S0001-600220030004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000400001 A propósito de "Terapia eléctrica de las arritmias cardiacas" Salazar Vargas Carlos ,CCSS Hospital R.A Calderón Guardia Programa de Cirugía Cardiovascular 10 2003 2003 45 138 138
S0001-600220030004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000400002 Floración algal nociva: Marea roja Jiménez Bolaños Francisco ,CCSS Hospital México Medicina Interna y Medicina de Emergencias 10 2003 2003 45 139 139
S0001-600220030004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000400003 Terapia eléctrica de las arritmias cardiacas Esquivel-Alfaro Lidieth Gutiérrez-Sotelo Oswaldo ,CCSS Hospital México Clínica de arritmias y marcapasos San José Costa Rica 10 2003 2003 45 140 144

Desde la introducción de la estimulación cardiaca mediante marcapasos implantables en la década de 1950, el tratamiento no farmacológico ("terapia eléctrica") de diversas anomalías del ritmo cardiaco ha evolucionado notablemente, contándose en la actualidad con diversas opciones terapéuticas, tales como los marcapasos de doble cámara, los sincronizadores o marcapasos biventriculares, los cardiodesfibriladores implantables y la ablación por catéter. Esta revisión comprenderá los aspectos generales de su funcionamiento, su electrocardiografía básica y sus principales aplicaciones clínicas, elementos que serán de utilidad para el médico que debe afrontar un paciente con una arritmia cardiaca, o que es portador de un dispositivo de estimulación.

Since the introduction of electrical cardiac stimulation by means of implantable pacemakers in the 1950’s decade, non-pharmacological treatment of several cardiac rhythm disorders has evolved importantly. Today we have many therapeutic options including dual chamber pacemakers, cardiac synchronisers, implantable cardiodefibrillators and catheter ablation therapy. In this review we assess generic aspects, basic electrocardiography and the most frequent clinical indications. All these issues will be of interest for physicians who face patients with cardiac arrhythmias or with implanted devices.

 Arritmia cardiaca desfibrilador terapia eléctrica marcapaso Gregoratos G Cheitlin M Conill A ACC/AHAguidelines for implantation of cardiac pacemakers and antiarrhythmia devices: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Pacemaker Implantation) J Am Coll Cardiol 1998 31 Peters RW Gold MR Pacing for patients with congestive heart failure and dilated cardmiopathy Cardiology clinics 2000 18 Glikson M Hayes DL Cardiac Pacing. AReview Med Clin of N Am 2001 Connolly SJ Sheldon R Roberts RS Gent M Arandomized trial of permanent cardiac pacing for the prevention of vasovagal syncope J Am Coll Cardiol 1999 33 Viskin S Glikson M Fish R Glik A Cooperman Y Saxon L Rate Smoothing with cardiac pacing for preventing Torsade de pointes Am J Cardiol 2000 86 Lau CP Tse HF Yu CM Teo WS Kam R Ng KS Huang SS Lin JL Fitts SM Hettrick DA Hill MR New Indication for Preventive Pacing in Atrial Fibrillation (NIPP-AF) Investigators. Dual-site atrial pacing for atrial fibrillation in patients without bradycardia Am J Cardiol 2001 88 Leclercq C Kass DA Retiming the failing heart: principles and current clinical status of cardiac resynchronization J Am Coll Cardiol 2002 Dhala A Sra J Blanck Z Deshpande S Jazayeri MR Akhtar M Ventricular arrhythmias, electrophysiologic studies, and devices Cardiol Clin 1999 17 Acomparision of Antiarrhythmic-drug Therapy with Implantable Defibrillators in patients Resuscitated from Near-fatal Ventricular Arrhythmias N Engl J Med 1997 337 Cooper JM Katcher MS Orlov MV Implantable Devices for the Treatment of Atrial Fibrillation N Engl J Med 2002 346 Calkins H Catheter ablation for cardiac arrhythmias Med Clin North Am 2001 85 Gutiérrez O Araya V Manual de arritmias cardiacas: Guía diagnóstica y terapéutica Manual de arritmias cardiacas: Guía diagnóstica y terapéutica 2002 269 San José Editorial de la Universidad de Costa Rica
S0001-600220030004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000400004 Alergia al látex: historia, epidemiología, prevención y tratamiento Porras Oscar ,CCSS Hospital Nacional de Niños Servicio de Inmunología y Reumatología Pediátrica San José Costa Rica 10 2003 2003 45 145 153

La alergia al látex de hule natural se ha convertido en un problema importante de salud en los trabajadores de la salud y en pacientes con espina bífida e intervenciones quirúrgicas múltiples. Las medidas preventivas permiten reducir la incidencia y son la mejor estrategia para intervenir en este problema de salud pública. Con el objetivo de aumentar el conocimiento sobre el problema de alergia al látex discutimos los aspectos relacionados con historia, epidemiología, diagnóstico, prevención y tratamiento. Se definen los términos sensibilización y alergia y se describen los aspectos químicos del látex de hule natural y de sus proteínas. La definición de grupos de riesgo permite desarrollar una estrategia en las instituciones de salud que disminuye la exposición y como consecuencia las manifestaciones clínicas de los individuos sensibilizados.

IgE-mediated allergy to natural rubber latex has become a significant health problem among health care workers, patients with spina bifida or with a history of multiple surgical interventions. Curative treatment using immunotherapy, is not the most effective approach. Preventive measures reduce latex allergy incidence and are a better strategy for this public health problem. In this article, we discuss history, epidemiology, diagnosis, prevention and treatment of latex allergy.The differences between sensitization and allergy and the chemical aspects of natural rubber and its proteins are analysed. The definition of a risk group allows the development of an strategy aimed to decrease exposure and clinical manifestations among sensitized patients.

 látex alergia hule natural guantes quirúrgicos alergia al látex alergia ocupacional hule natural Hepner DL Castells MC Latex allergy: an update Anesth Analg 2003 96 Ownby DR A history of latex allergy J Allergy Clin Immunol 2002 110 Alenius H Turjanmaa K Palosuo T Natural rubber latex allergy Occup Environ Med 2002 59 Sentencia 2003-1432 Sentencia 2003-1432 2003 Tesiorowski CC Latex allergies in the health care worker J Perianesth Nurs 2003 18 Opinion on natural rubber latex allergy Opinion on natural rubber latex allergy 2000 European Commission, Health and Consumer Protection Turjanmaa K Reunala T Condoms as a source of latex allergen and cause of contact urticaria Contact Dermatitis 1989 83 Turjanmaa K Diagnosis of latex allergy Allergy 2001 56 Quirce S Olaguíbel JM Alvarez MJ Tabar AI El látex. Un importante aeroalergeno implicado en el asma ocupacional An sis sanit Navar 2003 26 Hosler D Burkett SL Tarkanian MJ Prehistoric polymers: rubber processing in ancient Mesoamerica Science 1999 284 Quirce Gancedo S Conde-Salazar Gómez L Blanco Coverra C Quirce Gancedo S Obtención y procesamiento del caucho natural Alergia al látex 2002 Alergia al látex 2002 2002 Barcelona MRAEditions Recommendations for prevention of HIV transmission in health-care settings MMWR 1987 36 Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis B virus to health-care and public safety workers MMWR 1989 38 Fuchs T Latex allergy J Allergy Clin Immunol 1994 93 Zucker-Pinchoff B Latex allergy Mt Sinai J Med 2002 69 Nutter AF Contact urticaria to rubber Br J Dermatol 1979 101 Kurup VP Fink JN The spectrum of immunologic sensitization in latex allergy Allergy 2001 56 Karisola P Alenius H Mikkola J Kalkkinen J Kalkkinen N Helin J The major conformational IgE-binding epitopes of hevein (hev b6.02) are identified by a novel chimera based allergen epitope mapping strategy J Biol Chem 2002 277 Barber Hernández D Lombardero Vega M Blanco Coverra C Quirce Gancedo S Composición alergénica del latex Alergia al látex 2002 Alergia al látex 2002 2002 Barcelona MRAEditions Sánchez Palacios A Alergia al látex. Diagnóstico y aspectos terapéuticos Allergol et Immunopathol 2001 29 Ahmed DD Sobcsak SC Yunginger JW Occupational allergies caused by latex Immunol Allergy Clin North Am 2003 23 Lundberg M Wrangsjö K Johansson SGO Latex allergy from glove powder-an unintended risk with the switch from talc to cornstarch Allergy 1997 52 Anda M Gómez B Lasa E Arroabarren E Garrido S Echechipía S Alergia al látex. Manifestaciones clínicas en la población general y reactividad cruzada con alimentos An sis sanit Navar 2003 26 Turjanmaa K Alenius H Reunala T Palosuo T Recent developments in latex allergy Curr Opin Allergy Clin Immunol 2002 2 Blanco Guerra C Almeida Quintana L García Dumpiérrez A Blanco Coverra C Quirce Gancedo S Alergia al látex 2002 Alergia al látex 2002 2002 Barcelona MRAEditions Lavaud F Prevost A Cossart C Guerin L Bernard J Kochman S Allergy to latex, avocado pear, and banana: evidence for a 30 kd antigen in immunoblotting J Allergy Clin Immunol 1995 95 Blanco C Latex-fruit syndrome Curr Allergy Asthma Rep 2003 3 Sicherer SH Clinical implications of cross-reactive food allergens J Allergy Clin Immunol 2001 108 Aalberse RC Akkerdaas JH van Ree R Cross-reactivity of IgE antibodies to allergens Allergy 2001 56 Baur X Chen Z Allmers H Can a threshold limit value for natural rubber latex airborne allergens be defined? J Allergy Clin Immunol 1998 101 Heilman DK Jones RT Swanson MC Yunginger JW A prospective, controlled study showing that rubber gloves are the major contributor to latex aeroallergen levels in the operating room J Allergy Clin Immunol 1996 98 Brown RH Schauble JF Hamilton RG Prevalence of latex allergy among anesthesiologists: identification of sensitized but asymptomatic individuals Anesthesiology 1998 89 Schwartz LB Bradford TR Rouse C Irani AM Rasp G Van der Zwan JK Development of a new, more sensitive immunoassay for human tryptase: use in systemic anaphylaxis J Clin Immunol 1994 14 Castells MC Irani AM Schwartz LB Evaluation of human peripheral blood leukocytes for mast cell tryptase J Immunol 1987 138 Blanco Guerra C García Dumpiérrez A Almeida Quintana L Blanco Coverra C Quirce Gancedo S Utilidad y limitaciones de las técnicas diagnósticas Alergia al látex 2002 Alergia al látex 2002 2002 Barcelona Sociedad Española de Alergia e Immunología ClínicaMRAEditions Hamilton RG Peterson EL Ownby DR Clinical and laboratory-based methods in the diagnosis of natural rubber latex allergy J Allergy Clin Immunol 2002 110 Liss GM Sussman GL Latex sensitization: occupational versus general population prevalence rates Am J Ind Med 1999 35 Archambault S Malo JL Infante-Rivard C Ghezzo H Gautrin D Incidence of sensitization, symptoms, and probable occupational rhino-conjunctivitis and asthma in apprentices starting exposure to latex J Allergy Clin Immunol 2001 107 Garabrant DH Schweitzer S Epidemiology of latex sensitization and allergies in health care workers J Allergy Clin Immunol 2002 110 Carrillo Diaz T Figueroa Rivero J Navarro Déniz L Ortega Rodríguez N Blanco Coverra C Quirce Gancedo S Epidemiología y factores de riesgo de la alergía al látex Alergia al látex 2002 Alergia al látex 2002 2002 Barcelona Sociedad Española de Alergia e Immunología ClínicaMRAEditions Hochleitner B-W Menardi G Haussler B Ulmer H Kofler H Reider N Spina bifida as an independent risk factor for sensitization to latex J Urol 2001 166 Obojski A Chodorski J Barg W M?drala W Fal AM Ma?olepszy J Latex allergy and sensitization in children with spina bifida Pediatr Neurosurg 2002 37 Nieto Garcia A Mazón Ramos A Pamies Espinoza R Díaz Ruiz J Blanco Coverra C Quirce Gancedo S Espina bífida y alergia al látex Alergia al látex 2002 Alergia al látex 2002 2002 Barcelona Sociedad Española de Alergia e Immunología ClínicaMRAEditions Randolph C Latex allergy in pediatrics Curr Probl Pediatr 2001 31 Muller BA Minimizing latex exposure and allergy. How to avoid or reduce sensitization in the healthcare setting Postgrad Med 2003 113 Brehler R Kütting B Natural rubber latex allergy: a problem of interdisciplinary concern in medicine Arch Intern Med 2001 161 Baur X Chen Z Raulf-Heimsoth M Degens P Protein and allergen content of various natural latex articles Allergy 1997 52 Tabar AI Gómez B Arroabarren E Rodríguez M Lázaro I Anda M Perspectivas de tratamiento de la alergia al látex: inmunoterapia An sis sanit Navar 2003 26 Sastre Domínguez J Blanco Coverra C Quirce Gancedo S Inmunoterapía con látex Alergia al látex 2002 Alergia al látex 2002 2002 Barcelona Sociedad Española de Alergia e Immunología ClínicaMRAEditions Patriarca G Nucera E Buonomo A Del Ninno M Roncallo C Pollastrini E Latex allergy desensitization by exposure protocol: five case reports Anesth Analg 2002 94 Beezhold DH Hickey VL Sussman GL Mutational analysis of the IgE epitopes in the latex allergen Hev b 5 J Allergy Clin Immunol 2001 107 Milgrom H Fick RB Su JQ Reimann JD Bush RK Wathous ML Metzger WJ Treatment of allergic asthma with monoclonal anti-IgE antibody. rhuMAb-E25 study group N Engl J Med 1999 341 Turjanmaa K Kanto M Kautiainen H Reunala T Palosuo T Long-term outcome of 160 adult patients with natural rubber latex allergy J Allergy Clin Immunol 2002 110 Hunt LW Boone-Orke JL Fransway AF Fremstad CE Jones RT Swanson MC Amedical-center-wide, multidisciplinary approach to the problem of natural rubber latex alergy J Occup Environ Med 1996 38 Hunt LW Kelkar P Reed CE Yunginger JW Management of occupational allergy to natural rubber latex in a medical center: the importance of quantitative latex allergen measurement and objective follow-up J Allergy Clin Immunol 2002 110 Sussman GL Liss GM Deal K Brown S Cividino M Siu S Incidence of latex sensitization among latex glove users J Allergy Clin Immunol 1998 101 Phillips VL Goodrich MA Sullivan TJ Health care worker disability due to latex allergy and asthma: a cost analysis Am J Public Health 1999 89 Bolyard EA Tablan OC Williams WW Pearson ML Shapiro CN Deitchman SD Guideline for infection control in health care personnel, 1998 AJIC 1998 26 De La Hoz Caballer B Blanco Coverra C Quirce Gancedo S Estrategias para la prevención de la alergia al látex Alergia al látex 2002 Alergia al látex 2002 2002 Barcelona Sociedad Española de Alergia e Immunología ClínicaMRAEditions Allmers H Brehler R Chen Z Rauf-Heimsoth M Fels H Baur X Reduction of latex aeroallergens and latex-specific IgE antibodies in sensitized workers after removal of powered natural rubber latex gloves in a hospital J Allergy Clin Immunol 1998 102 Charous BL Schuenemann PJ Swanson MC Passive dispersion of latex aeroallergen in a healthcare facility Ann Allergy Asthma Immunol 2000 85 Swanson MC Bubak ME Hunt LW Yunginger JW Warner MA Reed CE Quantification of occupational latex aeroallergens in a medical center J Allergy Clin Immunol 1994 94 Quirce S Swanson MC Fernandez-Nieto M de las Heras M Cuesta J Sastre J Quantified environmental challenge with absorbable dusting powder aerosol from natural rubber latex gloves J Allergy Clin Immunol 2003 111 Cremer R Hoppe A Kleine-Diepenbruck U Blaker F Effects of prophylaxis on latex sensitization in children with spina bifida Eur J Pediatr Surg 1998 8 Cremer R Kleine-Diepenbruck U Hering F Holschneider AM Reduction of latex sensitization in spina bifida patients by a primary prophy-laxis programme (five years experience) Eur J Pediatr Surg 2002 12 Nakamura CT Ferdman RM Keens TG Davidson Ward SL Latex allergy in children on home mechanical ventilation Chest 2000 118 Gentili A Ricci G Di Lorenzo FP Pigna A Masi M Baroncini S Latex allergy in children with oesophageal atresia Paediath Anaesth 2003 13 Kotilainen HR Latex and vinyl examination gloves. Quality control procedures and implications for health care workers Arch Intern Med 1989 149 Crippa M Belleri L Mistrello G Carsana T Neri G Alessio L Prevention of latex allergy among health care workers: evaluation of the extractable latex protein content in different types of medical gloves Am J Ind Med 2003 44 Ownby DR Strategies for distinguishing asymptomatic latex sensitization from true occupational allergy or asthma Ann Allergy Asthma Immunol 2003 90 Kotilainen HR Avato JL Gantz NM Latex and vinyl nonsterile examination gloves: status report on laboratory evaluation of defects by physical and biological methods Appl Environ Microbiol 1990 56 Charous BL Blanco C Tarlo S Hamilton RG Baur X Beezhold D Natural rubber latex allergy after 12 years: recommendations and perspectives J Allergy Clin Immunol 2002 109 Baur X I are we closer to developing threshold limit values for allergens in the workplace? Ann Allergy Asthma Immunol 2003 90
S0001-600220030004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000400005 Sindrome metabólico en pacientes diabéticos tipo 2 e intolerantes a carbohidratos del EBAIS La Mansión, Nicoya Alvarado-Soto Viviana Jiménez-Navarrete Manuel Francisco ,CCSS EBAIS La Mansión Nicoya Costa Rica ,CCSS Hospital de La Anexión Nicoya Costa Rica 10 2003 2003 45 154 157

Objetivo: Analizar la frecuencia y las características clínicas del síndrome metabólico (SM), entre los pacientes diabéticos tipo 2 e intolerantes a carbohidratos en control en el EBAIS La Mansión, del área de salud Nicoya, en un período de un año. Materiales y métodos: estudio retrospectivo de 1 año de duración (septiembre de 2001 a agosto de 2002) de valoración de pacientes diabéticos en control en el EBAIS La Mansión, documentando nombre completo, número de expediente, domicilio, edad, sexo, presencia de diabetes e hipertensión arterial y años de evolución de ambas, índice de masa corporal, obesidad abdominal, triglicéridos, lipoproteína de alta densidad y glicemia (en ayunas). Se utilizó la clasificación del NCEP/ATP III norteamericano para la identificación clínica del SM. Se analizan los expedientes clínicos, tanto del EBAIS como del Hospital de La Anexión. Se mide la circunferencia abdominal, tanto a domicilio, como durante días de citas control por intermedio del ATAP. Resultados: Se estudiaron 67 pacientes diabéticos, el 59,7% entre los 40 y 60 años de edad, la mayoría mujeres (80,6%), de todos ellos el 68,6% resultaron con SM. Se estudiaron 9 intolerantes a carbohidratos, todas mujeres, 6 entre los 40 y 60 años de edad, de las cuales 6 resultaron con SM. El 45,7% de los diabéticos tenían de 0-4 años y el 23,9% de 5-9 años de evolución de su DM, mientras que en las IC, el 83,3% tenían de 0-4 años de evolución de su problema. Las asociaciones con HTAfueron un 56,5% y un 100% entre diabéticos e IC, respectivamente; con obesidad abdominal un 82,6% y un 83,3% entre diabéticos e IC, respectivamente; con hipertrigliceridemia un 60,9% y un 66,7%, respectivamente, y con HDLC baja un 76,1% y un 66,1%, respectivamente. La tríada de asociación más frecuente para el diagnóstico del SM, tanto en diabéticos como en IC, lo fue hiperglicemia, hipertensión arterial y obesidad abdominal. Conclusión: Dos terceras partes de los diabéticos e intolerantes a carbohidratos en control en el EBAIS La Mansión son portadores de síndrome metabólico, y la gran mayoría de ambos grupos posee menos de 5 años de evolución del diagnóstico de hiperglicemia. Lo anterior obliga a utilizar estrategias más agresivas en cuanto a detección, promoción de estilos de vida saludable, prevención de factores de riesgo y control metabólico entre los portadores del SM y sus familiares. Se propone además considerar este síndrome como problema de salud pública en Costa Rica.

In order to determine the presence of metabolic syndrome (MS) between hiperglycemic patients (type 2 diabetics and those with glucose intolerance) at a primary care center (La Mansión), a retrospective study was carried out between september 2001 to august 2002. The clinical diagnosis of MS was based on the guidelines of the NCEP/ATPIII. There were 67 diabetic patients, 59,7% of them between 40 and 60 years old and 80,6% were women. 68,6% of the 67 had MS. There were 9 patients with glucose intolerance, all women, 6 with MS. 45,7% of the diabetics and the 83,3% of the patients glucose intolerance with MS, have been diagnosed with hiperglycemia between 0-4 years. Associations with hypertension were 56,5% and 100% between diabetics and glucose intolerance respectively, with abdominal obesity were 82,6% and 83,3% between diabetics and glucose intolerance respectively, with high triglycerides 60,9% and 66,7% between diabetic and glucose intolerance respectively, with low high-density lipoprotein 76,1% and 66,1% between diabetics and glucose intolerance respectively. The 3 most frecuent clinical associations of MS were fasting glucose >110 mg/dl, hypertension and abdominal obesity. Around 60% of diabetics and glucose intolerance patients clinic had MS and the majority with only few years of the diagnosis of hiperglycemia and hypertension. In this community we need to use aggressive measures in changing lifestyles and metabolic control in these patients and in their families. It is necessary to consider MS as a public health problem in Costa Rica.

 diabetes mellitus síndrome metabólico atención primaria Reaven GM Syndrome X: 6 years later J Intern Med 1994 236 ^s736 Sowers JR Update on the Cardiometabolic Syndrome Clin Corners-tone 2001 4 Reusch JAE Current concepts in insulin resistance, type 2 diabetes mellitus, and the metabolic syndrome Current concepts in insulin resistance, type 2 diabetes mellitus, and the metabolic syndrome 2002 MdConsult.com Schafer AWaist is a Terrible Thing to Mind: Central Obesity, the Metabolic Syndrome, and Sleep Apnea Hypopnea Syndrome AWaist is a Terrible Thing to Mind: Central Obesity, the Metabolic Syndrome, and Sleep Apnea Hypopnea Syndrome 2002 MdCon-sult. com Pietropaolo M Le Roith D Pathogenesis of Diabetes: Our Current Understanding Clin Cornerstone 2001 4 Deedwania PC The Deadly Quartet Revisited Am J Med 1998 105 ^s1A Hanson RL Imperatore G Bennett PH Knowler WC Components of the "Metabolic Syndrome" and Incidence of Type 2 Diabetes Diabetes 2002 51 Hsueh WAy Law RE Cardiovascular risk continuum: implications of insulin resistance and diabetes Am J Med 1998 105 ^s1A Goldstein BJ Insulin resistance as the core defect in type diabetes mellitus Insulin resistance as the core defect in type diabetes mellitus 2002 MdConsult.com Stalking Syndrome X Stalking Syndrome X 2002 Ford ES Giles WH Dietz WH Prevalence of the Metabolic Syndrome Among US Adults. Findings From the Third National Health and Nutrition Examination Survey JAMA 2002 287 Fernández E YMorera O Síndrome X en Costa Rica (diabetes mellitus tipo II, obesidad con estigma dérmico) Rev Méd de Costa Rica y CA 1997 538 Bohannon NJV Coronary artery disease and diabetes Postgraduate Medicine 1999 105 Bosch X Alfonso F Bermejo J Diabetes y enfermedad cardiovascular. Una Mirada hacia la nueva epidemia del siglo XXI Rev Esp Cardiol 2002 55 Manual para la Atención Integral e la Diabetes Tipo 2. En el Primer Nivel de Atención Manual para la Atención Integral e la Diabetes Tipo 2. En el Primer Nivel de Atención 2002 San José Unidad de Imprenta CCSS Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) JAMA 2001 285 ^s19 Abraira C Duckworth W The Need for Glycemic Trials in Type 2 Diabetes Clinical Diabetes 2003 21 Huang ES Meigs JB Singer DE The effect of interventions to prevent cardiovascular disease in patients with type 2 diabetes mellitus Am J Med 2001 111
S0001-600220030004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000400006 Floraciones algales nocivas en la costa pacífica de Costa Rica: toxicología y sus efectos en el ecosistema y salud pública Freer Enrique Vargas-Montero Maribel ,Universidad de Costa Rica Centro de Investigación en Estructuras Microscópicas Costa Rica 10 2003 2003 45 158 164

Justificación y objetivos: Los primeros casos de intoxicación por floraciones algales nocivas (FAN) se reportaron en el país en 1990. Sin embargo desde finales de 1999 se ha observado un aumento drástico en el número de personas intoxicadas, especialmente en la costa pacífica del país. En Costa Rica existe gran desconocimiento acerca del problema. Debido al impacto que producen los fenómenos FAN en la salud pública, el turismo local y el ecosistema, es necesario describir las especies tóxicas y sus toxinas para tomar las medidas adecuadas de control y prevención. Métodos: Se realizaron muestreos de agua en varios sectores de la costa pacífica de nuestro país, con el objetivo de detectar las especies de microalgas potencialmente tóxicas y nocivas, y se interrogó a los pescadores locales. La identificación de las especies se realizó morfológicamente mediante microscopía de luz y electrónica de rastreo. Los hallazgos se compararon con la bibliografía y se propuso el potencial tóxico de estas microalgas, así como los métodos de análisis toxicológico, y la sintomatología de los afectados. Resultados: Observamos en Costa Rica un aumento en número de especies de microalgas productoras de FAN. Se reportaron las especies tóxicas productoras de FAN descritas por varios autores y las encontradas en este estudio. En algunas muestras de floraciones algales hemos encontrado bacterias grandes intracelulares, de forma bacilar, principalmente dentro del dinoflagelado Prorocentrum micans. Esta relación podría estar asociada a la toxigenicidad del alga. Hemos descrito la presencia de 26 dinoflagelados, 8 diatomeas y 1 cianobacteria tóxica en las FAN de las costas del Océano Pacífico costarricense. Conclusión: Se piensa que el aumento en la contaminación de las zonas costeras y el transporte de especies por medio de navíos pueden ser la causa de la aparición de estas microalgas. Estas son capaces de producir: intoxicación paralizante, amnésica, diarréica, neurotóxica, ciguatera y fiebre de Tamandré. Es importante que el personal de salud tenga un buen conocimiento de las FAN y se necesita con urgencia un adecuado programa de monitoreo y control en Costa Rica, para proteger a la población.

Justification and Objectives: The first cases of intoxication due to Harmful Algae Blooms (HAB) in Costa Rica were reported in 1990. However, towards the end of 1999 a drastic increase of poisoned people was observed, especially along our pacific coast. There is lack of information regarding the problems of HAB. Due to the impact of HAB on public health, local tourism and the ecosystem, it is necessary to describe toxic species and their toxins in order to apply adequate control and preventive measures. Methods: Water samples were taken in various locations along the costarican pacific coast with the aim of detecting potentially toxic and harmful species of microalgae. Species identification was carried out morphologically by means of light and scanning electron microscopy. These findings were compared with current literature and the potential toxin of these microalgae was proposed as well as the methods of toxico-logical analysis and the clinical findings of those affected. Results: Recently, an increase in the number of HAB producing microalgae species has been observed in Costa Rica. This study reports these findings together with ones from those of other authors related to HAB producing species in Costa Rica. In few algal bloom samples, large intracellular bacillary bacteria were found, mainly within the dinoflagellate Prorocentrum micans. This relation may be associated with the toxicity of the algae. Discussion: It is believed that the increase in coastal zone pollution and the transportation of species by means of ships ballast water may be the cause of the appearance of these microalgaes. The presence of 26 dinoflagellates, 8 diatoms and 1 cyanobacteria, all potentially harmful in HAB events, was currently demonstrated along the pacific coast of Costa Rica. These microalgae are capable of producing toxins which may cause: paralysis, amnesia, diarrheia, and neurotoxicity poisonings, ciguatera and Tamandré fever. It is important that health personnel be knowledgeable regarding HAB events and to implement an effective monitoring and program control in Costa Rica in order to protect the population.

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S0001-600220030004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000400007 Hepatitis virales agudas en un hospital de adultos, de 1992 a 2001 Acuña José Umaña Elizabeth Saldarriaga Mauricio Mora Jorge Brenes Fernando Martén Alfredo ,CCSS-UCR Hospital México Unidad Académica de Hepatología ,CCSS-UCR Hospital México Servicio de Urgencias ,CCSS-UCR Hospital México Servicio de Infectología y Servicio de Terapia Intensiva ,CCSS-UCR Hospital México Servicio de Anatomía Patológica 10 2003 2003 45 165 169

Justificación y objetivos: Debido al cambio de la distribución etiológica de las hepatitis virales agudas, percibido en la práctica clínica diaria en el ámbito nacional y confirmado en otros países, se hizo evidente la necesidad de realizar un análisis casuístico de las infecciones virales hepáticas agudas en nuestro país. Se puso enfasis en el virus productor de hepatitis Acuya presentación clínica es más severa en adultos en comparación con los niños. Métodos: Se registraron todos los casos de hepatitis viral aguda, ya fuese por virus A o virus B, que se presentaron al Hospital México del 12 de enero de 1992 al 28 de diciembre de 2001. El diagnóstico se realizó por detección de anti-VHAIgM, HbsAg y anti-HBc IgM. Además, se estudiaron todos los casos de hepatitis fulminante del mismo período, basados en parámetros clínicos y de laboratorio, para establecer el diagnóstico y la etiología. Resultados: Durante el período descrito, se lograron documentar 587 casos de hepatitis virales agudas, 235 por virus A y 352 por virus B lo que corresponde al 40% y al 60% respectivamente. Se presentaron con mayor frecuencia casos entre los 20 y 60 años. El 53,32% de los casos de hepatitis viral aguda correspondieron a hombres y el 46,68%, a mujeres. Se recolectaron 33 casos de hepatitis fulminante. De estos casos, 45,45% eran de etiología viral; un 33,33%, por virus Ay un 12,12%, por virus B. Se hallaron otras etiologías en menores porcentajes, como enfermedad de Wilson, hepatotoxicidad por anestésicos y degeneración grasa del embarazo. Un 2,56% del total de hepatitis virales se presentaron como hepatitis fulminantes. El 4,7% de hepatitis Acursó de forma fulminante. El manejo de los pacientes con hepatitis viral aguda se ofreció en su mayoría (62%) por medio del Servicio de Consulta Externa. Conclusiones: La infección por el virus de la hepatitis B fue predominante en los adultos estudiados, con distribución etiológica similar a lo reportado décadas atrás para zonas específicas del país. Aunque la distribución fue similar si se denota un número importante de hepatitis A de presentación fulminante, alcanzando un porcentaje del 4,7%. Se debe considerar en el futuro panorama de la salud nacional, la incursión de una vacuna para el virus de hepatitis A, que se inicie al nacimiento y se aplique a jóvenes y adultos en mayor riesgo.

Objectives and justification: Due to the change that has been sensed in Costa Rica’s daily clinical practice and confirmed in other countries regarding etiological distribution of acute viral hepatitis, it became clear the need of studying acute viral hepatitis infections, with more interest in the hepatitis A virus because its clinical presentation in adults is more severe tan in children. Methods: All cases of acute AB viral hepatitis were registered, from January 12, 1992 to December 28, 2001 at the Hospital Mexico. The diagnosis was made by detection of IgM anti-HAV, HbsAg and IgM anti-HBc. All cases of fulminant hepatitis from the same period were studied also. The diagnosis and etiology of these cases were based on clinical and laboratory parameters. Results: During the study on period, 587 cases of acute viral hepatitis were diagnosted, 235 by A virus and 352 by B virus, this corresponds to a 40% and 60% respectively. Most of the cases were found between the ages of 20 and 60 years. Fifty three percent of the cases occurred in men and 46,68% in women. Thirty three fulminant hepatitis cases were registered. Forty five percent were caused by viral infection; 33,33% from virus A and 12,12% from virus B. Other pathologies like Wilson disease, hepatotoxicity produced by the use of anesthetics and pregnancy fatty degeneration were found in smaller percentages. Two point fifty six percent of acute viral hepatitis had a fulminant clinical presentation. Four point seven percent of hepatitis Acases had a fulminant course. The management of the patients with acute viral hepatitis was mainly conducted (62%) by the Out-patient Gastroenterology Service. Conclusions: The predominant hepatitis infection in adults was caused by B virus. The etiological distribution was very similar to previous reports made decades ago for specific areas of the country, but the presentation of fulminant hepatitis A has increased (4,7%) considerably. The inclusion of vaccination against hepatitis A virus must be considered in the future of the national health system. This vaccine should be given at birth and applied to young patients and adults with high risk of acquiring severe infection.

 Esquivel J Fernández L Hevia F Martén A Mora J Salom I Diagnóstico y prevención de las hepatitis virales Diagnóstico y prevención de las hepatitis virales 1990 1ª ed San José EDNASSS-CCSS Hadler SC Hollinger FB Lemon SM Margolis HS Global impact of hepatitis Avirus infection; changing patterns Viral hepatitis and liver diseases Viral hepatitis and liver diseases 1991 Baltimore Williams & Wilkins Koff RS Hepatitis A LancetHepatitis A 1998 351 Steffen R DuPont HL Hepatitis B Manual of travel medicine and health Manual of travel medicine and health 1999 Hamilton, London & St. Louis. BC Decker Inc Visoná KA Eduarte CE Zamora E Salazar LM Estudio epidemiológico de las hepatitis virales en San Ramón y Palmares de 1972-1985 Acta Med Costarric 1989 33 Fauci Harrison Principios de Medicina Interna Harrison Principios de Medicina Interna 1998 II 14a ed Mc Graw-Hill Interamericana Romero R Lavine JE Viral hepatitis in children Semin Liver Disease 1994 14 Cuthbert JA Hepatitis A: old and new Clin Microbiol Rev 2001 14 Henning KJ Bell E Braun J Barker ND Acommunity-wide outbreak of hepatitis A: risk factors for infection among homosexual and bisexual men Am J Med 1995 99 Lucioni C Cipriani V Mazzi S Panunzio M Cost of an outbreak hepatitis Ain Puglia, Italy PharmacoEconomics 1998 13 Hutin YJ Pool V Cramer EH Amultistate foodborne outbreak of hepatitis A N Engl J Med 1999 340 Taylor ML García Z Holst I Seroprevalencia de los virus de las hepatitis A y B en grupos etarios de Costa Rica Acta Med Costarric 2001 43 Hollinger FB Ticehurst JR Fields BN Knipe DM Peter MH Hepatitis A virus Virology Virology 1996 1 3ª ed Philadelphia Lippincott-Raven Publishers Takahashi J Shimizu M Etiology and prognosis of fulminant viral hepatitis in Japan: a multicentre study.The Study Group of Fulminant Hepatitis Gastroenterol Hepatol 1991 6 O’Grady J Management of acute and fulminant hepatitis A Vaccine 1992 10 ^s1 Acharya SK Dasarathy S Kumer TL Fulminant hepatitis in a tropical population: clinical course, cause, and early predictors of outcome Hepatology 1996 23 Prevention of hepatitis A through active or passive immunizations: recommendations of the Advisory Committee on Immunisation Practices MMWR 1999 48 ^s12 Thoelen S Van Damme P Leenvaar-Kuypers A The first combined vaccine against hepatitis Aand B: an overview Vaccine 1999 17
S0001-600220030004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000400008 Normas para el manejo de exposiciones ocupacionales al VIH León-Bratti María Paz Mesion-Julio Alfredo Porras-Madrigal Oscar Solano-Chinchilla Antonio Herrera-Martínez Gisela , 10 2003 2003 45 170 174 Fauci AS HIV and AIDS: 20 years of science Nature Medicine 2003 9 Gerberding JL Clinical Practice. Occupational exposure to HIV in health care settings N Engl J Med 2003 348 Sulkowski MS Ray SC Thomas DL Needlestick transmission of hepatitis C JAMA 2002 287 Cardo DM Culver DH Ciesielski CA A case control study of HIV seroconversion in health care workers after percutaneous exposure N Engl J Med 1997 337 Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV and HIV and recommendations for postexposure prophylasis MMWR 2001 50 NIOSH alert: preventing needlestick injuiries in health care settings NIOSH alert: preventing needlestick injuiries in health care settings 1999 Cincinatti National Institute for Occupational Safety and Health
S0001-600220030004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022003000400009 Vólvulo intestinal secundario a divertículo de Meckel Massotto -Chaves Horacio Zúñiga -López Laura ,CCSS Hospital Monseñor Sanabria San José Costa Rica 10 2003 2003 45 175 177

El divertículo de Meckel es la anomalía congénita más frecuente del tracto gastrointestinal. La mayoría de veces se encuentra en forma incidental durante una laparotomía, o bien, en una autopsia. Cuando presenta síntomas (en aproximadamente un 4% de los casos) estos suelen ser secundarios a la presencia de mucosa gástrica ectópica, que puede producir ulceraciones, hemorragia y perforación, procesos inflamatorios o bien obstrucción intestinal, como en el caso que se presenta.

Meckel´s diverticulum is the most common congenital anomaly of the gastrointestinal tract. In most cases it is found incidentaly during a laparotomy or in autopsies. When it is simptomatic (in about 4% of cases) it could be sencondary to ulceration, bleeding or perforation due to ectopic gastric mucosa; to inflamation or to intestinal obstruction, as in the case presented here.

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