Presente y futuro de la medicina interna / Present and future of internal medicine

To mention the crisis of Internal Medicine has become a commonplace, that is extremely wrong, because Internal Medicine is stronger than ever, with many recent and important contributions like randomised clinical trials, meta analysis, evidence-based diagnosis, cost-benefits analaysis, etc. We consider as Internists the General Internist, the sub-specialist and the primary care physician. Among them, it is the General Internist who needs to redefine his working areas, that are progressively moving from the hospital into ambulatory care. Internal Medicine is stretched by 3 strong vectorial forces: 1. Its own development and technological progress. 2. Economical factors trying to limit increasing costs. 3. Social forces demanding a better quality of care Internal Medicine shall need to equilibrate all these forces and be prepared to solve future challenges such as demographic changes, including an ageing population, the compression of morbidity, increasing demands of better care and quality of life, contemption of excessively high cost and now technical and ethical problems. The internist should be the best prepared specialist to cope with these challenges; but to better assume them, deep changes in pre and post graduate medical education are needed

Marcadores de fibrogénesis hepática en pacientes alcohólicos / Hepatic fibrogenesis markers in alcoholic patients

Serum P-III-P and laminim levels were measured in asymptomatic alcoholics during detoxication treatment. Liver biopsies were obtained, in order to detect liver damage, which was graded with a numeric score, considering values over 6 as severe damage. Serum fibrogenesis markers were also measured in a group of decompensated alcoholic cirrhotics. P-III-P levels were significantly higher in cirrhotic patients compared to alcoholics with or without liver damage and to normal controls. Laminin was not different between groups. P-III-P did not correlate with histological score in asymptomatic patients. In this study P-III-P and P1 laminin were not usefull discriminators of severe liver damage among asymptomatic alcoholics; their levels were found to rises significantly only when liver disease has become clinically evident

Síndrome hepatopulmonar en pacientes cirróticos descompensados / Hepatopulmonary syndrome in decompensed cirrhotic patients

Hypoxemia is common in cirrhotic patients and when obvious pulmonary or cardiac causes are discarded, it is attributed to the so-called hepatopulmonary syndrome. The aim of this work was to assess the frequency of hypoxemia and orthodeoxia ans its relationship with the degree of liver failure, in cirrhotic alcoholic patients. We studied 30 alcoholic cirrhotics. In all, arterial blood gases were measured in supine and standing positions in 26 a chest X ray examination was done and in 20 a spirometry. Twelve patients had a subnormal PaO2 and this parameter fell more than 10 percent when assuming the standing position in one of these. The same reduction was observed in 2 subjects with normal supine PaO2. In the chest X ray examinations, pleural effusions were observed in five hypoxemic subjects and 4 with normal PaO2. Likewise minimal athelectasis was found in 6 and 7 subjects and interstitial infiltrates in one and two subjects. A significant association between hypoxemia and Pugh score was observed. Similarly, subjects with hypoxemia had a higher frequency of large esophageal varices. It is concluded that hypoxemia is frequent in alcoholic cirrhotic patients and since it is associated to obvious pulmonary causes, it may be attributed to the hepatopulmonary syndrome

El sistema mayor de histocompatibilidad como factor de riesgo de la enfermedad hepática alcohólica / Major histocompatibility system as a risk factor of alcoholic hepatic disease

Several associations between alleles of the major histocompatibility system and alcoholic liver disease have been described. However, these are weak and changes from one population to another. The aim of this work was to search for a possible genetic risk factor for alcoholic liver disease among chilean alcoholics. We studied blood groups, serum proteins and HLA antigens in 39 alcoholic cirrhotics, 104 asymptomatic alcoholics and 44 non alcoholic controls. Asymptomatic alcoholics were also subjected to a percutaneous liver biopsy that showed moderate to severe histological liver damage in 46 subjects (44 percent). No differences in the studied genetic markers, were found among the four groups. It is concluded that this study does not confirm previously reported associations between genetic markers and alcoholic liver disease