Giant paratubal cyst: report of a case in second level public hospital.

BACKGROUND: Giant paratubal cysts are mostly benign tumors, with an incidence of 10%. The incidence rate of neoplasms is 2% to 3%, including papillary carcinoma and serous papillary neoplasms. CASE REPORT: A 35-year-old woman who began her current condition 3 years after her pregnancy, with urgency when urinating, abdominal pain and sensation of abdominal mass, who was diagnosed and protocolized in a second public level hospital of the State of Mexico, treated with open surgery, and good postoperative evolution.

ANTECEDENTES: Los quistes paratubáricos gigantes son en su mayoría tumores benignos, con una incidencia del 10%. La tasa de incidencia de neoplasias es del 2 al 3%, incluyendo carcinoma papilar y neoplasias papilares serosas. CASO CLÍNICO: Mujer de 35 años que comenzó su condición actual 3 años después de un embarazo, con urgencia al orinar, dolor abdominal y sensación de masa abdominal, que fue diagnosticada y protocolizada en un hospital público de segundo nivel del Estado de México, tratada con cirugía abierta y con buena evolución posoperatoria.

Modelling of Temperature-Attributable Mortality among the Elderly in Lisbon Metropolitan Area, Portugal: A Contribution to Local Strategy for Effective Prevention Plans.

Epidemiological studies on the impact of determining environmental factors on human health have proved that temperature extremes and variability constitute mortality risk factors. However, few studies focus specifically on susceptible individuals living in Portuguese urban areas. This study aimed to estimate and assess the health burden of temperature-attributable mortality among age groups (0-64 years; 65-74 years; 75-84 years; and 85+ years) in Lisbon Metropolitan Area, from 1986-2015. Non-linear and delayed exposure-lag-response relationships between temperature and mortality were fitted with a distributed lag non-linear model (DLNM). In general, the adverse effects of cold and hot temperatures on mortality were greater in the older age groups, presenting a higher risk during the winter season. We found that, for all ages, 10.7% (95% CI: 9.3-12.1%) deaths were attributed to cold temperatures in the winter, and mostly due to moderately cold temperatures, 7.0% (95% CI: 6.2-7.8%), against extremely cold temperatures, 1.4% (95% CI: 0.9-1.8%). When stratified by age, people aged 85+ years were more burdened by cold temperatures (13.8%, 95% CI: 11.5-16.0%). However, for all ages, 5.6% of deaths (95% CI: 2.7-8.4%) can be attributed to hot temperatures. It was observed that the proportion of deaths attributed to exposure to extreme heat is higher than moderate heat. As with cold temperatures, people aged 85+ years are the most vulnerable age group to heat, 8.4% (95% CI: 3.9%, 2.7%), and mostly due to extreme heat, 1.3% (95% CI: 0.8-1.8%). These results provide new evidence on the health burdens associated with alert thresholds, and they can be used in early warning systems and adaptation plans.

Modelling climate change impacts on attributable-related deaths and demographic changes in the largest metropolitan area in Portugal: A time-series analysis.

Previous studies have consistently analyzed the impact that extreme temperatures will have on human health. However, there are very few data on temperature-related mortality burden considering future demographic changes in a context of climate change in Portugal. This study aims to quantify the impact of climate change on heat-, cold-, and net change mortality burdens, taking into account the future demographic changes in Lisbon Metropolitan Area, Portugal. We applied a time-series generalized linear model with a quasi-Poisson model via a distributed lag nonlinear model to project temperature-related mortality burden for two climatological scenarios: a present (or reference, 1986-2005) scenario and a future scenario (2046-2065), in this case the Representative Concentration Pathway RCP8.5, which reflects the worst set of expectations (with the most onerous impacts). The results show that the total attributable fraction due to temperature, extreme and moderate cold, is statistically significant in the historical period and the future projected scenarios, while extreme and moderate heat were only significant in the projected future summer period. Net differences were attributed to moderate cold in the future winter months. Projections show a consistent and significant increase in future heat-related mortality burden. The attributable fraction due to heat in the future period, compared to the historical period, ranges from 0 to 1.5% for moderate heat and from 0 to 0.5% for extreme heat. Adaptation should be implemented at the local level, so as to prevent and diminish the effects on citizens and healthcare services, in a context of climate change.

Bootstrap approach to validate the performance of models for predicting mortality risk temperature in Portuguese Metropolitan Areas.

BACKGROUND: There has been increasing interest in assessing the impacts of extreme temperatures on mortality due to diseases of the circulatory system. This is further relevant for future climate scenarios where marked changes in climate are expected. This paper presents a solid method do identify the relationship between extreme temperatures and mortality risk by using as predictors simulated temperature data for cold and hot conditions in two urban areas in Portugal. METHODS: Based on the mortality and meteorological data from Porto Metropolitan Area (PMA) and Lisbon Metropolitan Area (LMA), a distributed lag nonlinear model (DLNM) was implemented to estimate the temperature effects on mortality due to diseases of the circulatory system. The performance of the models was validated via bootstrapping approaching by creating resamples with replacement from the validating data. Bootstrapping was also used to identify the best candidate model and to evaluate the sensitivity of the spline functions to the exposure-lag-response relationship. RESULTS: It is found that the model is able to reproduce the temperature-related mortality risk for two metropolitan areas. Temperature previously simulated by climate models is useful and even better than observed temperature. Although, the biases in predictions in both metropolitan areas are low, mortality risk predictions in PMA are more accurate than in LMA. Using parametric bootstrapping, we found that the overall cumulative association estimated under different bi-dimensional exposure-lag-response relationship are relatively stable, especially for the model selected by Quasi-Akaike Information Criteria (QAIC). Exposure to summer temperature conditions is best related to mortality risk. The association between winter temperature and mortality risk is somewhat less strong. CONCLUSIONS: The use of QAIC to choose from several candidate models provides valid predictions and reduced the uncertainty in the estimated relative risk for circulatory disease mortality. Our findings can be applied to better understand the characteristics and facilitate the prevention of circulatory disease mortality in Porto and Lisbon Metropolitan Areas, namely if we consider the actual context of climate change.

Effects of extreme temperatures on cerebrovascular mortality in Lisbon: a distributed lag non-linear model.

Cerebrovascular diseases are the leading cause of mortality in Portugal, especially when related with extreme temperatures. This study highlights the impacts of the exposure-response relationship or lagged effect of low and high temperatures on cerebrovascular mortality, which can be important to reduce the health burden from cerebrovascular diseases. The purpose of this study was to assess the effects of weather on cerebrovascular mortality, measured by ambient temperature in the District of Lisbon, Portugal. A quasi-Poisson generalized additive model combined with a distributed lag non-linear model was applied to estimate the delayed effects of temperature on cerebrovascular mortality up to 30 days. With reference to minimum mortality temperature threshold of 22 °C, there was a severe risk (RR = 2.09, 95% CI 1.74, 2.51) of mortality for a 30-day-cumulative exposure to extreme cold temperatures of 7.3 °C (1st percentile). Similarly, the cumulative effect of a 30-day exposure to an extreme hot temperature of 30 °C (99th percentile) was 52% (RR = 1.65, 95% CI 1.37, 1.98) higher than same-day exposure. Over the 13 years of study, non-linear effects of temperature on mortality were identified, and the probability of dying from cerebrovascular disease in Lisbon was 7% higher in the winter than in the summer. The findings of this study provide a baseline for future public health prevention programs on weather-related mortality.

Cocaína adulterada con levamisol: reporte de tres casos clínicos / Levamisole-adulterated cocaine: a report on three clinical cases

El consumo de clorhidrato y pasta base de cocaína en Uruguay tiene una prevalencia de vida del 6,9% y 0,7% respectivamente. Las complicaciones tóxicas secundarias al consumo dependen de la concentración del alcaloide así como de la presencia de adulterantes. El levamisol, antihelmíntico veterinario, reconocido adulterante de la cocaína en Estados Unidos (2003), fue detectado en Uruguay en el año 2013. Este adulterante genera complicaciones tales como neutropenia, vasculitis cutánea, glomerulonefritis, hemorragia pulmonar y leucoencefalopatía. Se describen los tres primeros casos clínicos de complicaciones por levamisol como adulterante de cocaína reportados al Centro de Información y Asesoramiento Toxicológico. Los pacientes eran consumidores crónicos con edades entre los 35 y 40 años. En los tres casos se objetivó un púrpura retiforme con centro necrótico asociado a anticuerpos ANCA positivos con tendencia a presentarse en lóbulos de orejas, mejillas y extremidades, tal como se reporta en las vasculitis por levamisol. Se reportó neutropenia asociada en un caso. Los tres pacientes presentaron anemia. Dos casos presentaron falla renal aguda. El tratamiento principal fue el cese del consumo, lo que produjo una reversión completa de las complicaciones. Todos requirieron debridación o injertos de piel, o ambos. Se discuten y analizan las complicaciones mencionadas así como el riesgo que conlleva la reexposición y los tratamientos propuestos para las mismas, tales como los factores de crecimiento de granulocitos, antibióticos de amplio espectro y los corticoides. Se requiere un alto índice de sospecha para vincular estas manifestaciones clínicas a la presencia de levamisol como adulterante de la cocaína.

Consumption of cocaine hydrochloride and cocaine base paste (CBP) in Uruguay has a lifetime prevalence of 6.9% and 0.7% respectively. Complications associated to toxic side effects of cocaine abuse depend on the concentration of the alkaloid, as well as on the presence of adulterants. Levamisole, a veterinary anthelmintic, a well know cocaine adulterant in the US was identified in Uruguay in 2013. This adulterant results in complications such as neutropenia, skin vasculitis, glomerulonephritis and leukoencephalopathy. The study describes the first three clinical cases of complications resulting from cocaine cut with levamisole reported to the Toxicology Center for Information and Counseling. The patients included were chronic cocaine abusers between 35 and 40 years old. Retiform purpura was detected in the three cases with a necrotic center associated to ANCA antibodies, with a tendency to appear in the earlobes, cheeks, and limbs, as it is reported in levamisole associated vasculitis. Neutropenia was reported in one case. The three patients had anemia. Two of the cases presented acute kidney failure. The main treatment was interruption of consumption, what resulted in a complete reversion of complications. All patients required debridement or skin grafts, or both. The above mentioned complications are discussed and analyzed, as well as the risk re-exposure and the suggested treatments involve, as the granulocytes growth factors, broad spectrum antibiotics and corticoids. A high degree of suspicion is required to associate these clinical manifestations to the presence of levamisole as a cocaine adulterant.

O consumo de cloridrato e pasta base de cocaína no Uruguai tem uma prevalência de vida de 6,9% e 0,7% respectivamente. As complicações tóxicas secundarias ao consumo dependem da concentração do alcaloide como também da presença de adulterantes. O levamisol, anti-helmíntico veterinário, um conhecido adulterante da cocaína nos Estados Unidos (2003), foi detectado no Uruguai em 2013. Este adulterante gera complicações tais como neutropenia, vasculite cutânea, glomerulonefrite, hemorragia pulmonar e leucoencefalopatia. Os três primeiros casos clínicos de complicações por levamisol como adulterante de cocaína informados ao Centro de Información y Asesoramiento Toxicológico são descritos. Os pacientes eram consumidores crônicos com idades entre 35 e 40 anos. Nos três casos se observou púrpura retiforme com centro necrótico associado a anticorpos ANCA positivos com tendência a apresentação nos lóbulos das orelhas, bochechas e extremidades, como estão descritas nas vasculites por levamisol. Em um caso foi observada neutropenia. Três pacientes apresentaram anemia e dois falha renal aguda. O tratamento principal foi a cessação do consumo com reversão total das complicações. Foi necessário realizar debridação ou enxertos de pele, ou ambos em todos os casos. As complicações mencionadas bem como o risco vinculado à reposição e os tratamentos propostos para as mesmas, como por exemplo os fatores de crescimento de granulócitos, antibióticos de amplio espectro e corticoides, são discutidos e analisados. É necesssário um alto índice de suspeita para vincular estas manifestações clínicas à presença de levamisol como adulterante da cocaína.

Nitrogen oxides and ozone in Portugal: trends and ozone estimation in an urban and a rural site.

This study provides an analysis of the spatial distribution and trends of NO, NO2 and O3 concentrations in Portugal between 1995 and 2010. Furthermore, an estimation model for daily ozone concentrations was developed for an urban and a rural site. NO concentration showed a significant decreasing trend in most urban stations. A decreasing trend in NO2 is only observed in the stations with less influence from emissions of primary NO2. Several stations showed a significant upward trend in O3 as a result of the decrease in the NO/NO2 ratio. In the northern rural region, ozone showed a strong correlation with wind direction, highlighting the importance of long-range transport. In the urban site, most of the variance is explained by the NO2/NOX ratio. The results obtained by the ozone estimation model in the urban site fit 2013 observed data. In the rural site, the estimated ozone during extreme events agrees with observed concentration.

Towards operational modeling and forecasting of the Iberian shelves ecosystem.

There is a growing interest on physical and biogeochemical oceanic hindcasts and forecasts from a wide range of users and businesses. In this contribution we present an operational biogeochemical forecast system for the Portuguese and Galician oceanographic regions, where atmospheric, hydrodynamic and biogeochemical variables are integrated. The ocean model ROMS, with a horizontal resolution of 3 km, is forced by the atmospheric model WRF and includes a Nutrients-Phytoplankton-Zooplankton-Detritus biogeochemical module (NPZD). In addition to oceanographic variables, the system predicts the concentration of nitrate, phytoplankton, zooplankton and detritus (mmol N m(-3)). Model results are compared against radar currents and remote sensed SST and chlorophyll. Quantitative skill assessment during a summer upwelling period shows that our modelling system adequately represents the surface circulation over the shelf including the observed spatial variability and trends of temperature and chlorophyll concentration. Additionally, the skill assessment also shows some deficiencies like the overestimation of upwelling circulation and consequently, of the duration and intensity of the phytoplankton blooms. These and other departures from the observations are discussed, their origins identified and future improvements suggested. The forecast system is the first of its kind in the region and provides free online distribution of model input and output, as well as comparisons of model results with satellite imagery for qualitative operational assessment of model skill.

Púrpura de Schõnlein-Henoch, presentación en el adulto / Schõnlein-Henoch purpura, presentation in the adult

Los síndromes plurigandulares autoinmunes se definen por la coexistencia de al menos dos insuficiencias glandulares a consecuencia de una pérdida de la inmunotolerancia. Existen 4 tipos, siendo el tipo 2 el más frecuente. Es condición indispensable la presencia de insuficiencia suprarrenal primaria para hacer el diagnóstico de éste último, pudiendo muchas veces ésta preceder a las otras endocrinopatías que lo conforman: enfermedad tiroidea autoinmune y/o diabetes mellitus tipo 1. La insuficiencia suprarrenal primaria se caracteriza por la producción adrenal deficiente de cortisol, mineralocorticoides y andrógenos. Es una enfermedad poco frecuente que se presenta habitualmente en mujeres en edad media, siendo su etiología más prevalente la adrenalitis autoinmune. Se discute el caso de una paciente de 35 años que consulta por híperpigmentación de piel y episodios presincopales como presentación de una Enfermedad de Addison. La paciente presentó además amenorrea de 8 años de evolución y un bocio grado II lo cual nos llevó a plantear que era portadora de un sindrome plurigandular autoinmune tipo 2.

Ergotismo secundario a la asociación ergotamina-ritonavir: A propósito de 3 casos / Ergotism secondary to ergotamine-ritonavir association: Report of three cases

Ergotism is a complication of the acute intoxication or chronic abuse of ergot derivatives. It may be manifested by a vasomotor syndrome with peripheral vascular disease frequently involving extremities. We report three patients infected with human immunodeficiency virus (HIV), in antiretroviral treatment (ART) that included a protease inhibitor as ritonavir, and had received self-medicated ergotamine. They developed symptoms of peripheral vascular disease and the physical examination showed no arterial pulses in the affected vessels. Arterial Doppler confirmed signs of diffuse arterial spasm in all of them. An arteriography was performed to the second patient and it showed obliteration of the distal sector of the ulnar and radial arteries. Ergotism secondary to ergotamine-ritonavir association was diagnosed. Patients were treated discontinuing the administration of involved drugs, arterial vasodilators and prophylactic anticoagulation, with marked improvement of symptoms.

Tuberculoma cerebral en paciente inmunocompetente / Brain tuberculoma in an inmunocompetent patient

Uruguay presenta baja prevalencia de tuberculosis, ubicándose en la etapa de control de la endemia. El tuberculoma cerebral representa el 1% del total de casos de tuberculosis en inmunocompetentes. Se presenta el caso clínico de una mujer, de 45 años, diabética tipo 2, con un cuadro clínico progresivo de paresia e hipoestesia braquial derecha y crisis epilépticas parciales simples. Estudios imagenológicos evidenciaron lesiones frontoparietales izquierdas, la serología para virus de inmunodeficiencia humana (VIH): negativa, la velocidad de eritrosedimentación: 24 mm/h; el PPD: 3 mm. Se realizó biopsia esteroatáxica. La anatomía patológica evidenció granulomas con necrosis caseosa y el cultivo Mycobacterium tuberculosis. Se comenzó tratamiento según pautas nacionales de la Comisión Honoraria de Lucha Antituberculosa, obteniéndose remisión clínica e imagenológica. La literatura revisada muestra que la demora en el diagnóstico en paciente inmunocompetentes es aproximadamente cuatro veces mayor que en inmunodeprimidos. La presentación clínica es inespecífica, siendo frecuentes la cefalea, la crisis epiléptica generalizada y hemiparesia. La RM es el estudio de mayor sensibilidad diagnóstica, no existiendo imágenes patognomónicas de tuberculoma. El tratamiento es médico; el tratamiento neuroquirúrgico se reserva para casos con hipertensión endocraneana y progresión bajo tratamiento médico. La respuesta al tratamiento se monitoriza con la remisión de los síntomas y el control imagenológico, destacándose la lenta resolución imagenológica.

[Ergotism secondary to ergotamine-ritonavir association. Report of three cases]. / Ergotismo secundario a la asociación ergotamina-ritonavir. A propósito de 3 casos.

Ergotism is a complication of the acute intoxication or chronic abuse of ergot derivatives. It may be manifested by a vasomotor syndrome with peripheral vascular disease frequently involving extremities. We report three patients infected with human immunodeficiency virus (HIV), in antiretroviral treatment (ART) that included a protease inhibitor as ritonavir, and had received self-medicated ergotamine. They developed symptoms of peripheral vascular disease and the physical examination showed no arterial pulses in the affected vessels. Arterial Doppler confirmed signs of diffuse arterial spasm in all of them. An arteriography was performed to the second patient and it showed obliteration of the distal sector of the ulnar and radial arteries. Ergotism secondary to ergotamine-ritonavir association was diagnosed. Patients were treated discontinuing the administration of involved drugs, arterial vasodilators and prophylactic anticoagulation, with marked improvement of symptoms.

Reacciones adversas cutáneas a medicamentos: Vigilancia durante un año en un Hospital Universitario. Uruguay 2008-2009 / Adverse cutaneous reactions to Drugs among hospitalized patients: A one year surveillance

Background: Adverse cutaneous reactions to Drugs (CDRs) are of particular interest among all adverse Drug reactions (ADR) due to their frequency, potential severity and because of the importance of an early diagnosis. Antimicrobial agents, anticonvulsants and non-steroidal anti-inflammatory Drugs are the Drugs associated to the highest risk of CDRs. Aim: To assess CDRs in hospitalized patients and identify the Drugs involved. Material and Methods: All patients hospitalized in the Hospital de Clínicas in Montevideo, Uruguay, with suspected CDRs, detected during one year, were included in this prospective study. The imputability was established using the Karch and Lasagna algorithm modified by Naranjo. We analyzed age, gender, Drugs involved, causal disease, severity, latency and evolution. Results: Seventeen patients, aged 17 to 85 years (15 females) with CDRs were identifed. Twelve had morbilliform exanthemas, four had reactions with eosinophilia and systemic symptoms and one had a Stevens Johnson syndrome. The Drugs involved were antimicrobials in nine cases, hypouricemic agents in four cases, anticonvulsants in three cases and aspartic insulin in one. Twelve patients had a life threatening reaction and one required admission to the intensive care unit. No deaths occurred. Conclusions: CDRs were more common in women and most of them were caused by antimicrobial agents.

[Adverse cutaneous reactions to drugs among hospitalized patients: a one year surveillance]. / Reacciones adversas cutáneas a medicamentos: Vigilancia durante un año en un Hospital Universitario. Uruguay 2008-2009.

BACKGROUND: Adverse cutaneous reactions to Drugs (CDRs) are of particular interest among all adverse Drug reactions (ADR) due to their frequency, potential severity and because of the importance of an early diagnosis. Antimicrobial agents, anticonvulsants and non-steroidal anti-inflammatory Drugs are the Drugs associated to the highest risk of CDRs. AIM: To assess CDRs in hospitalized patients and identify the Drugs involved. MATERIAL AND METHODS: All patients hospitalized in the Hospital de Clínicas in Montevideo, Uruguay, with suspected CDRs, detected during one year, were included in this prospective study. The imputability was established using the Karch and Lasagna algorithm modified by Naranjo. We analyzed age, gender, Drugs involved, causal disease, severity, latency and evolution. RESULTS: Seventeen patients, aged 17 to 85 years (15 females) with CDRs were identifed. Twelve had morbilliform exanthemas, four had reactions with eosinophilia and systemic symptoms and one had a Stevens Johnson syndrome. The Drugs involved were antimicrobials in nine cases, hypouricemic agents in four cases, anticonvulsants in three cases and aspartic insulin in one. Twelve patients had a life threatening reaction and one required admission to the intensive care unit. No deaths occurred. CONCLUSIONS: CDRs were more common in women and most of them were caused by antimicrobial agents.

Predictors of dropout from a multidisciplinary heart failure program: a nested case study.

BACKGROUND: Chronic heart failure is a growing public health issue that is reaching epidemic proportions. In the last few years, multidisciplinary management programs have been developed to improve its management. Yet, some patients take advantage of these programs, whereas others do not. METHODS: Several demographic, medical, and social variables were evaluated as contributors to dropout after enrollment into a multidisciplinary heart failure program using a nested case-control design. A total of 14 patients and 42 controls were interviewed using a standardized questionnaire. Possible associations were explored by means of chi Mantel-Haenszel test and a binary logistic regression model. RESULTS: The only significant factor associated with dropout was social isolation. Patients who lived alone, without family support, had a significantly greater dropout risk (odds ratio, 12.5; 95% confidence interval, 1.35-11.6). CONCLUSIONS: For patients who live alone, an individualized approach may be better than a multidisciplinary management program, but this hypothesis should be investigated in future studies.

Hipertensión arterial pulmonar y mortalidad en pacientes con enfermedad pulmonar obstructiva crónica / Pulmonary arterial hypertension and mortality in patients with chronic obstructive pulmonary disease

Se estudiaron con ecocardiograma doppler color 33 pacientes con EPOC avanzada que se integraron al programa de rehabilitación respiratoria del Hospital de Clínicas. Se encontraron indicadores de hipertensión arterial pulmonar en 12 pacientes (36 por ciento), insuficiencia tricuspídea en 20 pacientes (61 por ciento), e hipertrofia del ventrículo derecho en 15 pacientes (33 por ciento). Se encontró correlación negativa entre el grado de obstrucción al flujo aéreo y la presión arterial pulmonar estimada; no hubo correlación entre gases en sangre, volúmenes pulmonares, función respiratoria en ejercicio y los hallazgos ecocardiográficos. La probabilidad de sobrevida fue significativamente menor para los pacientes con diagnóstico de hipertensión arterial pulmonar. Se destaca la relevancia clínica del diagnóstico y su valor pronóstico

Fibrilación auricular y tromboembolia sistemática / Atrial fibrilation and systemic thromboembolism

La fibrilación auricular es un trastorno del ritmo muy frecuente al que se ve enfrentado el médico en su práctica diaria. Se asocia a incremento de la mortalidad a causa de la cardiopatía subyacente y por la frecuencia de fenómenos tromboembólicos en especial a nivel encefálico. Existe información suficiente actual como para identificar grupos de riesgo y la posibilidad cierta de ejercer impacto terapéutico favorable. Aún quedan muchas interrogantes sin responder, motivo de varios ensayos multicentricos actuales (PATAF, SPAF III, AFASAK II)