S0001-600220060002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022006000200001 Nódulo pulmonar solitario Salazar Vargas Carlos , 06 2006 2006 48 60 60
S0001-600220060002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022006000200002 Ketamina en el manejo del dolor refractario por cáncer Vargas Rumoroso Karla Sofía Salas Herrera Isaías , 06 2006 2006 48 61 65

Los pacientes con cáncer presentan dolor en el rango entre moderado e intenso durante el transcurso de su enfermedad, principalmente en la etapa terminal. La escalera analgésica de la Organización Mundial de la Salud (OMS) se ha empleado como guía terapéutica para tratar a estos pacientes; utiliza tres grupos de fármacos: opiáceos, antiinflamatorios no esteroideos (AINES) y coadyuvantes. Dentro de estos últimos se encuentra la ketamina, un derivado fenciclidínico que interactúa con los receptores N-metil-D-aspartato (NMDA). Tradicionalmente ha sido utilizado como inductor de la anestesia general, y en dosis subanestésicas se emplea para el tratamiento del dolor refractario al uso de opioides.

Patients with cancer suffer moderate to severe pain during the course of their disease, mainly during the terminal phase. The World Health Organization Pain Relief Ladder has been used as a therapeutic guide for the treatment of these patients, which uses 3 kinds of drugs: opioids, non steroidal anti-inflammatory drugs, and adjuvants. Ketamine is one of the latter; it is a phencyclidine derivative that interacts with N-methyl-D-aspartate (NMDA) receptors. Traditionally it has been used as an anesthesia induction drug, and subanesthetic doses are used for relief of pain refractory to opioids.

 dolor cáncer analgesia ketamina pain cancer analgesia ketamine National cancer control programmes: policies and manage trial guidelines National cancer control programmes: policies and manage trial guidelines 2002 Ginebra Adherencia a los tratamientos a largo plazo: pruebas para la acción Adherencia a los tratamientos a largo plazo: pruebas para la acción 2003 Ginebra Fine P Low-dose ketamine in the management of opioid resistant terminal cancer pain J Pain Symptom Manage 1999 17 Patterson D Shahar S Loeser J Burn pain Bonica’s management of pain Bonica’s management of pain 2001 ^ePhiladelphia Lippincott, Williams and Wilkins Weinbroum A A single small dose of postoperative ketamine provides rapid and sustained improvement in morphine analgesia in the presence of morphine resistant pain Anesth Analg 2003 96 Bell R Dahl J Moore R Kalso E Peri-operative ketamine for acute post-operative pain: a quantitative and qualitative systematic review Acta Anaesthesiol Scand 2005 49 Kafali H Aldemir B Kaygusuz K Gursoy S Kunt N Small-dose ketamine decreases postoperative morphine requirements Eur J Anaesthesiol 2004 N ov Fine P Ketamine: From Anesthesia to Palliative Care AAHPM Bulletin 2003 3 Richebe P Rivat C Laulin JP Maurette P Simonnet G Ketamine improves the management of exaggerated postoperative pain observed in perioperative fentanyl-treated rats Anesthesiology 2005 102 Jackson K Ashby M Martin P "Burst" Ketamine for refractory cancer pain: an open-label audit of 39 patients J Pain Symptom Manage 2001 22 Pasero C McCaffery M Pain control: ketamine: low doses may provide relief for some painful conditions Am J Nurs 2005 105 Langsjo J Maksimow A Salmi E Kaisti K Aalto S Oikonen V Hinkka S Aantaa R Sipila H Viljanen T Parkkola R Scheinin H S-ketamine anesthesia increases cerebral blood flow in excess of the metabolic needs in humans Anesthesiology 2005 103 Shimoyama M Shimoyama N Gorman A Elliot R Inturrici C Oral Ketamine is antinociceptive in the rat: the role of norketamine Pain 1999 81 Krystal J Karper L Benett A Interactive effects of subanestetic ketamine and subhypnotic lorazepam in humans Psichopharmacology 1998 38 Fisher K Coderre T Hagen N Targeting the N-Methyl-D-Aspartate receptor for chronic pain management: preclinical animal studies, recent clinical experience and future research directions J Pain Symptom Manage 2000 20 Annetta M Iemma D Garisto C Tafani C Proietti R Ketamine: new indications for an old drug Curr Drug Targets 2005 6 Lynch M Clark A Sawynok J Sullivan M Topical amitriptyline and ketamine in neuropathic pain syndromes: an open-label study J Pain 2005 6 Reves J Miller Intravenous nonopioid anesthetics Miller’s anesthesia Miller’s anesthesia 2005 ^ePhiladelphia Hanley and Belfus Larcher A Laulin J Celerier E Le Moal M Simonnet G Acute tolerance associated with a single opiate administration: involvement of N-methyl-D-aspartate-dependent pain facilitatory systems Neuroscience 1998 84 Akin Takmaz S Inan N Gunal S Kaymak C Sakalli M Dikmen B Ketamine combined with morphine for the management of cancer pain in a patient with meperidine tolerance and addiction Agri 2005 J ul 17 Anghelescu DL Oakes LL Ketamine use for reduction of opioid tolerance in a 5-year-old girl with end-stage abdominal neuroblastoma J Pain Symptom Manage 2005 30 Fitzgibbon EJ Viola R Parenteral ketamine as an analgesic adjuvant for severe pain: development and retrospective audit of a protocol for a palliative care unit J Palliat Med 2005 8 Lossignol DA Obiols-Portis M Body JJ Successful use of ketamine for intractable cancer pain Support Care Cancer 2005 13 Slatkin NE Rhiner M Ketamine in the treatment of refractory cancer pain: case report, rationale, and methodology J Support Oncol 2003 1 Kotlinska-Lemieszek A Luczak J Subanesthetic ketamine: an essential adjuvant for intractable cancer pain J Pain Symptom Manage 2004 28 Rae F Eccleston C Kalso E Ketamine as adjuvant to opioids for cancer pain. A Qualitative Systematic Review J Pain Symptom Manage 2003 26 Thogulava R Saxena A Sushma B Oral Ketamine as an adjuvant to oral morphine for neuropathic pain in cancer patients J Pain Symptom Manage 2002 23 Kannan T Oral ketamine as an adjuvant to oral morphine for neuropathic pain in cancer patients J Pain Symptom Manage 2002 23 Friedman R Li V Keuppers F Atkinson G Oral Ketamine in hepatocellular carcinoma Pain medicine 2000 1 McDonnell F Sloan J Hamann S Advances in cancer pain management Current Pain Headache Rep 2001 5 Ban C Tsui H Dawn D Sunil D Malherbe S Intravenous Ketamine Infusion as an Adjuvant to Morphine in a 2-Year-Old With Severe Cancer Pain From Metastatic Neuroblastoma J Pediatr Hematol Oncol 2004 26 Mercadante S Arcuri E Tirelli W Analgesic Effect of Intravenous Ketamine in Cancer Patients on Morphine Therapy: A Randomized, Controlled, Double-Blind, Crossover, Double-Dose Study J Pain Symptom Manage 2000 20 Yang C Wong C Chang J Intrathecal ketamine reduces morphine requirements in patients with terminal cancer pain Canadian J of Anaesthesia 1996 43 Carr D Goudas L Denmana W BroOkoff D Staats P Brennen L Green G Albine R Hamilton D Rogers M Firestone L Alvin R Mermelstein F Safety and efficacy of intranasal ketamine for the treatment of breakthrough pain in patients with chronic pain: a randomized,double-blind, placebo-controlled, crossover study Pain 2004 108 Gammaitoni A Gallagher R Welz-Bosna M Topical ketamine gel: possible role in treating neuropathic pain Pain Med 2000 1 Yaster M Yaster M General anesthesia Pediatric pain management and sedation handbook Pediatric pain management and sedation handbook 1997 ^eSt. Louis Mosby-Yearbook
S0001-600220060002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022006000200003 Estado actual de la vacuna conjugada contra Streptococcus pneumoniae Sierra- Fernandez Hernán Schultz- Faingezicht Malka Soley-Gutiérrez Carolina Guevara- Jiménez Silvia Arguedas- Mohs Adriano ,Instituto de Atención Pediátrica ,Universidad de Ciencias Médicas 06 2006 2006 48 66 71

Las infecciones por Streptococcus pneumoniae son frecuentes en la población pediátrica especialmente en los niños menores de 2 años. El S. pneumoniae puede producir infecciones invasoras con una alta tasa de mortalidad y morbilidad como lo son las meningitis bacterianas, la neumonía y bacteremias siendo a la vez el agente que con mayor frecuencia se detecta en el oído medio de niños con otitis media. En la actualidad existe una vacuna conjugada contra esta bacteria que protege contra los siete serotipos de S. pneumoniae más frecuentes en el mundo y que a su vez son los mismos serotipos que presentan una mayor incidencia de resistencia a los antibioticos de uso frecuente. La vacuna no solo protege contra este tipo de infecciones sino que se ha demostrado que disminuye la colonización nasofaringea de los niños que han recibido la vacuna produciendo a su vez, una reducción en el numero de infecciones, por esta bacteria, en poblaciones de personas mayores de 5 años, incluyendo adultos y personas mayores a los 65 años (efecto rebaño). Con base en los serotipos aislados en niños costarricenses con otitis media, se puede calcular que la cobertura de esta vacuna en Costa Rica sería de aproximadamente un 74% e incluyendo mayoritariamente, los serotipos que presentan resistencia antimicrobriana más frecuentemente.

The heptavalent S. pneumoniae conjugate vaccine has shown to be safe and effective in preventing pediatric invasive infections and otitis media caused by S. pneumoniae. The routine use of these vaccines has dramatically reduced the incidence of invasive pneumococcal diseases in children younger than 2 years old and because of a reduction in colonization of the children’s nasopharynx, the transmission from child to adult has been reduced and the number of secondary S. pneumoniae infections in adults. Another benefit of the routine use of this vaccine has been the reduction of vaccine-type antimicrobial resistant strains. Based on the S. pneumoniae serotype distribution in Costa Rica, the predicted vaccine protection is calculated in 74%.

 S. pneumoniae enfermedad invasora vacuna conjugada S. pneumoniae vaccine serotype Preventing pneumococcal disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP) Preventing pneumococcal disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP) 2000 49 MMWR Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP) Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP) 1997 46 Peter G Klein JO Long SS Pickering LK Prober CG Streptococcus pneumoniae Principles and practice of pediatric infectious diseases Principles and practice of pediatric infectious diseases 2003 2 ^ePhiladelphia Churchill Livingstone Pneumococcal vaccine Wkly Epidemiol Report 2003 14 Dagan R Relamed M Piglansky L Greenberg D Abramson O Mendelman PM Reduction of nasopharyngeal carriage of pneumococci during the second year of life by a heptavalent conjugate pneumococcal vaccine J Infect Dis 1996 174 Shinefield HR Black SB Postlicensure surveillance for Haemophilus influenzae type b invasive disease alter use of Haemophilus influenzae type b oligosaccharide CRM197 conjugate vaccine in the large defined United Status population: a four year eight month follow up Pediatr Infect Dis J 1995 14 Progress toward elimination of Haemophilus influenzae type b among infants and children: United States, 1987-1993 MMWR 1994 43 Prevention of pneumococcal disease: recommendation of the Advisory Committee on Immunization Practices (ACIP) MMWR 1997 46 Ulloa R Avila M Herrera M Herrera J Arguedas A Invasive pneumococcal disease in Costa Rican children: a seven year survey Pediatr Infect Dis J 2003 22 Eskola J Kilpi T Palmu A Jokinen J Haapakoski J Herva E Efficacy of a Pneumococcal conjugate vaccine against acute otitis media N Engl J Med 2001 344 Niemelä M Uhari M Möttönen M Pokka T Cost arising from otitis media Acta Paediatr 1999 88 Gates GA Cost-effectiveness considerations in otitis media treatment Otolaryngol Head Neck Surg 1996 14 Kaplan B Wandstrat TL Cunningham JR Overall cost in the treatment of otitis media Pediatr Infect Dis J 1997 16 Bondy J Berman S Glazner J Lezotte D Direct expenditures related to otitis media diagnosis: extrapolations from a pediatric Medicaid cohort Pediatrics 2000 105 National Committee for Clinical and Laboratory Standards: twelfth informational supplement. NCCLS document. M100-S12 National Committee for Clinical and Laboratory Standards: twelfth informational supplement. NCCLS document. M100-S12 2002 Wayne^ePennsylvania Hava DL Le Mieux J From nose to lung: the regulation behind Streptococcus pneumoniae virulence factors Molec Microbiol 2003 50 Ghaffar F Friedland I Mccraken G Dynamics of nasopharyngeal colonization by S.pneumoniae Pediatr Infect Dis J 1999 18 Brueggemann AB Peto TE Crook DW Butler JC Kristinsson K Spratt B Temporal and geographic stability of the serogroup- specific invasive disease potential of Streptococcus pneumoniae in children J Infect Dis 2004 190 Fernebro J Andersson I Sublett J Morfeldt E Novak R Tuomanen E Capsular expression in Streptococcus pneumoniae negatively affects spontaneous and antibiotic-induced lysis and contributes to antibiotic tolerance J Infect Dis 2004 Pickering LK Pneumococcal Infections Red book: 2003 Report of the Committee on Infectious Diseases Red book: 2003 Report of the Committee on Infectious Diseases 2003 26 Elk Grove Village^eIL American Academy of Pediatrics Arguedas A Dagan R Guevara S Porat N Soley C Pérez A Brilla R Middle ear fluid Streptococcus pneumoniae serotype distribution in Costa Rican children with otitis media Pediatr Infect Dis J 2005 24 Arguedas A Dagan R Soley C Loaiza C Knudsen K Porat N Perez A Brilla E Herrera ML Microbiology of otitis media in Costa Rican children, 1999 through 2001 Pediatr Infect Dis J 2003 22 Dagan R Vacunas neumocóccicas conjugadas para prevenir la portación y propagación de neumococos resistentes a los antibióticos Arch. argent pediatr 2002 100 Vives M García ME Saenz P Mora M Mata L Sabharwal H Nasopharyngeal colonization in Costa Rican children during the first year of life Pediatr Infect Dis J 1997 16 García JA Fresnadillo MJ Dynamics of nasopharyngeal colonization by potential respiratory pathogens J Antimicrob Chemother 2002 50 Fattom A Lue C Szu SC Mestecky J Serum antibody response in adult volunteers elicited by injection of Streptococcus pneumoniae type 12F polysaccharide alone or conjugated to diphtheria toxoid Infect Immun 1990 58 Nieminen T Kayhty H Leroy O Eskola J Pneumococcal conjugate vaccination in toddlers: mucosal antibody response measured as circulating antibody-secreting cells and as salivary antibodies Pediatr Infect Dis J 1999 18 Adderson EE Antibody repertoires in infants and adults: effects of T-independent and T-dependent immunizations Springer Semin Immunopathol 2001 23 Perez-Melgosa M Ochs HD Linsley PS Laman JD van Meurs M Flavell R Carrier-mediated enhancement of cognate T cell help: the basis for enhanced immunogenicity of meningococcal outer membrane protein polysaccharide conjugate vaccine Eur J Immunol 2001 31 Wasserman RL Sorensen R Evaluating children with respiratory tract infections: the role of immunization with bacterial polysaccharide vaccine Pediatr Infect Dis J 1999 18 Huo Z Spencer O Miles J Johnson J Holliman R Sheldon J Antibody response to pneumolysin and to pneumococcal capsular polysaccharide in healthy individuals and Streptococcus pneumoniae infected patients Vaccine 2004 22 Obaro SK Adegbola RA Chang I Banya WA Jaffar S Mcadam K Safety and immunogenicity of a nonavalent pneumococcal vaccine conjugated to CRM 197 administered simultaneously but in a separate syringe with diphtheria, tetanus and pertussis vaccines in Gambian infants Pediatr Infect Dis J 2000 19 Dagan R Kaythty H Wuorimaa T Yaich M Bailleux F Zamir O Tolerability and immunogenicity of an eleven valent mixed carrier Streptococcus pneumoniae capsular polysaccharide-diphtheria toxoid or tetanus protein conjugate vaccine in Finnish and Israeli infants Pediatr Infect Dis J 2004 23 Whitney C Farley M Hadler J Harrison L Bennett NM Lynfield R Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine N Engl J Med 2003 348 Black S Shinefield H Fireman B Lewis E Ray P Hansen J Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children Pediatr Infect Dis J 2000 19 Black S Shinefield H Baxter R Austrian R Bracken L Hansen J Postlicensure surveillance for pneumococcal invasive disease after use of heptavalent pneumococcal conjugate vaccine in Northern California Kaiser Permanente Pediatr Infect Dis J 2004 23 Palmu AI Verho J Jokinen J Karma P Kilpi T The seven valent pneumococcal conjugate vaccine reduces tympanostomy tube placemente in children Pediatr Infect Dis J 2004 23 Hausdorff W Yothers G Dagan R Kilpi T Pelton S Cohen R Multinacional study of pneumococcal serotypes causing acute otitis media in children Pediatr Infect Dis J 2002 21 Dagan R Givon-Lavi N Shkolnik L Yagupsky P Fraser D Acute otitis media caused by antibiotic-resistant Streptococcus pneumoniae in southern Israel: implication for immunizing with conjugate vaccines J Infect Dis 2000 181 Fireman B Black SB Shinefield HR Lee J Lewis E Ray P Impact of the pneumococcal conjugate vaccine on otitis media Pediatr Infect Dis J 2003 22 Arguedas A Loaiza C Pérez A Vargas F Herrera M Rodríguez G Microbiology of otitis media in Costa Rican children Pediatr Infect Dis J 1998 17 Porat N Arguedas A Spratt B Trefler R Brilla E Loaiza C Emergence of penicillin nonsusceptible Streptococcus pneumoniae clones of non-vaccine serotypes: Serotype 11A and 15B/C variants of resistant clones of serotypes included in the pneumococcal conjugate vaccines J Infect Dis 2004 190
S0001-600220060002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022006000200004 Tabaquismo como factor de riesgo del infarto agudo al miocardio Leal-Mateos Manrique Solano- Chinchilla Teresita , 06 2006 2006 48 72 76

Justificación: El tabaquismo es la principal causa de enfermedad, discapacidad y muerte prematura prevenible mundialmente; actualmente, es aceptado como un factor de riesgo para el desarrollo de enfermedades cardiovasculares. Sin embargo, aunque el tabaco es conocido como una causa directa de IAM, en el país es limitado el conocimiento de su fracción atribuible. Objetivo: Este estudio tiene como propósito evaluar el impacto que provoca el tabaquismo sobre los pacientes con IAM, por medio de su fracción atribuible. Así, pretende estimar la proporción de personas que podrían prevenir su desarrollo, si se evitara la exposición a este factor de riesgo. Métodos: Se realizó un estudio de casos y controles en los servicios de medicina interna y cirugía del Hospital San Juan de Dios, en el periodo comprendido entre el 1 de abril y el 23 de septiembre de 2005. Se definió como fumador aquel paciente que hubiera fumado al menos un cigarro por día, durante un año. De acuerdo con el hábito de fumar, se clasificaron en: No fumadores (quienes nunca habían fumado), fumadores (quienes fumaran actualmente) y exfumadores. La magnitud de las asociaciones entre la exposición y el riesgo de la enfermedad se evaluó mediante la razón de probabilidades (Odds Ratio en inglés) para datos apareados 2:1, definiendo como no expuestos aquellos pacientes clasificados como no fumadores. Los exfumadores con más de 15 años de haber abandonado el hábito fueron clasificados como no fumadores (dados los beneficios que representa esta situación a largo plazo) y aquellos con menos de 15 años de haberlo abandonado, fumadores. Con el fin de medir el impacto del tabaquismo sobre los pacientes que padecen de infarto agudo al miocardio se utilizó el indicador de fracción atribuible. Para todo lo anterior se utilizó Epitable, del programa EpiInfo 6. Resultados: La Razón de Probabilidades para datos apareados 2:1 mostró una asociación positiva entre el fumado y del desarrollo de un IAM, de 2,58 (IC95% 1,17-5,70). La fracción atribuible en los expuestos fue del 64,7% (IC 95% 14,6-82,5). Discusión: Se puede concluir que un poco más de la mitad los casos que se diagnosticaron con IAM en el HSJD, durante el periodo de estudio obedecen a la exposición activa de los pacientes al tabaquismo.

Rationale: Cigarrette smoking is the main, preventable cause of premature illness, disability and death worldwide. At present, is widely recognized as a risk factor for the development of cardiovascular disease. Nevertheless, even though tobacco is generaly accepted as a direct cause of acute myocardial infarction, in our country, knowledge about its attributable fraction is limited. Objective: The purpose of this study is to evaluate the impact of cigarrette smoking on acute myocardial infarction patients measuring its attributable fraction. With this study, our purpose is to estimate the proportion of patients who could prevent the development of an acute myocardial infarction if exposure to this risk factor was avoided. Methods: A case-control study was done in the internal medicine and surgery wards at the San Juan de Dios Hospital comprising the period between april the 1st and september the 23rd of 2005. A smoker was defined as any patient which had smoked, at least, 1 cigarrette a day during 1 year. According to their smoking habits, the patients were classified as: non smokers (never smoked), smokers (current smokers) and ex-smokers. The magnitude of the associations between the exposure and the risk of illness was measured by means of the 2:1 paired odds ratio in which we defined those not exposed as the non smokers. Those who had not smoked for over 15 years were classified as non smokers (given the long-term benefits which quitting entails) and those who had not smoked for less than 15 years were classifed as smokers. To measure the impact of cigarrette smoking on acute myocardial infarction patients, we used the indicator called Attributable Fraction. For this purpose, we used the EPITABLE feature a in EpiInfo 6®. Results: The 2:1, paired odds ratio showed a positive association between smoking and the development of acute myocardial of 2.58 (95% CI 1.17 to 5.70) The attributable fraction in those exposed was 64.7% (95% CI 14.6 to 82.5). Conclusion: Slightly over half of the cases diagnosed as acute myocardial infarction at the San Juan de Dios Hospital are related to cigarrette smoking.

 Tabaco infarto agudo al miocardio epidemiología fracción atribuible Tobacco acute myocardial infart epidemiology attributable fraction Volumen 1: La salud en las Américas Volumen 1: La salud en las Américas 1998 Edición de 1998 ^eWashington D.C OPS Roselló M Guzmán S Mortalidad por infarto agudo al miocardio: Distribución geográfica y lugar de ocurrencia. Costa Rica, 1970- 2002 Rev Costarr Cardiol 2003 5 Gillum R Trends in acute myocardial infarction and coronary heart disease death in the United States J Am Coll Cardiol 1994 23 Mac Govern P Pankow J Shahar E Doliszny K Folsom A Blackburn H Recent trends in acute coronary heart disease N Engl J Med 1996 334 Rosamond W Chambless L Folsom A Cooper L Conwill D Clegg L Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994 N Engl J Med 1998 Law M Wald N Why heart disease mortality is low in France: the time lag explanation BMJ 1999 318 Tunstall H Vanuzzo D Hobbs M Mähönen M Cepaitis Z Kuulasmaa K Estimation of contribution of change in classic risk factors to trends in coronary-event rates across the WHO MONICA Project populations Lancet 2000 355 Sigfusson N Puska P Pekkanen J Tuomilheto J Jousilahti P Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland BMJ 1994 309 Tunstall H Woodward M Tavendale R A´Brook R McCluskey M Comparison of the prediction by 27 different factors of coronary heart disease and deaths in men and women of the Scottish heart health study: cohort study BMJ 1995 315 Informe sobre la salud en el mundo 2003: Forjemos el futuro Informe sobre la salud en el mundo 2003: Forjemos el futuro 2003 Ginebra OMS Doll R Peto R Wheatley K Gray R Sutherland I Mortality in relation to smoking: 40 years observation on male British doctors BMJ 1994 309 Kuri P Alegre J Mata M Hernández M Mortalidad atribuible al consumo de tabaco en México Salud Pública Mex 2002 44 ^sSupl 1 Salazar E Sánchez LM López LA Estrada A Lazcano E Hernández M El tabaquismo y su fracción atribuible en la enfermedad isquémica cardiaca Salud Pública Mex 2002 44 ^sSupl 1 Banegas J Diez L Rodríguez F González J Graciano A Villar F Mortalidad atribuible al tabaquismo en España en 1998 Med Clin 2001 117 Parish S Collins R Youngman L Cigarette smoking, tar yields and non-fatal myocardial infarction: 14.000 UK cases and 32.000 controls BMJ 1995 311 Mähönen MS McElduff P Dobson Aj Kuulasmaa KA Evans AE Current smoking an the risk of non-fatal myocardial infarction in the Who MONICA Project populations Tobacco Control 2004 13 Naidoo B Stevens W McPherson K Modeling the short term consequences of smoking cessation in England on the hospitalisation rates for acute myocardial infarction and stroke Tobacco Control 2000 9 Wen CP Cheng TY Lin CL Wu HN Levy DT Chen LK The health benefits of smoking cessation for adult and for pregnant women in Taiwan Tobacco Control 2005 14
S0001-600220060002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022006000200005 Traqueostomía percutánea por dilatación: Reporte de 70 casos Ramírez- Arce Jorge A Padilla- Cuadra Juan I. Sánchez- Arias Mario , 06 2006 2006 48 77 83

Justificación: La traqueostomía es el procedimiento quirúrgico más frecuentemente practicado en pacientes de cuidado crítico. En los últimos años ha sido introducida la realización de este procedimiento en la modalidad de traqueostomía percutánea guiada por broncoscopía. Se presenta la experiencia inicial en este procedimiento, en el Hospital R.A. Calderón Guardia, San José, Costa Rica. Materiales y métodos: A 70 pacientes consecutivos se les realizó traqueostomía percutánea por dilatación con guía broncoscópica, en el período comprendido entre agosto de 2002 y octubre de 2004, en los servicios de Medicina Crítica y Terapia Intensiva del Hospital Dr. Rafael Ángel Calderón Guardia. Se utilizó la técnica y bandeja de herramientas diseñada por Ciaglia y modificada para un dilatador único, curvo y progresivo. Se documentaron las características epidemiológicas y las complicaciones de cada procedimiento. Resultados: El 80% del grupo eran hombres. Las principales complicaciones fueron: desaturación transitoria (7.14%), fractura de anillo traqueal (4.2%), punción de broncoscopio (4.2%), extubación no planeada (2.85%) y sangrado mínimo (2.85%). El tiempo quirúrgico promedio fue de 8.14 minutos. No hubo mortalidad asociada con el procedimiento. Conclusión: Se concluye que esta modalidad de traqueostomía es segura en pacientes críticamente enfermos y que puede ser practicada por médicos intensivistas, procurando un equipo interdisciplinario que brinde guía broncoscópica y supervisión quirúrgica. Además, puede considerarse de primera elección en el paciente críticamente enfermo.

Tracheostomy is the most common surgical procedure performed in critical care patients. In the last few years, a technique known as percutaneous dilational tracheostomy guided by bronchoscopy was introduced. We present our experience with this procedure at the Hospital R.A. Calderón Guardia, San José Costa Rica. Materials and method: A percutaneous tracheostomy was perform in 70 patients between august 2002 and october 2004 at the Critical Care Unit of the Hospital Dr. Rafael Angel Calderón Guardia. The procedure was performed following a modification of the Ciaglia technique. Epidemiological data and complications were collected. Results: Eighty percent were men and 20 % women. The main complications were transient low oxygen saturation (7.14 %), tracheal ring fracture (4.2 %), bronchoscope puncture (4.2 %), unplanned extubation (2.85%) and mild bleeding (2.85%). Average surgical time was 8.14 minutes. There was no mortality associated with the procedure. Conclusion: This technique is safe and can be performed by medical intensivists. There should be a multidisciplinary team to support the performance of this procedure. Percutaneous tracheostomy should be the first choice technique for tracheostomy in the critical care unit.

 Traqueostomía percutánea broncoscopía cuidado intensivo percutaneous tracheostomy branchoscopy intensive care Shelden CH Pudenz RH Freshwater DB Crue BL A new method for tracheostomy J Neurosurg 1955 12 Toye FJ Weinstein JD A percutaneous tracheostomy device Surgery 1969 65 Ciaglia P Firsching R Syniec C Elective percutaneous dilational tracheostomy: a new simple bedside procedure; preliminary report Chest 1985 87 Byhahn C Wilke HJ Halbig S Lischke V Westphal K Percutaneous Tracheostomy: Ciaglia Blue Rhino versus the Basic Ciaglia Technique of Percutaneous Dilational Tracheostomy Anesth Analg 2000 91 Schachner A Ovil Y Sidi J Rogev M Heillbron Y Levy MJ Percutaneous tracheostomy: a new method Crit Care Med 1989 17 Griggs WM Worthlet LG Gilligan JE Thomas PD Myburg JA A single percutaneous tracheostomy Surg Gynecol Obstet 1990 170 Anon JM Escuela MP Gomez V Garcia de Lorenzo A Montejo JC Lopez J Use of percutaneous tracheostomy in intensive care units in Spain. Results of a national survey Intensive Care Med 2004 J un 30 Fikkers BG Fransen GA van der Hoeven JG Briede IS van den Hoogen FJ Tracheostomy for long-term ventilated patients: a postal survey of ICU practice in The Netherlands Intensive Care Med 2003 A ug 29 Evans A Winslow EH Oxygen saturation and hemodynamic response in critically ill, mechanically ventilated adults during intrahospital transport Am J Crit Care 1995 4 Waydhas C Schneck G Duswald KH Deterioration of respiratory function after intrahospital transport of critically ill surgical patients Intensive Care Med 1995 21 Upadhyay A Maurer J Turner J Tiszenkel H Rosengart T Elective bedside tracheostomy in the intensive care unit J Am Coll Surg 1996 183 Van Natta FL Morris SA Eddy VA Nunn CR Rutherford EJ Neuzil D Jenkins JM Bass JG Elective bedside surgery in critically injured patients is safe and cost-effective Ann Surg 1988 227 Moe KS Stoeckli SJ Schmid S Weymuller EA Percutaneous tracheostomy: A comprehensive evaluation Ann Otol Rhinol Laringol 1999 108 Holdgaard HO Pedersen J Jensen RH Outzen KE Midtgaard T Johansen Iler MÄ Paaske PB Percutaneous dilational tracheostomy versus conventional surgical tracheostomy Acta Anaesthesiol Scand 1998 92 McHenry CR Raeburn CD Lange RL Priebe PP Percutaneous tracheostomy: A cost effective alternative to standard open tracheostomy Am Surg 1997 63 Stoeckli SJ Breibach T Schmid S A clinical and histologyc comparison of percutaneous dilational versus conventional surgical tracheostomy Laryngoscope 1997 107 Marx WH Ciaglia Graniero KD Some important details in the technique of percutaneous dilational tracheostomy via the modified Seldinger technique Chest 1996 101 Hill BB Zweng TN Maley RH Charash WE Toursarkissian B Kearney PA Percutaneous dilational tracheostomy: report of 356 cases J Trauma 1996 41 Friedman Y Mayer AD Bedside percutaneous tracheostomy in critically ill patients Chest 1993 104 Leptidis G Papanicolaou S Athanassiadi K Zogby H Iordanidou O Katsaris G Modified technique of percutaneous dilational tracheostomy in 600 cases World J Surg 2002 O ct 26 Mittendorf EA McHenry CR Smith CM Yowler CJ Peerless JR Early and late outcome of bedside percutaneous tracheostomy in the intensive care unit Am Surg 2002 A pr 68 Sun KO Obstruction of tracheostomy tube by tracheal wall after percutaneous tracheostomy Anaesthesia 1996 51 Rigg CD Percutaneous dilational tracheostomy: mal position leading to delayed weaning Anaesthesia 1995 50 Sakabu SA Levine JH Brischetto MJ Taylor RW Taylor S Airway obstruction with percutaneous tracheostomy Chest 1997 111 Dulguerov P Gysin C Perneger TV Chevrolet JC Percutaneous or surgical tracheostomy: A meta-analysis Crit Care Med 1999 27 Cobean R Beales M Moss C Bredenberg CE Percutaneous dilatational tracheostomy Arch Surg 1996 131 Friedman Y Fildes J Mizock B Samuel J Patel S Appavu S Comparison of percutaneous and surgical tracheostomies Chest 1996 110 Meyer M Critchlow J Mansharamani N Angel LF Garland R Ernst A Repeat bedside percutaneous dilational tracheostomy is a safe procedure Crit Care Med 2002 M ay 30 Byhahn C Westphal K Meininger D Gurke B Kessler P Lischke V Single-dilator percutaneous tracheostomy: a comparison of PercuTwist and Ciaglia Blue Rhino techniques Intensive Care Med 2002 S ep 28 Johnson JL Cheatham ML Seagraves SG Block EF Nelson LD Percutaneous dilational tracheostomy: a comparison of single- versus multiple-dilator techniques Crit Care Med 2001 J un 29 Rumback MJ Newton M Truncale Thomas Schwartz Skai W Adams James W Hazard Patrick B A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients Crit Care Med 2004 32 Quintel M Roth H Tracheostomy for the critically ill: impact of new technologies Curr Opin Crit Care 2000 6 Barba CA Angood PD Kauder DR Latenser B Martin K McGonigal MD Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective and easy-to-teach procedure Surgery 1995 118 Winkler WB Karnik R Seelmann O Havlicek J Slany J Bedside percutaneous dilational tracheostomy with endoscopic guidance: Experience with 71 patients Intensive Care Medicine 1994 20
S0001-600220060002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022006000200006 Causas más frecuentes de nódulo pulmonar solitario y su relación con el cáncer pulmonar Yu Tseng Fulin Jiménez- Castro Marlene Valverde- Robert Raúl ,Caja Costarricense de Seguro Social ,Caja Costarricense de Seguro Social 06 2006 2006 48 84 87

Justificación y objetivo: El cáncer de pulmón ha aumentado en los últimos años y ha llegado a ocupar, tanto en hombres como en mujeres, el noveno lugar de incidencia en América Latina. En Costa Rica constituye la tercera causa de muerte por tumores malignos en hombres y la sexta en mujeres. El objetivo del presente estudio es determinar las causas más frecuentes del nódulo pulmonar solitario y entre ellas, el sitio que ocupa el cáncer pulmonar. Método: Se estudiaron 49 pacientes que ingresaron con el diagnóstico de nódulo pulmonar solitario, o se les descubrió 1 durante su internamiento y cumplieron con los criterios de inclusión. Todos fueron referidos al servicio de Cirugía de Tórax y Cardiovascular del Hospital Dr. Rafael A. Calderón Guardia, en el periodo comprendido entre enero de 1996 y diciembre de 2001. La información de siguientes variables: sexo, edad y clasificación histoló-gica de las biopsias, obtuvo a partir de de los expedientes clínicos. Resultados: De los 49 pacientes, 26 eran mujeres (53%). La edad más frecuente estuvo en el grupo de 50 años o más. Predominaron las entidades benignas y dentro de ellas, el histoplasmoma ocupó el primer lugar. En la patología maligna predominó el tumor carcinoide. El cáncer de pulmón y el linfoma se ubicaron en el segundo lugar. Conclusiones: En esta muestra se encontró como causa más frecuente de nódulo pulmonar solitario, una de carácter benigno; hubo un bajo porcentaje de nódulos de carácter maligno.

Justification and objectives: Lung cancer has increased in the last few years. It ranks ninth in cancer incidence in Latin America, equally affecting men an women. Lung carcinoma is the third most common cause of death among men and the sixth cause of death among women in Costa Rica. The objective of this study was to determine the rate for lung cancer to appear as a solitary pulmonary nodule according to the records of the Chest Surgery Service of the Rafael Angel Calderón Guardia Hospital in San José. Methods: 49 patients were included in the study. Some were admitted with the diagnosis of solitary pulmonary nodule, others had another illness and during their hospital stay a solitary pulmonary nodule was also found. This study was conducted from january 1996 to december 2001. The data were gathered form the patients charts Result: From the 49 patients with this diagnosis, 23 were men (47%) and 26 were women (53%). The most frequently occurring age groups was equal or over 50 years. The tumors were most frequently benign. The predominant histological, report of bening pathology was histoplasmoma and the prevailing magnant pathology was that of carcinoid tumors followed by lung cancer and linfoma. Conclusion: The results obtained in this groups show that a solitary pulmonary nodule is frequently benign with a low malignant percentage. There is a low incidence of lung cancer, presenting as a solitary pulmonary nodule.

 nódulo pulmonar solitario histoplasmoma tumor carcinoide histología solitary pulmonary nodule histoplasmoma carcinoide tumor histology Fraser RG Peter Paré JA paré PD Fraser RS Genereux GP Fraser RG Peter Paré JA Paré PD Fraser RS Genereux GP Neoplastic Disease of the Lung Diagnosis of Disease of the Chest Diagnosis of Disease of the Chest 1989 3 ^ePhiladelphia W.B. Saunders Company Pedrosa CS Cepeda MT Sánchez AP Casanova R El tórax: lesiones intersticiales infiltrativas difusas Diagnóstico por imagen compendio de radiología clínica Diagnóstico por imagen compendio de radiología clínica 1998 McGraw Hill Interamericana Estévez JC Peña RE Sagreda PJ Justel JP Heras SG Suárez del Villa T Guía de actualización ante un nódulo pulmonar solitario Guía de actualización ante un nódulo pulmonar solitario 2001 , no Pud Med Bermúdez S Solarte I Roa J Bermúdez M Acero R Enfoque del paciente asintomático con alteración radiológica Neumología Neumología 2000 Mcgraw Hill Interamericana Shaffer K Role of Radiology form imaging and biopsy of solitary pulmonary nodules Chest 1999 116 Información estadística registro nacional de tumores Información estadística registro nacional de tumores Lillington Ga Debinger L Investigating the solitary pulmonary nodule Patient Care 2000 34 Velez H Rojas W Borrero J Restrepo J Fundamentos de medicina neumología Fundamentos de medicina neumología 1993 ColombiaCIB Cruz Estrada A Espinoza Roy J López Barcera J Ramiro HM Halabe CJ Lifshitz GA López BJ Nódulo pulmonar solitario El Internista medicina interna para internistas El Internista medicina interna para internistas 2002 2 McGraw-Hill Interamericana Rusch VW Ginsberg RJ Schwatz S Shires G spencer F Galloway AC Fisher JE Daly JM Pared torácica, pleura, pulmón y mediastino Principio de Cirugía Vol 1 Principio de Cirugía Vol 1 2000 7 McGraw-Hill Buján GR Jiménez FJ Arias OG Nódulo pulmonar solitario Rev Med de CR y Cent 2000 57 D’Amico T Sabiston DC Jr Sabiston DC Jr Spencer FC Neoplasms of the lung.I Carcinoma of the lung Surgery of the Chest Vol 1 Surgery of the Chest Vol 1 1995 6 ^ePhiladelphia WB Saunders Company García-Navarro GA Rosell Costa R Farreras VP Rozman C Tumores broncopulmonares Medicina Interna Medicina Interna 2000 Harcourt Peña AM Factores predictores de malignidad del nódulo pulmonar solitario en el Hospital Nacional Edgardo Rebagliati Marthins 1998- 2000 Factores predictores de malignidad del nódulo pulmonar solitario en el Hospital Nacional Edgardo Rebagliati Marthins 1998- 2000 Torres A Czischke del Pozo C Jara V Begoña I Nódulo pulmonar solitario Rev Chilena de Cirugía 2001 54
S0001-600220060002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022006000200007 Acidosis láctica secundaria a terapia antirretroviral en pacientes con VIH/sida Hasbum-Fernández Benhard Rojas-Solano José Gutiérrez-Jaikel Luis León-Bratti María Paz , 06 2006 2006 48 88 90

La acidosis láctica es una complicación infrecuente de la terapia antirretroviral para VIH. Su aparición se ha relacionado con la administración de análogos nucleósidos de la transcriptasa inversa, en especial estavudina y didanosina. Se presentan los 2 casos que se manejaron en el año 2005 en el Servicio de Medicina del Hospital México. En ambos el desenlace fue fatal, aún cuando se utilizaron todas las medidas terapéuticas recomendadas.

Lactic acidosis is a rare complication of antiretroviral treatment for HIV. Its occurrence has been related to the use of transcriptase reverse nucleoside analogues, especially estavudine and didanosine. We present here 2 cases of HIV patients who suffered lactic acidosis and were treated at the Internal Medicine Department of the Hospital Mexico, San Jose, Costa Rica. Both cases had a fatal evolution, despite that both received all the therapeutic measures recommended in the literature.

 acidosis láctica terapia antirretroviral lactato L - carnitina lactic acidosis antiretroviral therapy lactate L - carnitine Informe sobre la epidemia mundial de SIDA. Cuarto informe mundial Informe sobre la epidemia mundial de SIDA. Cuarto informe mundial 2004 UNAIDS/04.168 Hammer SM Katzenstein DA Hughes MD Gundacker H Schooley RT Haubrick TH A trial comparing nucleoside monotherapy with combination therapy in HIV-infected adults with CD4 cell counts from 200 to 500 per cubic millimeter N Engl J Med 1996 335 Imhof A Ledergerber B Gunthard HF Haupts S Weber R Swiss HIV Cohort Study. Risk Factors for and Outcome of Hyperlactatemia in HIV-Infected Persons: Is There a Need for Routine Lactate Monitoring ? Clin Infect Dis 2005 41 Bartlett JG Gallant JE Medical management of HIV Medical management of HIV 2004 Johns Hopkins Medicine Cote HC Brumme ZL Craib KJ Alexander CS Wynnoven B Ting L Changes in mitochondrial DNA as a marker of nucleoside toxicity in HIV-infected patients N Engl J Med 2002 346 John M Moore CB James IR Nolan D Upton RP McKinnon EJ Mallal SA Chronic hyperlactatemia in HIV infected patients taking antiretroviral therapy AIDS 2001 15 Lewis W Dalakas MC Mitochondrial toxicity of antiviral drugs Nat Med 1995 1 Olano JP Borucki MJ Wen JW Massive hepatic steatosis and lactic acidosis in a patient with AIDS who was receiving zidovudine Clin Infect Dis 1995 21 Lenzo NP Garas BA French MA Hepatic steatosis and lactic acidosis associated with stavudine treatment in a HIV patient: a case report AIDS 1997 11 Brinkman K Vrouenraets S Kauffmann R Weigel H Frissen J Treatment of nucleoside reverse transcriptase inhibitor induced lactic acidosis AIDS 2000 14 Claessens YE Chiche JD Mira JP Cariou A Bench-to-bedside review: Severe lactic acidosis in HIV patients treated with nucleoside analogue reverse transcriptase inhibitors Critical Care 2003 7
S0001-600220060002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022006000200008 Serendipia médica en un error de prescripción: Un caso de denuncia por mala práctica médica Flores-Sandí Grettchen , 06 2006 2006 48 91 94

Se presenta el caso de una estudiante universitaria de 22 años, quien interpuso una denuncia contra su médico por mala práctica profesional, por un error de prescripción que se constató en instancias judiciales y administrativas. Ese error médico produjo que la ofendida se sometiera a un tratamiento de consecuencias dolorosas muy intensas, no advertidas, pues ni siquiera fueron expresamente deseadas por el médico. Pero esto no fue lo medular para resolver el caso, lo importante en la resolución de la causa, desde el punto de vista penal, fue el aspecto de lesividad (presencia o no de lesiones), pues la particularidad del caso radica en que el medicamento curó a la paciente. En el análisis del caso los elementos considerados fueron que la paciente no presentó secuelas por este error; las indicaciones de los medicamentos utilizados; el padecimiento que presentaba y el efecto terapéutico que tuvo el medicamento instaurado; y los presupuestos de iatrogenia y serendipia médica.

A 22 year old female, student, prosecute her doctor of mal praxis. Although a prescription error was demonstrated by the authorities, the really important reason to judge the case in court, was the absence of damage. Because in this particular case the drug cured the patient. The medicolegal analysis was based on: the absence of sequelae secondary of this mistake; the indications of the utilized medication; the illness and the terapeutical effect of the prescribed medication; and iatrogenesis and serendipity.

 serendipia mala práctica médica prescripción serendipity mal practice prescription Acné: nuevas estrategias de tratamiento Revista médica ILADIBA 2001 El peeling químico El peeling químico Diccionario de Especialidades Farmacéuticas Diccionario de Especialidades Farmacéuticas 2002 -2 33 Panamericana de Libros de Medicina, S. A Tullio A. A Diccionario médico-legal Diccionario médico-legal Buenos Aires Patitó JA Lossetti O Trezza F Guzmán C Stingo N Tratado de medicina legal y elementos de patología forense Tratado de medicina legal y elementos de patología forense 2003 Editorial Quorum Millan J. A Serendipia 1999-2000 Serendipia 1999-2000 Arias J.E 40 años de la serendipia Penzias - Wilson 40 años de la serendipia Penzias - Wilson Ciencia por casualidad Ciencia por casualidad Duque Macías J Mateos Vázquez M Descubrimientos de la ciencia y la tecnología que sucedieron sin buscarlos. La Serendipia, 2003 Descubrimientos de la ciencia y la tecnología que sucedieron sin buscarlos. La Serendipia, 2003 Hernández-Chavarría F Rivera P Serendipia e investigación en microbiología Rev. Col de MQC de Costa Rica 2001 8
S0001-600220060002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022006000200009 Costa Rica en el Exterior , 06 2006 2006 48 95 95