, which the United Nations convened in New York City, and adopted the declaration that provided the basis for formulating the Millennium Development Goals (MDGs). The eight goals are part of a long series of initiatives that governments, the United Nations system, and international financial institutions have undertaken to reduce world poverty. Three of the eight goals deal with health, so the health sector will be responsible for implementing, monitoring, and evaluating measures proposed to meet targets that have been formulated: to reduce by two-thirds the mortality rate in children under 5 years of age between 1990 and 2015; to reduce by three-quarters the maternal mortality rate between 1990 and 2015; and to halt and begin to reverse the spread of HIV/AIDS by the year 2015, as well as to halt and begin to reverse the incidence of malaria, tuberculosis, and other major diseases. The health sector must also work with other parties to achieve targets connected with two other of the goals: to improve access to affordable essential drugs, and to reduce the proportion of persons who do not have safe drinking water. Adopting a strategy focused on the most vulnerable groups-ones concentrated in locations and populations with the greatest social exclusion-would make possible the largest total reduction in deaths among children, thus reaching the proposed target as well as producing greater equity. In the Region of the Americas the principal challenges in meeting the MDGs are: improving and harmonizing health information systems; designing health programs related to the MDGs that bring together the set of services and interventions that have the greatest impact, according to the special characteristics of the populations who are intended to be the beneficiaries; strengthening the political will to support the MDGs; and guaranteeing funding for the measures undertaken to attain the MDGs

Descendientes de africanos en la Región de las Americas y equidad en materia de salud / People of African descent in the Region of the Americas and health equity

The Region of the Americas and the Caribbean has a complex demographic profile from an ethnic and racial perspective. One of the largest groups is composed of persons of African descent, who in some countries, such as Brazil and the Dominican Republic, comprise 46 and 84% of the total population, respectively. Recent analyses of the statistics available in some countries of the Region show wide gaps in terms of living conditions and health in these communities, as well as gaps in access to health services. PAHO, through its Public Policy and Health Program, under the Division of Health and Human Development, supports sectorial efforts and those of civil organizations that aim to improve health conditions in this segment of the population, while taking into account their sociodemographic and cultural characteristics. This article briefly summarizes health conditions and access to health services in selected countries, as well as some aspects of the recent changes to the legislation in those countries. Finally, collaborative activities on the part of United Nations agencies and international financial institutions for the benefit of people of African descent and other ethnic minorities are described