S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400001 Violencia basada en género: un problema de Salud Pública Ávila-Agüero María Luisa ,Ministra de Salud 10 2007 2007 49 178 179
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400002 Comentarios sobre el informe emitido por la Contraloría General de la República en relación con algunas deficiencias encontradas en las instituciones de la CCSS Arrea-Baixench Carlos ,Academia Nacional de Medicina 10 2007 2007 49 180 181
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400003 Efectos no hipolipemiantes de las estatinas Ramos-Esquivel Allan León-Céspedes Carlos ,Universidad de Costa Rica 10 2007 2007 49 182 189

Las estatinas se han convertido en una de las drogas más prescritas en el mundo. Este tipo de fármacos es utilizado en el tratamiento de la dislipidemia y en la prevención de la enfermedad cardiovascular. Recientemente ha surgido nueva evidencia sobre sus mecanismos de acción y son bien conocidas sus propiedades pleiotrópicas, más allá de la disminución de los niveles de colesterol. Esta característica farmacodinámica ha llamado la atención de muchos investigadores quienes sugieren su uso en diferentes enfermedades que se centran en la inflamación, en desórdenes de la inmunidad y en la proliferación celular. Aunque hay amplia evidencia que reconoce su eficacia en diversos modelos de enfermedades, todavía existe una falta de estudios que apoyen su uso en la práctica clínica. En este trabajo se revisa el mecanismo de acción de estos fármacos y de la base fisiopatológica que sugiere su uso clínico en diferentes enfermedades.

Statins have become one of the most prescribed drugs in theworld.This medications are in the treatment of dyslipidemia and in the prevention of cardiovascular diseases. Recently, new evidence has emerged about their mechanisms of action and their pleiotropic properties well beyond lowering cholesterol levels. This pharmacodynamic action has called the attention of many investigators who suggest their use in several diseases centered on inflammation, immune disorders and cell proliferation. Although there is wide evidence that recognizes its efficacy in several disease models, there is still a lack of studies to approve their use in clinical practice. We present a review of their pharmacodynamic properties focusing on the pathophysiology that suggests their clinical use in the treatment of several diseases.

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Am J Med 2005 118 Cordle A Koenigsknecht-Talboo J Wilkinson B Limpert A Landreth G Mechanisms of statins - mediated inhibition of small G-protein funtcion J Biol Chem 2005 280 Cordle A Landreth G 3-Hydroxy-3-Methylglutaryl CoA reductase inhibitors attenuate beta amyloid - induced microglial inflammatory responses J Neurosci 2005 25 Bi X Baudry M Liu J Yao Y Fu L Brucher F Inhibition of geranylgeranylation mediates the effects of 3-hydroxy-3methylglutaryl (HMG)-CoA reducatse inhibitors on microglia J Biol Chem 2004 279 Masse I Bordet R Deplanque D Al Khedr A Richard F Libersa C Lipid lowering agents are associated with a slower cognitive decline in Alzheimer`s Disease J Neurol Neurosurg Psychiatry 2005 76 Wolozin B Kellman W Rousseau P Celesia G Siegel G Decreased prevalence of Alzheimer disease associated with 3-Hydroxy-3 Methylglutaryl coenzyme A reductase inhibitors Arch Neurol 2000 57 Jick H Zornberg G.L Jick S.S Seshadri S Drachman D.A Statins and the risk of dementia Lancet 2000 356 Zandi P Sparks L Khachaturian A Tschanz J Norton M Steinberg M Do statins reduce the risk of incident dementia and Alzheimer`s disease Arch Gen Psychiatry 2005 62 Li G Higdon R Kukull W Peskind E Van Valen K Tsuang D Statin therapy and risk of dementia in the elderly Neurology 2004 63 Rea T.D Breitner J.C Pstay B.M Fitzpatrick A.L Lopez O.L Newman A.B Statin use and the risk of incident dementia Arch Neurol 2005 62 Padala K Padala P Potter J Simvastatin - induced decline in cognition Ann Phamacother 2006 40 Demer L Vascular calcification and osteoporosis: inflammatory responses to oxidized lipids Int J Epidemiol 2002 31 Hamaerman D Osteoporosis and atherosclerosis: biological linkages and the emergence of dual-purpose therapies QJM 2005 98 Das U Nitric oxide as the mediator of the antiosteoporotic actions of estrogen, statins, and essential fatty acids Exp Biol Med 2002 227 Doherty T Asotra K Fitzpatrick L Qiao J.H Wilkin D Detrana R Calcification in atherosclerosis and chronic inflammation at the arterial crossroads Proc Natl Acad Sci 2003 110 Parhami F Garfinkel A Demer L Role of lipids in osteoporosis Arterioscl Thromb Vasc Biol 2000 20 Majima T Komatsu Y Fukao A Ninomiya K Matsumara T Nakao K Short-term effects of atorvastatin on bone turnover in male patients with hypercholesterolemia Endocr J 2007 54 Garrett I Mundy G The role of statins as potential targets for bone formation Arthritis Res 2002 4 Fisher J.E Rogers M.J Halasy J.M Luckman S.P Hughes D.E Masarachia P.J Alendronate mechanism of action: geranylgeraniol, an intermediate in the mevalonate pathway, prevents inhibition of osteoclast formation, bone resorption, and kinase activation in vitro Proc Natl Acad Sci 1999 96 Samelson E Kiel D Broe K Zhang Y Cupples LA Hannan M Metacarpal cortical area and risk of coronary heart disease. The Framingham Study Am J Epidemiol 2004 159 Poli A Bruschi F Cesana B Rossi M Paoletti R Crosignani PG Plama low density lipoprotein cholesterol and bone mass in postmenopausal women Obstet Gynecol 2003 102 Chan A Andrade S Boles M Buist D Chase G Donahue J Inhibitors of hydroxymethylglutaryl-coenzime A reductase and risk of fracture among older women Lancet 2000 355 Meier C Schlienger R Kraenzlin M Schlegel B Jick H HMG-CoA reductase inhibitors and the risk of fractures JAMA 2000 283 Pasco J Kutowicz M Kerry S Nicholson G Statin use, bone mineral density, and fracture risk. Geelong Osteoporosis Study Arch Intern Med 2002 162 Wang P Solomon D Mogun H Avorn J HMG - CoA reductase inhibitors and the risk of hip fractures in elderly patients JAMA 2000 283 Scranton R Young M Lawler E Solomon D Gagnon D Gaziano JM Statin use and fracture risk. Study of an US Veterans Population Arch Intern Med 2005 165 Bauer D Mundy G Jamal S Black D Cauley J Ensrud K Use of statins and fracture. 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Crit Care 2006 10
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400004 Asesoramiento genético a mujeres en edad fértil sobrevivientes de cáncer Castro-Volio Isabel ,Universidad de Costa Rica 10 2007 2007 49 190 197

Las personas que han padecido cáncer en su infancia, adolescencia, o antes de la menopausia, y han sobrevivido, merecen, además de cantidad, calidad de vida. Un aspecto muy importante del bienestar personal se relaciona con la procreación. Lamentablemente, es posible que las mismas terapias que les han salvado la vida, puedan comprometer su fertilidad, el pronóstico del embarazo y del parto, o la salud del bebé. De igual manera, en aquellos tipos de cáncer con influencia hormonal, nace la duda sobre la prudencia de un embarazo posterior. Otro aspecto fundamental es la posibilidad de transmitir el cáncer a generaciones futuras. El objetivo de esta revisión es apoyar al personal de salud en el abordaje de esta temática e ilustrar la forma como el asesoramiento genético puede contribuir al manejo de estos casos.

Survivors of pediatric, adolescent or pre-menopausal cancer also deserve good quality of life. An important aspect of personal roll being is related to procreation. It is possible that some of the therapeutic interventions which have saved their lives could have jeopardized their fertility, their future deliveries or their offspring health. Hereditary transmission of cancer is another source of concern. Cancer is a new paradigm for genetic counseling. All these issues are approached in this review.

 cáncer embarazo asesoramiento genético cancer pregnancy genetic counseling survivors Baker DL Schuette JL Uhlmann WR A guide to genetic counseling A guide to genetic counseling 1998 ^eNew York Wiley - Liss Harper PS Practical genetic counseling Practical genetic counseling 1998 5 Oxford Butterworth - Heinemann Elements of cancer genetics risk assessment and counseling (PDQ®). Health professional version Elements of cancer genetics risk assessment and counseling (PDQ®). Health professional version Robinson LL Green DM Hudson M Meadows AT Mertens AC Packer RJ Long - term outcomes of adult survivors of childhood cancer Cancer 2005 104 Sklar CA Mertens AC Mitby P Whitton J Stoval M Kasper C Premature menopause in survivors of childhood cancer: a report from the Childhood Cancer Survivor Study J Natl Cancer Inst 2006 98 Chemaitilly W Mertens AC Mitby P Whitton J Stoval M Yasui Y Acute ovarian failure in the childhood cancer survivor study J Clin Endocrinol Metab 2006 91 Schover LR After the deluge, the emerging landscape of childbearing potential in pediatric cancer survivors J Natl Cancer Inst 2006 98 Brougham MF Wallace WH Subfertility in children and young people treated for solid and haematological malignancies Br J Haematol 2005 131 Lee SJ Schover LR Partridge AH Patrizio P Wallace WH Hagerty K American Society of Clinical Oncology recommendations on fertility preservation in cancer patients J Clin Oncol 2006 24 Falcone T Bedaiwy MA Fertility preservation and pregnancy outcome after malignancy Curr Opin Obstet Gynecol 2005 17 Sonmezer M Oktay K Fertility preservation in female patients Hum Reprod Update 2004 10 Arnon J Meirow D Lewis-Roness H Ornoy A Genetic and teratogenic effects of cancer treatments on gametes and embryos Hum Reprod Update 2001 7 Byrne J Rasmussen SA Steinhorn SC Conneally RR Myers MH Lynch CF Genetic disease in offspring of long-term survivors of childhood and adolescent cancer Am J Hum Genet 1998 62 Meistrich ML Byrne J Genetic disease in offspring of long term survivors of childhood and adolescent cancer treated with potentially mutagenic therapies Am J Hum Genet 2002 70 Boyce JD Tawn E Winther JF Donaldson SS Green DM Mertens AC Genetic effects of radiotherapy for childhood cancer Health Physics 2003 85 Tawn EJ Whitehouse CA Winther JF Curwen GB Rees GS Stoval M Chromosome analysis in childhood cancer survivors and their offspring - no evidence for radiotherapy - induced persistent genomic instability Mutat Res 2005 583 Rees GS Trikic MZ Winther JF Tawn EJ Stoval M Olsen JH A pilot study examining germline minisatellite mutations in the offspring of Danish childhood and adolescent cancer survivors treated with radiotherapy Int J Radiat Biol 2006 82 Meirow D Schiff E Appraisal of chemotherapy effects on reproductive outcome according to animal studies and clinical data J Natl Cancer Inst Monogr 2005 34 Critchley HO Wallace WH Impact of cancer treatment on uterine function J Natl Cancer Inst Monogr 2005 Signorello LB Cohen SS Bosetti C Stovall M Kasper CE Weathers RE Female survivors of childhood cancer: preterm birth and low birth weight among their children J Natl Cancer Inst 2006 98 Green DM Whitton JA Stovall M Mertens AC Donaldson SS Ruymann FB Pregnancy outcome of female survivors of childhood cancer: a report from the Childhood Cancer Survivor Study Am J Obstet Gynecol 2002 187 Lantinga GM Simons AH Kamps WA Potsma A Inminent ovarian failure in childhood cancer survivors Eur J Cancer 2006 42 Van Dalen EC van der Pal HJ van den Bos C Kok WE Caron HN Kremer LC Clinical heart failure during pregnancy and delivery in a cohort of female childhood cancer survivors treated with anthracyclines Eur J Cancer 2006 42 Calhoun K Hansen N The effect of pregnancy on survival in women with a history of breast cancer Breast Dis 2005 -2 23 Kroman N Mouridsen HT Prognostic influence of pregnancy before, around, and after diagnosis of breast cancer Breast 2003 12 Park M Davidson R Fox K Preservation of fertility and the impact of subsequent pregnancy in patients with premenopausal breast cancer Semin Oncol 2006 33 Banks E Reeves G Pregnancy in women with a history of breast cancer BMJ 2007 334 Ives A Saunders C Bulsara M Semmens J Pregnancy after breast cancer: population based study BMJ 2007 334 Travis LB Hill D Dores GM Gospodarowicz M van Leeuwen FE Holowaty E Cumulative absolute breast cancer risk for young women treated for Hodgkin lymphoma J Nat Cancer Inst 2005 19 Hill DA Gilbert E Dores GM Gospodarowicz M van Leeuwen FE Holowaty E Breast cancer risk following radiotherapy for Hodgkin lymphoma: modification by other risk factors Blood 2005 106 Normas y Procedimientos para el tratamiento de cáncer en Costa Rica Normas y Procedimientos para el tratamiento de cáncer en Costa Rica 2005 Fenlay J Bray F Pisani P Parkin DM GLOBOCAN 2002: cancer incidence, mortality and prevalence GLOBOCAN 2002: cancer incidence, mortality and prevalence Lyon IARC Press Bennet RL Hampel HL Mandell JB Marks JH Genetic counselors: translating genomic science into clinical practice J Clin Invest 2003 112 Pharoah PD Day NE Duffy S Easton DF Ponder BA Family history and the risk of breast cancer: a systematic review and meta-analysis Int J Cancer 1997 71 Friedenson B Assessing and managing breast cancer risk: clinical tools for advising patients Med Gen Med 2004 6 1 Risch HA McLaughlin JR Cole DE Rosen B Bradley L Fan I Population BRCA1 and BRCA2 mutation frequencies and cancer penetrances: a kin-cohort study in Ontario, Canada J Nat Cancer Inst 2006 98 Narod SA Modifiers of risk of hereditary breast cancer Oncogene 2006 25 Cullinane CA Lubinski J Neuhausen SL Ghadirian P Lynch HT Isaacs C Effect of pregnancy as a risk factor for breast cancer in BRCA1/BRCA2 mutation carriers Int J Cancer 2005 117 Friedman E Kotsopoulos J Lubinski J Lynch HT Ghadirian P Neuhausen SL Spontaneous and therapeutic abortions and the risk of breast cancer among BRCA mutation carriers Breast Cancer Res 2006 8 Tryggvadottir L Olafsdottir EJ Gudlaugsdottir S Thorlacius S Jonasson JG Tulinius H BRCA2 mutation carriers, reproductive factors and breast cancer risk Breast Cancer Res 2003 5 Andrieu N Goldgar DE Easton DF Rookus M Brohet R Antoniou AC Pregnancies, breast-feeding, and breast cancer risk in the International BRCA1/2 Carrier Cohort Study (IBCCS) J Natl Cancer Inst 2006 98 Antoniou AC Shenton A Maher ER Watson E Woodward E Lallo F Parity and breast cancer risk among BRCA 1 and BRCA 2 mutation carriers Breast Cancer Res 2006 8
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400005 Implicaciones metabólicas del consumo exesivo de fructosa Esquivel-Solís Viviana Gómez-Salas Georgina ,Universidad de Costa Rica 10 2007 2007 49 198 202

En los últimos años se ha dado un auge importante en la producción de alimentos endulzados con edulcorantes distintos a la sacarosa o azúcar de mesa, que por aportar menos calorías, son utilizados ya sea para perder peso o para mantener un peso saludable, o bien, para ofrecer opciones alimenticias a individuos que padecen de diabetes o intolerancia a la glucosa. Uno de los edulcorantes de mayor utilización es el jarabe de maíz alto en fructosa, el cual, en comparación con la sacarosa, tiene un costo más bajo y un menor efecto sobre las concentraciones sanguíneas de glucosa. Sin embargo, nuevas investigaciones están relacionando el consumo excesivo del jarabe de maíz alto en fructosa con la incidencia y prevalencia de enfermedades crónicas como la obesidad, la diabetes, las dislipidemias, el síndrome metabólico y las enfermedades cardiovasculares. El presente artículo describe las posibles implicaciones metabólicas asociadas a enfermedades asociados con consumo excesivo de fructosa.

During recent years there has been a remarkable increase in the production of foods sweetened sugar substitutes with less caloric value, that are used in dietary programs to lose weight to maintain a healthy weight as well as to offer options for individuals with diabetes or glucose intolerance. One of the most common sweeteners is high fructose corn syrup, a less expensive sweetener that has a lower postprandial hyperglycemic effect compared to sucrose. However new research has shown that prolonged consumption of high fructose diet would contribute to the development of chronic diseases such as obesity, diabetes, lipid disorders, metabolic syndrome and cardiovascular diseases. This paper describes the possible metabolic implications related to different diseases associated with an excessive fructose consumption.

 Dietas excesivas en fructosa sirope de maíz alto en fructosa obesidad insulino resistencia y dislipidemia fructose corn syrup high infructose obesity insulin resistance dyslipidemia Mehnert H Sugar substitutes in the dieabetic diet Int Z Vitam Ernahrungsforsch Beih 1976 15 Basciano H Federico L Adeli K Fructose, insulin resistance, and metabolic dislipidemia Nutrition and Metabolism 2005 2 Havel P Dietary fructose: Implications for dysregulation of energy homeostasis and lipid/carbohydrate metabolism Nutrition Review 2005 63 Hein GL Storey M White J Lineback DR Highs and Lows of High fructose corn syrup. A Report form the Center fro Food and Nutrition Policy and Its Ceres Workshop Nutrition Today 2005 40 Bantle JP Is fructose the optimal low glycemic index sweetener? Nestle Nutr Workshop Ser Clin Perform Progamme 2006 11 Schorin MD High fructose corn syrups. Part 1 and 2 Nutrition Today 2005 40 Putman J Food Consumption, prices and expenditures, 1970- 1991 1999 US Department of Agricultu Nelson DL Cox MM Lehninger principles of Biochemistry Lehninger principles of Biochemistry 2004 4 ^eNew York Worth Pusblishers Bray G Nielsen S Popkin B Consumption of high-fructose corn syrup in beverages may play the rol in the epidemic of obesity Am J Clin Nut 2004 79 Fornaguera J Gómez G Bioquímica: la ciencia de la vida Bioquímica: la ciencia de la vida 2004 San José Editorial Universidad Estatal a Distancia Benyon S Metabolismo y nutrición Metabolismo y nutrición 1998 Harcort Brace de España Cui XL Schlesier AM Fisher EL Cequeira C Ferraris RP Fructose- induced increases in neonatal rat intestinal fructose transport involve the PI3-kinase/Akt signalling pathway Am J Physiol Gastrointest Liver Physiol 2005 288 Bantle J Raatz S Thomas W Goergopoulos A Effects of dietary fructose on plasma in healthy subjects Am J Clin Nutri 2000 72 Dirlewanger M Schineiter P Jéquier E Tappy L Effects of fructuose on hepatic glucose metabolism in humans Am J Physiol Endocrinol Metab 2000 279 Elliott S Kein N Stern J Teff K Havel P Fructuose, weight gain, and the insulin resistence syndrome AM J Clin Nutr 2002 76 Kelley GL Azhar S Reversal of high dietary fructose-induced PPARα suppression by oral administration of lipoxygenase cyclooxygenase inhibitors Nutrition & Metabolism 2005 2 Teff KL Elliot SS Tschop M Kieffer TJ Rader D Heiman M Townsend RR Keim NL D’alessio D Havel PJ Dietary fructose reduces circulating insulin and leptin, attenuates postprandial suppression of ghrelin and increases triglycerides in women J Clin Endocrinol Metab 2004 89 Kelley GL Allan G Azhar S High dietary fructose induces a hepatic stress response resulting in cholesterol and lipid dysregulation Endocrinology 2004 145 Musick T Cymet TC Carbohydrate and calories: is not what we use to think Compr Ther 2006 32 Sartorelli DS Cardoso MA Association between dietary carbohydrates and type 2 diabetes mellitus: epidemiological evidence Arq Bras Endocrinol Metabol 2006 50 Rayssiguier Y Gueux E Nowacki W Rock E Mazur A High fructose consumption combined with low dietary magnesium intake may increase the incidence of metabolic syndrome by inducing inflammation Magnes Res 2006 19 Hawkins M Grabriely I Wozniak R Vilcu C Shamoon H Rossetti L Fructose improves the ability of hyperglycemia per se to regulates glucose production in type 2 diabetes Diabetes 2002 51 Ganon MC Nutall FQ Westphal SA Fan S Ercan-Fang N Metabolic response to carbohydrate, high-starch meals compared with moderate carbohydrate low-starch meals in subjects with type 2 diabetes Diabetes Care 1998 21 Gross LS Li L Ford ES Liu S Increased consumption of refined carbohydrate and the epidemic of type 2 diabetes in the United States: an ecologic assessment Am J Clin Nutr 2004 19 Davail S Ridea N Bernardet MD Guy G Hoo-Paris R Effect of dietary fructose on liver steatosis in overfed mule ducks Horm Metab Res 2005 37 Bizeau ME Pagliassotti MJ Hepatic adaptation to sucrose and fructose Metabolism Clinical and Experimental 2005 54 Bessesen H The role of Carbohydrates in Insuline Resistence J. Nutr 2001 131 Zammit VA Waterman IJ Topping D Mc Kay G Insulin stimulation of hepatic triacylglicerol secretion and the etiology of insuline resistance J. Nutr 2001 131 Daly M Sugars, insulin sensitivity, and the postprandial state Am J Clin Nutric 2003 78 Jürgens H Haass W Castañeda T Schümann A Koebnick C Dombrowski F Otto B Nawrocki A Schere P Spranger J Ristow M Joost H Havel P Tschöp M Consuming fructose-sweetened beverages increases body adiposity in mice Obesity research 2005 13 Wu T Giovannucci E Pischon T Hankinson S Nader J Rimn E Fructose, glycemic load, and quantity and quality of carbohydrate in relation to plasma C-peptide concentrations in US women Am J Clin Nutr 2004 80 Walker CG Zariwala MG Holness MJ Sugden MC Diet obesity and diabetes: a current update Clin Sci 2007 112
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400006 Potencia estadística en el diseño de estudios clínicos Camacho-Sandoval Jorge ,UNA 10 2007 2007 49 203 204
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400007 Brotes de diarrea e intoxicaciones transmitidas por alimentos en Costa Rica, 2005 Bolaños-Acuña Hilda Ma Acuña-Calvo María Teresa Duarte-Martínez Francisco Salazar-Castro Wagner Oropeza-Barrios Gletty Sánchez-Salazar Luz Marina Campos-Chacón Elena ,Instituto Costarricense de Investigación y Enseñanza en Nutrición y Salud (INCIENSA) 10 2007 2007 49 205 209

Justificación y objetivo: En la actualidad, las enfermedades de transmisión alimentaria, incluyendo las diarreas e intoxicaciones, constituyen uno de los problemas de salud pública de mayor importancia a nivel mundial, ya que ocasionan alta morbilidad y mortalidad, generan grandes costos a los servicios de salud, pérdidas económicas, demandas y pérdida de confianza de los consumidores. El objetivo del trabajo es analizar la información disponible en el Centro Nacional de Referencia en Bacteriología del INCIENSA (CNRB), de los brotes de diarrea e intoxicaciones alimentarias ocurridos en 2005, en los que se refirieron muestras clínicas o de alimentos, para identificar los agentes y vehículos de infección asociados. Materiales y métodos:Se realizó el análisis descriptivo de la información epidemiológica y de laboratorio disponible en el CNRB en relación con los brotes de diarrea e intoxicaciones alimentarias ocurridos en 2005. Resultados:Durante el período el CNRB documentó 23 brotes de diarrea e intoxicaciones alimentarias, para un total aproximado de 819 afectados, en su mayoría procedentes de la gran área metropolitana. Trece de los brotes fueron intrafamiliares (diez de ellos debidos a especies y serotipos de Shigella); sin embargo, el mayor número de enfermos se presentó en los brotes comunitarios y los que se produjeron en poblaciones cautivas, asociados a rotavirus, Escherichia coli enterotoxigénica y Clostridium perfringens productor de toxina A, con 518, 138 y 54 enfermos, respectivamente. Conclusión:Estos hallazgos evidencian deficiencias en la cadena de transporte, conservación y manipulación de los alimentos, así como en la higiene personal, y pueden ser de utilidad para la implementación de intervenciones inmediatas.

Justification and objective:Food borne diseases ncluding diarrhea and food poisoning represent one of the major public health problems worldwide, since they cause high morbidity and mortality, generate great health service and economic losses, law suits and consumer distrust. This study analyze information available in the Bacteriology National Reference Center from INCIENSA, regarding diarrhea and food poisoning outbreaks that took place in the year 2005, where clinical and/or food samples were sent to INCIENSA in order to identify the agents and vehicles associated with the infections. Materials and methods:A descriptive analysis of the laboratory and epidemiological data concerning the 2005 foodborne intoxications and diarrheal outbreaks was performed. Results:During 2005, CNRB documented a total of 23 diarrheal outbreaks and food poisonings for an approximate total of 819 cases, mainly from the Great Metropolitan Area. Thirteen of the outbreaks were intra-familiar (ten of them due to different Shigella species and serotypes); however, the largest number of cases was found in community outbreaks and in captive populations, associated with rotavirus, enterotoxigenic Escherichia coli and toxin A producer Clostridium perfringens, with 518, 138 and 54 cases respectively. Conclusion: These findings suggest deficiencies in the transportation, conservation and manipulation food chain, including personal hygiene and could be useful for the implementation of immediate interventions.

 diarrea enfermedad transmitida por alimentos intoxicación alimentaria Shigella spp Salmonella spp C. perfringens toxina A E. coli enterotoxigénica Staphylococcus aureus rotavirus diarrhea alimentary intoxications Helms M Simonsen J Molbak K Foodborne bacterial infection and hospitalization Clin Infect Dis 2006 42 Vigilancia epidemiológica de enfermedades transmitidas por los alimentos y sistemas de alerta en materia de inocuidad de los alimentos Foro Mundial FAO/OMS de Autoridades de Reglamentación sobre Inocuidad de los Alimentos 12-14 de octubre de 2004 Bangkok Guía de sistemas de vigilancia de las enfermedades transmitidas por alimentos (VETA) y la investigación de brotes Guía de sistemas de vigilancia de las enfermedades transmitidas por alimentos (VETA) y la investigación de brotes 2001 Buenos Aires Farmer JJ Kelly T Balows A Hausler NJ Herrmann KL Isenberg HD Shadomy HJ Enterobacteriaceae Manual of clinical microbiology Manual of clinical microbiology 1991 ^eWashington, D.C American Society for Microbiology Press Kelly MT Hickman-Brenner FW Farmer JJ Balows A Hausler NJ Herrmann KL Isenberg HD Shadomy HJ Vibrio Manual of clinical microbiology Manual of clinical microbiology 1991 ^eWashington, D.C American Society for Microbiology Press Olsvik O Strockbine A Persing D PCR detection of heat-stable, heat-labile and shiga like toxin genes in Escherichia coli Diagnostic molecular microbiology: Principles and applications Diagnostic molecular microbiology: Principles and applications 1993 ^eWashington, D.C American Society for Microbiology Press Bacteriological analytical manual on line Bacteriological analytical manual on line 2001 Maryland FDA Decreto de notificación obligatoria de enfermedades No. 30945-S Decreto de notificación obligatoria de enfermedades No. 30945-S 27 d e en La Gaceta Chin J El control de las enfermedades transmisibles El control de las enfermedades transmisibles 2001 17 ^eWashington, DC OPS Rodríguez E Gamboa MM Vargas P Clostridium perfringens en carnes crudas y cocidas y su relación con el ambiente en Costa Rica Arch Latinom Nutr 2002 52 Qadri F Svennerholm AM Faruque AS Bradley R Enterotoxigenic Escherichia coli in developing countries: Epidemiology, microbiology, clinical features, treatment and prevention Clin Microbiol Rev 2005 18 Daniels NA Enterotoxigenic Escherichia coli: traveler's diarrhea comes home Clin Infect Dis 2006 42 Global Salm Surv country databank Global Salm Surv country databank Ginebra World Health Organization Global Salm-Surv (WHO GSS) Outbreak of multidrug-resistant Salmonella Newport - United States, January-April 2002 MMWR 2002 51 Bangtrakulnonth A Pornreongwong S Pulsrikarn C Sawanpanyalert P Hendriksen RS Lo Fo Wong D Salmonella serovars from humans and other sources in Thailand, 1993-2002 Emerg Infect Dis 2004 10 Demczuk W Ahmed R Woodward D Clark C King L Dore K Laboratory surveillance data for enteric pathogens in Canadá: Annual Summary 2001 Laboratory surveillance data for enteric pathogens in Canadá: Annual Summary 2001 2001 Manitoba Enteric Disease Program, National Microbiology Laboratory, The Canadian Science Centre for Human and Animal Health Hoshino Y Kapikian AZ Rotavirus serotypes: classification and importance in epidemiology, immunity, and vaccine development J Health Popul Nutr 2000 18
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400008 Reseción esofágica por cáncer, experiencia del Servicio de Cirugía de Tórax del Hospital Dr. Rafael Á. Calderón Guardia Mainieri-Hidalgo José Alberto ,Caja Costarricense de Seguro Social 10 2007 2007 49 210 215

Durante el período comprendido entre 1990 y 2006, 28 pacientes fueron sometidos a resección esofágica por cáncer en el Servicio de Cirugía de Tórax del Hospital Dr. Rafael Á. Calderón Guardia. La edad promedio fue de 65 años y la relación hombre mujer, de 6 a 1. El antecedente de tabaquismo se confirmó en un 80%, etilismo en un 75% y 8 pacientes eran conocidos portadores de esófago de Barret. Disfagia, dolor epigástrico y pérdida de peso fueron los síntomas más frecuentes; siendo la epigastralgia debida a otra patología digestiva coexistente, como reflujo o enfermedad péptica. Los pacientes clasificados como estadio IIb, III y IV recibieron terapia de inducción y aunque en 3 de estos no se encontró tumor residual en la pieza quirúrgica, en 2 casos quedó tumor adherido a la aorta. A 21 pacientes se les realizó esofagectomía total con ascenso gástrico y anastomosis cervical y a 7 esofagectomía parcial con ascenso gástrico al tórax en 5 y 2 esófago-yeyuno anastomosis, una intratorácica y otra abdominal. La complicación más frecuente fue la claudicación respiratoria por bronconeumonía, que se produjo en 7 pacientes y que fue mortal en 3. Dos de estos pacientes presentaron además fuga de anastomosis, una en el cuello y otra en el tórax. A largo plazo la complicación más frecuente fue estrechez de la anastomosis, que en los 7 casos se ha manejado con dilataciones. La mortalidad quirúrgica fue del 10.7% y en los 3 casos la bronconeumonía fue la causa principal. La supervivencia a 5 y 10 años fue del 31.5% y el 18%, respectivamente.

Between 1990 and 2006, 28 patients had esophageal cancer resection at the Department of Thoracic Surgery of the Hospital Calderón Guardia of the Costa Rican Social Security System. The mean age was 65 years with a high male predominance of 6:1. Eighty percent of the patients were smokers, 75% drinkers and 8 patients had previous diagnosis of Barret’s esophagus. Dysphagia, epigastric pain and weight loss were the most frequent symptoms but the pain was related to preexisting peptic disease or esophagitis secondary to gastric reflux. Stage IIb, III and IV patients received neoadyuvant therapy. Three of these cases did not show residual tumor and 2 had residual aortic disease. Twenty one patients had total esophagectomy and 7 patiens had partial esophagectomies with gastric anastomosis in 5 and 2 esophagojejunostomies. Major complications were respiratory distress and bronchopneumonia in 7 patients, and anastomotic leak in 2. Thirty days mortality was 10.7%. The 3 patients died with bronconeumonía and one with cervical and other thoracic leak. Seven patients developed anastomotic strictures treated with dilatations. Survival at 5 and 10 years was 31.5% and 18% respectively.

 Cáncer de esófago cirugía de esófago ascenso gástrico esophageal cancer esophageal surgery gastric pull-up Mortalidad por tumores malignos según localización anatómica Mortalidad por tumores malignos según localización anatómica 2002 Ide H Tsutomu N Nakamura T Hayashi K Endo T Kobayashi A Eguchi R Hanyu F Esophageal squamous cell carcinoma: pathology and prognosis World J Surg 1994 18 Becker HD Esophageal cancer, early disease: diagnosis and current treatment World J Surg 1994 18 Watson A Operable esophageal cancer. Current results from the Wes World J Surg 1994 18 Enzinger PC Mayer RJ Esophageal cancer N Engl J Med 2003 349 Hölscher AH Dittler HJ Siewert JR Staging of squamous esophageal cancer: accuracy and value World J Surg 1994 18 Van Dam J Endosonographic evaluation of the patient with esophageal cancer Chest 1997 112 Lerut T Coosemans W Van Raemdonck D Dillemans B de Leyn P Marnette JM Surgical treatment of Barrett’s carcinoma: correlations between morphologic findings and prognosis J Thorac Cardiov Surg 1994 107 Daly JM Fry WA Little AG Winchester DP McKee RF Stewart AK Fremgen AM Esophageal cancer: results of an American College of Surgeons patient care evaluation study J Am Coll Surg 2000 190 Nishihira T Nakamo T Mori S Adjuvant therapies for cancer of the thoracic esophagus World J Surg 1994 18 Kelsen DP Ginsberg R Pajak TF Sheahan DG Gunderson L Mortimer J Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer N Engl J Med 1998 339 Lerut TE Leyn P Coosemans W Van Raemdonck D Cuypers P Van Cleynenbreughel B Advanced esophageal carcinoma World J Surg 1994 18 Aikou T Shimazu H Difference in main lymphatic pathways from the lower esophagus and gastric cardia Jpn J Surg 1989 19 Altorki NK Skinner DB Segalin A Stephens JK Ferguson MK Little AG Indications for esophagectomy in nonmalignant Barrett’s esophagus: a 10 year experience Ann Thorac Surg 1990 48 Cameron AJ Ott BJ Payne WS The incidence of adenocarcinoma in columnar-lined (Barret’s) esophagus N Engl J Med 1985 313 Mainieri JA Smith I Mainieri G Acalasia. Estudio de 27 casos en el Hospital Dr.Rafael Á. Calderón Guardia Acta Médic Costarric 2003 45 Gisbert JP Losa C Barreiro A Pajares JM Acalasia esofágica. Revisión de sus aspectos clínicos, diagnósticos y terapéuticos Revista Clínica Española 2000 200 Bremner CG Barrett’s oesophagus Br J Surg 1989 76 DeMeester SR DeMeester TR Columnar mucosa and intestinal metaplasia of the esophagus. Fifty years of controversy Ann Surg 2000 231 Lundell L Olbe L Current state of treatment of carcinoma of the oesophagus and gastro-oesophageal juntion. Clinical review Acta Chir Scand 1990 156 Shaheen N Ransohoff DF Gastroesophageal reflux, Barrett esophagus and esophageal cancer JAMA 2002 287 Rao DN Sanghvi LD Desai PB Epidemiology of esophageal cancer Sem Surg Oncol 1989 5 Collard JM Romagnoli R Hermans BP Malaise J Radical esophageal resection for adenocarcinoma arising in Barrett’s esophagus Am J Surg 1997 174 Fok M Law SYK Wong J Operable esophageal carcinoma: current results from Hong Kong Worl J Surg 1994 18 Swaroop VS Damle SR Advani SH Desai PB Nutrition and esophageal cancer Sem Surg Oncol 1989 5 Fok M Cheng SWK Wong J Endosonography in patient selection for surgical treatment of esophageal carcinoma World J Surg 1992 16 Sharma OP Subnani S Role of computerized tomography imaging in staging oesophageal carcinoma Sem Surg Oncol 1989 5 Patel AN Buenaventura PO Current staging of esophageal carcinoma Surg Clin N Am 2005 85 Krasna MJ Minimally invasive staging for esophageal cancer Chest 1997 112 Roth JA Pass HI Flanagan MM Graeber GM Rosemberg JC Steinberg S Randomized clinical trial of preoperative and postoperative adjuvant chemotherapy with cisplatin, vindesine and bleomycin for carcinoma of the esophagus J Thorac Cardiovasc Surg 1988 96 Forastiere AA Heitmiller RF Kleimberg L Multimodality therapy for esophageal cancer Chest 1997 112 Gamliel Z Krasna MJ Multimodaly treatment of esophageal cancer Surg Clin N Am 2005 85 Mariette C Finzi L Fabre S Balon JM Van Seuningen I Triboulet J-PJ Factors predictive of complete resection of operable esophageal cancer: a prospective study Ann Thorac Surg 2003 75 Hölscher AH Siewert JR Surgical treatment of early esophageal cancer Dig Surg 1997 14 Hölscher AH Siewert JR Surgical treatment of early esophageal cancer Dig Surg 1997 14 Nichols FC Allen MS Deschamps C Cassivi SD Pairolero PC Ivor Lewis esophagogastrectomy Surg Clin N Am 2005 85 Horstmann O Becker H Nustede R Verreet PR Röher HD Drainage of cervical esophagogastrostomy: essential or dangerous? Dig Surg 1997 14 Wilson SE Stone RS Scully M Ozeran L Benfield JR Modern management of anastomotic leak after esophagogastrostomy Am J Surg 1982 144 Iannettoni MD Whyte RL Orringer MB Catastrophic complications of the cervical esophagogastric anastomosis J Thorac Cardiovasc Surg 1995 110 Soga J Ohyama S Suzuki T Tanaka O Sasaki K Ishizaki E Muto T Carcinomas involving the esophagogastric juntion Int Surg 1990 75 Lin J Iannettoni MD Transhiatal esophagectomy Surg Clin N Am 2005 85 Hennessy TPJ Lymph node dissection World J Surg 1994 18 Zhang DW Cheng GY Huang GJ Zhang RG Liu XY Mao YS Wang YG Operable squamous esophageal cancer: current results from the East World J Surg 1994 18 Chassin JL Esophagogastrectomy: Data favoring end-to-side anastomosis Ann Surg 1978 188 Bardini R Asolati M Rulo A Bonavina L Baseggio S Peracchia A Anastomosis World J Surg 1994 18 Law SYK Fok M Wong J Risk analysis in resection of squamous cell carcinoma of the esophagus World J Surg 1994 18 Altorki NK Girardi L Skinner DB Squamous cell carcinoma of the esophagus: therapeutic dilemma World J Surg 1994 18 Gelfand GAJ Finley RJ Quality of life with carcinoma of the esophagus World. J Surg 1994 18 Ranson JM Patel GK Clift SA Womble NE Read RC Extended and limited types of Barrett’s esophagus in the adult Ann Thor Surg 1982 33 Berenson MM Riddell RH Skinner DB Malignat transformation of esophageal columnar epithelium Cancer 1978 41 Arce VJ Fernández SA Pucci CJJ Urzola GE Flores ME Bolaños EM Sustitución del esófago por el estómago sin toracotomía Act Méd Costarric 1979 22
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400009 Pulmón hiperlucente Jiménez-Gutiérrez Florana Soto-Quirós Manuel E ,Hospital Nacional de Niños 10 2007 2007 49 216 218

El pulmón hiperlucente unilateral también se ha denominado síndrome de Swyer-James, síndrome de Macleod o enfisema lobular o unilateral. Es una enfermedad poco frecuente que se caracteriza por una hiperclaridad pulmonar o lobar unilateral asociada a un atrapamiento aéreo en la espiración. En cuanto a la etiología, existe evidencia que se atribuye a una enfermedad adquirida que aparece tras una infección pulmonar durante la infancia, probablemente una bronquiolitis una neumonía viral. El cuadro clínico es variable: algunos pacientes se encuentran asintomáticos, otros con infecciones de vías respiratorias bajas a repetición, y los que presentan disnea de esfuerzo. El diagnóstico se suele realizar como un hallazgo incidental al hacer una radiografía de tórax a un niño por infecciones respiratorias repetidas, o en la edad adulta en una exploración radiológica de rutina, en una persona por lo demás asintomática. El diagnóstico diferencial de este síndrome se debe hacer con otras entidades torácicas que disminuyen la densidad radiológica pulmonar unilateral. A continuación se describe el caso clínico de un niño que es portador de pulmón hiperlucente.

Unilateral hiperlucent lung is also known as Swyer-James Syndrome, Macleod Syndrome, lobular or unilateral emphysema. It is an uncommon disease characterized by hiperlucency of one lobe or lung and air trapping upon expiration. This syndrome is considered to be an acquired disease that appears secondary to respiratory infections during the early years of life, probably bronchiolitis and/ or viral pneumonia. The clinical presentation varies among patients. Some of them are asymptomatic, others present a history of recurrent episodes of pulmonary infections from early years of life or present exertional dyspnea. The diagnosis is usually made accidentally by a chest radiograph in a child with history of respiratory infections or in an adult during a routine chest x- ray. It is important to differentiate this syndrome from other causes of unilateral pulmonary hiperlucency on conventional chest x-rays. Few cases of Swyer-James Syndrome in children have been reported, we present herein the clinical case of a patient who had a Para influenza 3 bronchopneumonia when he was a month and eighteen days of age. The ensuring chest radiographs showed a hiperlucent lung. Further testing confirmed the clinical diagnosis of an unilateral hiperlucent lung.

 pulmón hiperlucente síndrome Swyer-James síndrome Macleod parainfluenza 3 unilateral hiperlucent lung Swyer-James Syndrome Macleod Syndrome parainfluenza 3 Muller N.L Unilateral hiperlucent lung: Macleod vrs. Swyer-James Clinical Radiology 2004 59 Muller NL Colman NC Paré PD Diagnóstico radiológico de las enfermedades del tórax. Enfermedades de la vía aérea Diagnóstico radiológico de las enfermedades del tórax. Enfermedades de la vía aérea 2003 1 Madrid Editorial Elsevier Wood BP Swyer-James Syndrome E Medicine Journal 2001 2 Tortajada M García M García E Hernández R Consideraciones diagnósticas sobre el llamado síndrome del pulmón hiperclaro unilateral (síndrome de Swyer-James o de Macleod) Allergol et Inmunopathol 2004 32 Marchevsky A Guintu R Koss M Fuller C Houck W McKenna RJ Swyer-James (Macleod) Syndrome with placental transmogrification of the lung: a case report and review for literature Arch Pathol Lab Med 2005 129 Pedrosa C Casanova R Diagnóstico por imagen. Grandes síndromes y signos: insuficiencia respiratoria, hiperclaridad pulmonar, Epoc, tromboembolismo pulmonar Diagnóstico por imagen. Grandes síndromes y signos: insuficiencia respiratoria, hiperclaridad pulmonar, Epoc, tromboembolismo pulmonar 1997 2 Madrid Editorial McGraw-Hill- Interamericana Nuchtern JG Harberg FJ Congenital lung cysts Semin Pediatr Surg 1994 3 Coran AG Drongowski R Congenital cystic disease of the tracheobronchial tree in infants and children: experience with 44 consecutive cases Arch Surg 1994 129 McAdams HP Kirejeczk WM Rosado-de-Christenson ML Bronchogenic cyst: imaging features with clinical and histopathologic correlation Radiology 2000 217 Kravitz RM Congenital malformations of the lung Pediatr Clin North Am 1994 41
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400010 Hernia diafragmática postraumática latente, como causa de muerte súbita en un adulto mayor Vargas- Sanabria Maikel Flores- Sandí Grettchen ,Poder Judicial 10 2007 2007 49 219 222

Se presenta el caso de un adulto mayor, conocido consumidor habitual de licor, con antecedente de politraumatismo por precipitación 11 meses atrás, e historia de sintomatología inespecífica y muerte súbita. Al realizarse la autopsia médico legal se encontró una hernia diafragmática traumática izquierda, con el estómago completamente dentro de la cavidad pleural de ese lado. La hernia diafragmática traumática es una complicación conocida y poco común del trauma toraco abdominal cerrado, que puede permanecer latente por períodos prolongados y pasar inadvertido en un adulto mayor, haciendo que su diagnóstico diferido sea un verdadero reto para el médico. Además, puede manifestarse súbitamente, en el peor de los casos, con la muerte. Desde el punto de vista médico legal, este caso constituye una excepción, pues se trata de una muerte súbita que no obedeció a causas naturales.

 ruptura diafragmática hernia diafragmática traumática muerte súbita complicaciones diferidas del trauma diaphragmatic injury traumatic diaphragmatic hernia sudden death delayed complications of trauma Vargas E Medicina legal Medicina legal 2002 Segunda Editorial Trillas Brunicardi F Andersen D Billiar T Dunn D Hunter J Pollock R Shwartz: Principos de Cirugía Shwartz: Principos de Cirugía 2006 Octava Editorial Mc Graw Hill Ospino G Martínez P Valverde R Vólvulo gástrico intratorácio secundario a hernia diafragmática izquierda crónica postraumática Acta Méd Costarric 2005 47 Jarry J Razafindratsira T Lepront D Pallas G Eggenspieler P Dastes FD Tension faecopneumotorax as the rare presenting feature of a traumatic diaphragmatic hernia Ann Chir 2006 131 Eren S Kantarci M Okur A Imaging of diaphragmatic rupture after trauma Clin Radiol 2006 61 Sousa JP Baptista JP Martins L Pimentel J Traumatic diaphragmatic hernias: retrospective analysis Rev Port Pneumol 2006 12 Llanos J Paredes N Schiappacasse G Escalona A O`Brien A Hernia diafragmática traumática complicada: presentación como íleo Rev Chil Rad 2005 11 Rattan KN Magu S Agrawal K Ratan S Traumatic diaphragmatic herniation Indian J Pediatr 2005 72 Iochum S Ludig T Walter F Imaging of diaphragmatic injury: A diagnosis challenge? Radiographics 2002 22 Singh S Kalan M Moreyra C Buckman RF Diaphragmatic rupture presenting 50 years after the traumatic event J Trauma 2000 49 Hsu YP Chen RJ Fang JF Lin BC Blunt diaphragmatic rupture in elderly patients Hepatogastroenterology 2005 52 Delgado J Laurini M Lesiones traumáticas del diafragma Lesiones traumáticas del diafragma 2001 Facultad de Medicina. Hospital Maciel Montevideo Vázquez LA Rodríguez Y Pila R Pérez M Hernia diafragmática traumática: "la gran imitadora" Archivo Médico de Camagüey 2006 10 5 Patitó J 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 Primera Editorial Quórum Gisbert JA Medicina Legal y Toxicología Medicina Legal y Toxicología 2001 Quinta Editorial Masson Knight B Medicina forense de Simpson Medicina forense de Simpson 1999 Segunda Editorial El Manual Moderno Kvitko LA Factores de la causalidad médico legal. Cátedra de Medicina Legal y Deontología Médica Factores de la causalidad médico legal. Cátedra de Medicina Legal y Deontología Médica Facultad de Medicina. Universidad de Buenos Aires
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400011 Tuberculosis hepática primaria como causa de fiebre de origen desconocido Villalobos-Zúñiga Manuel Antonio Quintanilla-Gallo Júvel Gourzong-Taylor Charles ,Caja Costarricense de Seguro Social San José 10 2007 2007 49 222 225

Se presenta el caso de un paciente de 29 años de edad, quien se presentó con un cuadro de fiebre, sudoración nocturna y pérdida de peso, el que inicialmente fue catalogado como dengue clásico, pero que al persistir, fue abordado como fiebre de origen desconocido. Debido a que las pruebas de laboratorio y gabinete iniciales no fueron concluyentes, fue necesario realizar una laparotomía exploratoria para obtener material histológico en el que se demostraron granulomas caseosos en el hígado y formas similares a micobacterias con las tinciones especiales. Con el tratamiento antifímico, se observó una respuesta clínica favorable, por lo que se concluye que el cuadro corresponde a una probable TB hepática.

We present herein the case of a 29 a year old patient with fever, night sweats and weight loss. At the beginning he was thought to be suffering from classic dengue. Since the situation persisted for 3 weeks he was treated as classic fever of unknown origin. Due to non conclusive laboratory tests he underwent an exploratory laparotomy in order to get histologic samples, these showed caseous granulomas. This finding leads us to the diagnosis y hepatic tuberculosis. The patient was treated and the fever disappeared and 2 months later he started to gain weight.

 tuberculosis hepática fiebre de origen desconocido granulomas caseosos hepatic tuberculosis fever of unknown origin granulomas caseousus Fitzgerald D Hass DW Mandell G Mycobacterium tuberculosis Benett’s principles and pcantice of Infectous Diseases Benett’s principles and pcantice of Infectous Diseases 2005 Sixth ^ePhiladelphia Livingstone Mourad O Palda V Detshy A A Comprehensive Evidence-Based Approach to Fever of Unknown Origin Arch Intern Med 2003 163 Burke A Fever Infec Dis Clin Nor Am 1996 10 Loja D Vilca M Granulmatous tuberculous hepatitis as cause of fever of unknown origin Rev Gastroenterol Perú 2002 22 Chin C Mycobacteriosis in patients with fever of unknown origin Microbiol Immunol Infect 2003 36 Schluger N Tuberculosis Clin in Chest Med 2005 26 Ozaras R Is laparotomy necessary in the diagnosis of fever of unknown origin? Acta Chir Belg 2005 105 D'Cruz K Laparoscopic intervention in resistent hepatosplenic tuberculosis presenting as pyrexia of unknown origin Trop Gastroenterol 2005 26 Surendra K Alladi M Anju S Dipendra K Milliary tuberculosis: new insights into an old disease Lancet Inf Dis 2005 5 Desai CS Josh AG Abraham P Desai DC Deshponde RB Bhaduri A Shah SR Hepatic tuberculosis in absence of disseminated abdominal tuberculosis Ann Hepatol 2006 5 Geraint J A clinicopathological classification of granulomatous disorders Postgrad Med J 2000 76 Gaya D Thorbum D Oien KA Morris AJ Stanley AJ Hepatic granulomas: a 10 year single centre experience J Clin Pathol 2003 56 Matheus T Muñoz S Granulomatous liver disease and cholestasis Clin Liver Dis 2004 8 Singh N Paterson D Mycobacterium tuberculosis Infection in Solid- Organ Transplant Recipients: Impact and Implications for Management Clin Inf Dis 1998 27
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400012 Carcinoma metaplásico de mama. Revisión de 6 casos diagnosticados en el Hospital México, durante el período 2000-2006 Lazo-Valladares Ángel Fallas-Muñoz Marco Alfaro-Alcocer Eduardo ,Caja Costarricense de Seguro Social 10 2007 2007 49 226 229

El carcinoma metaplásico de mama es un tipo de carcinoma invasor sumamente raro (menos del 1% de todos los casos) y de alto grado histológico.1 Incluye un grupo heterogéneo de entidades malignas infrecuentes2 caracterizadas por mezclar un componente epitelial ductal invasor de alto grado con un componente escamoso o sarcomatoide que puede adoptar un fenotipo variable (con producción de matriz ósea, condroide o de células fusiformes).3 Estos tumores se caracterizan además por presentar parámetros de comportamiento agresivo, como ser grandes, de alto grado histológico, sin expresión de receptores hormonales ni de Her2/neu, pero que clínicamente presentan un pronóstico semejante al del carcinoma ductal usual, si se estratifica por estadios.4 En este estudio se revisaron 6 casos de carcinomas metaplásicos diagnosticados en el Hospital México entre 2000 y 2006, con el fin de establecer las variables clínicas y morfológicas de estos tumores y de determinar en la medida de lo posible su comportamiento biológico. En resumen, se encontraron hallazgos semejantes a los reportados en la bibliografía, con predominio de tumores grandes, de alto grado y con componente metaplásico de tipo escamoso, metástasis axilares en la tercera parte de la serie, receptores hormonales y Her2/neu negativos.

Metaplasic breast cancer is a very unusual type of invasive carcinoma (less than 1% of all cases) and of high histological grade.1 This category includes an heterogeneous group of unusual malignant entities2 with a mixture of an epithelial invasive ductal component of high grade with a squamous or sarcomatoid component, that may show a variable phenotype (with production of bone or chondroid matrix or spindle cells).3 These tumors usually present parameters of aggressive behavior such as large size, high histological grade, no expression of estrogen and progesterone receptors or Her2/ neu; but clinically have similar prognosis to the usual invasive ductal carcinoma when stratified by stage.4 We present 6 cases of metaplasic breast cancer seen at the Hospital México between 2000 and 2006 with the purpose of establishing the clinical and morphologic variants of these tumors and their biologic behavior. In summary our findings were consistent with those reported in the literature. This are predominantly large tumors, with high histological grade and metaplasic component usually of the squamous type, metastases to axillary lymph nodes in approximately 1/3 of the cases and no expression of hormonal receptors or Her2/neu.

 Cáncer de mama carcinoma metaplásico receptores de estrógenos y progesterona Expresión de Her-2 Breast cancer metaplastic carcinoma estrogen and progesterone receptors Her-2 expresion Kumar V Abbas A Fausto N "Robbins y Cotran Patología Estructural y Funcional" "Robbins y Cotran Patología Estructural y Funcional" 2005 7 Iturriaga A de Llano P Arrechea M Beloquí R Gómez M Martínez J Pérez B Hardisson D Tejerina E Esteban I Suárez A Carcinoma metaplásico verus carcinosarcoma de mama. ¿Dos nombres, una entidad? Revisión de 7 casos Carcinoma metaplásico verus carcinosarcoma de mama. ¿Dos nombres, una entidad? Revisión de 7 casos Congreso Virtual Hispanoamericano de Anatomía Patológica 2005 Madrid Dpto. Anatomía Patológica Hospital Universitario La Paz Rosen P Patología mamaria de Rosen Patología mamaria de Rosen 2005 2 editorial AMOLCA Amillano K Elorriaga K Alberro J Martín A Rezola R Plazaola A Carcinoma metaplásico de mama. Revisión a propósito de un caso Oncología 2004 27 Leibl S Moinfar F Metaplasic breast carcinomas are negative for Her-2 but frequently Express EGFR (Her-1): potential relevance to adjuvant treatment with EGFR tyrosine kinase inhibitors? J Clin Pathol 2005 58
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400013 Delusión parasitaria como causa de denuncia por responsabilidad profesional médica Raudales-García Ismael Flores-Sandí Grettchen ,Poder Judicial 10 2007 2007 49 230 230
S0001-600220070004 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022007000400014 Costa Rica en el exterior , 10 2007 2007 49 215 215