S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200001 Dr. Carlos Prada Díaz: (QdDG) Arrea-Baixench Carlos ,Académia Nacional de Medicina 04 2009 2009 51 70 70
S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200002 Hacia una nueva Salud Pública: determinantes de la Salud Ávila-Agüero María Luisa ,Ministra de Salud 04 2009 2009 51 71 73 Parkes MW Horwitz P Water, ecology and health: ecosystems as settings for promoting health and sustainability Health Promot Int 2009 24 Blouin C Chopra M van der Hoeven R Trade and social determinants of health Lancet 2009 373 Lemstra M Neudorf C Beaudin G Health disparity knowledge and support for intervention in Saskatoon Can J Public Health 2007 98 Dunn JR Housing and inequalities in health: a study of socioeconomic dimensions of housing and self reported health from a survey of Vancouver residents J Epidemiol Community Health 2002 56 Dunn JR Walker JD Graham J Weiss CB Gender differences in the relationship between housing, socioeconomic status, and self-reported health status Rev Environ Health 2004 19 Popay J Bartley M Owen C Gender inequalities in health: social position, affective disorders and minor physical morbidity Soc Sci Med 1993 36 Johnson S Abonyi S Jeffery B Hackett P Recommendations for action on the social determinants of health: a Canadian perspective Lancet 2008 372 Schrecker T Labonté R De Vogli R Globalisation and health: the need for a global vision Lancet 2008 372 McGibbon E Etowa J McPherson C Health-care access as a social determinant of health Can Nurse 2008 104 Raphael D Getting serious about the social determinants of health: new directions for public health workers Promot Educ 2008 15 Muntaner C Chung H Commentary: macrosocial determinants, epidemiology, and health policy: should politics and economics be banned from social determinants of health research? J Public Health Policy 2008 29 Lalonde M Guest editorial: A more positive approach to health promotion Can Nurse 1974 70 Lalonde M Social values and public health Can J Public Health 1974 65 Lalonde M The physician and health promotion Can Med Assoc J 1977 116
S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200003 El papel de las estatinas en insuficiencia cardíaca Chen Ku Chih Hao ,Hospital San Juan de Dios Servicio de Endocrinología 04 2009 2009 51 74 75 Legakos SW The Challenge of Subgroup Analyses - Reporting without Distorting N Engl J Med 2006 354 Hulley S Grady D Bush T Furberg C Herrington D Riggs B Randomized Trial of Estrogen plus Progestin for Secondary Prevention of Coronary Heart Disease in Postmenopausal Women JAMA 1998 280 Risks and Benefits of Estrogen plus Progestin in Healthy Postmenopausal Women JAMA 2002 288 Kjekshus J Apetrei E Barrios V Böhm M Cleland JGF Cornel JH Rosuvastatin in Older Patients with Systolic Heart Failure N Engl J Med 2007 357 Effect of Rosuvastatin in Patients with Chronic Heart Failure (the GISSI-HF trial): a randomised, doubleblind, placebo-controlled trial Lancet 2008 372 Ridker PM Danielson E Fonseca FAH Genest J Gotto AM Kastelein JJP Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C reactive Protein N Engl J Med 2008 359 Khush K Waters D Bittner D Deedwania PC Kastelein JJ Lewis SJ Effect of high-dose atorvastatin on hospitalizations for heart failure: Subgroup analysis of the treating to new targets (TNT) study Circulation 2007 115
S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200004 La inflamación y su papel en el desarrollo del cáncer gástrico Inflammation and its Role in the Development of Gastric Carcinoma Alpízar-Alpízar Warner Une Clas Sierra Rafaela ,Universidad de Bergen Hospital Universitario Haukeland Departamento de Patología Bergen Noruega ,Universidad de Costa Rica Instituto de Investigaciones en Salud (INISA) San José Costa Rica 04 2009 2009 51 76 81

La infección por Helicobacter pylori produce, en algunos pacientes, inflamación crónica en el estómago, gastritis atrófica y cáncer gástrico. Los mecanismos moleculares que conducen de la infección a la inflamación crónica y al cáncer son desconocidos. La magnitud y el proceso de la inflamación dependen del tipo de cepa de H. pylori y de la respuesta del hospedero ante la infección. Esta respuesta inflamatoria está regulada por citoquinas, algunas de las cuales han sido asociadas con cambios en la secreción de ácido en el estómago y con el riesgo de desarrollar cáncer gástrico y varias lesiones gástricas precancerosas. Sin embargo, la relación entre citoquinas y cáncer gástrico no es del todo clara. Esta revisión se enfoca en los procesos inflamatorios asociados con el desarrollo del cáncer gástrico.

Helicobacter pylori infection results, in some patients, in chronic inflammation of the stomach, atrophic gastritis and gastric cancer. The molecular mechanisms that lead from infection to chronic inflammation and gastric cancer are not understood. The degree of inflammation varies and depends on the H. pylori strain and the host response against the infection. The inflammatory response is regulated by cytokines, some of which have been associated with acid gastric secretion changes and with increased risk of stomach cancer and some precancerous lesions. Nevertheless, the relationship between cytokines and gastric cancer is not clear yet. This review focuses on the inflammatory processes associated with the development of gastric malignancies.

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the gastric mucosa J Infect Dis 2003 188 Beales IL Calam J Interleukin 1 beta and tumour necrosis factor alpha inhibit acid secretion in cultured rabbit parietal cells by multiple pathways Gut 1998 42 Takashima M Furuta T Hanai H Sugimura H Kaneko E Effects of Helicobacter pylori infection on gastric acid secretion and serum gastrin levels in Mongolian gerbils Gut 2001 48 Idriss HT Naismith JH TNF alpha and the TNF receptor superfamily: structure-function relationship(s) Microsc Res Tech 2000 50 Beutler B TNF, immunity and inflammatory disease: lessons of the past decade J Investig Med 1995 43 Strieter RM Kunkel SL Bone RC Role of tumor necrosis factoralpha in disease states and inflammation Crit Care Med 1993 21 Higuchi T Seki N Kamisono S Yamada A Kimura A Kato H Polymorphism of the 5’-flanking region of the human tumor necrosis factor (TNF)-alpha gene in Japanese Tissue Antigens 1998 51 Skoo T van`t Hooft FM Kallin B Jovinge S Boquist S Nilsson J A common functional polymorphism 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cytokines and gastrin levels in asymptomatic subjects infected by Helicobacter pylori (H. pylori) Immunopharmacol Immunotoxicol 2001 23 Genta RM The immunobiology of Helicobacter pylori gastritis Semin Gastrointest Dis 1997 8 Roebuck KA Regulation of interleukin-8 gene expression J Interferon Cytokine Res 1999 19 Matsushima K Baldwin ET Mukaida N Interleukin-8 and MCAF: novel leukocyte recruitment and activating cytokines Chem Immunol 1992 51 Eck M Schmaußer B Scheller K Brändlein S Müller-Hermelink HK Pleiotropic effects of CXC chemokines in gastric carcinoma: differences in CXCL8 and CXCL1 expression between diffuse and intestinal types of gastric carcinoma Clin Exp Immunol 2003 134 Koch AE Polverini PJ Kundel SL Harlow LA DiPietro LA Elner VM Interleukin-8 as a macrophage-derived mediator of angiogenesis Science 1992 258 Strieter RM Kundel SL Elner VM Matonyi CL Koch AE Polverini PJ Interleukin-8: Acorneal factor that induces neovascularization Am J Pathol 1992 141 Taguchi A Ohmiya 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S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200005 Estatinas en la insuficiencia cardiaca Statins in Heart Failure Ramos-Esquivel Allan ,Universidad de Costa Rica Departamento de Farmacología 04 2009 2009 51 83 88

Desde su descubrimiento hace cerca de 30 años, las estatinas han desempeñado un papel importante en el tratamiento y prevención de las enfermedades cardiovasculares, con base, inicialmente, en las propiedades hipolipemiantes de esta clase de fármacos. Con el advenimiento de nuevos conocimientos sobre su mecanismo de acción y de sus propiedades pleiotrópicas, se ha planteado la utilidad clínica de las estatinas en diversas enfermedades. Ha surgido evidencia sugestiva de la eficacia de estos fármacos en la insuficiencia cardiaca a partir de múltiples teorías. A continuación se revisan el fundamento fisiopatológico que sustenta su utilización en este síndrome y la actual evidencia clínica en favor o en contra de tal uso.

Since their discovery 30 years ago, statins have played an important role in the treatment and prevention of cardiovascular diseases based on their lipid lowering properties. Given their pleiotropic activity, their clinical utility in the treatment of several diseases has been discussed. Lately, based on multiple theories, evidence has emerged regarding the efficacy of these drugs in heart failure patients. A review is presented of the physiopathological basis supporting their use and of clinical evidence in favor and against it.

 insuficiencia cardiaca estatinas heart failure statins Plehn J Davis Sacks F Rouleau J Pfeffer M Bernstein V Reduction of stroke incidence after myocardial infartion with pravastatin: The cholesterol and recurrent events (CARE) study Circulation 1999 99 MRC / BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high - risk individuals: a randomized placebo - controlled trial Lancet 2002 360 Raina A Pickerin T Shimbo D Statin use in heart failure: A cause of concern? Am Heart J 2006 152 Aronow W Epidemiology, Pathophysiology Prognosis and Treatment of Systolic and Diastolic Heart Failure Cardiol Rev 2006 14 Owan TE Hodge DO Herges RM Jacobsen SJ Roger VL Redfield MM Trends in prevalence and outcome of heart failure with preserved ejection fraction N Engl J Med 2006 355 Ulate-Montero G Ulate-Campos A Actualización en los mecanismos fisiopatológicos de la insuficiencia cardiaca Act Med Costarric 2008 50 Hoshijima M Sah V Wang Y Chien K Heller J The low molecular weight GTPase rho regulates myofibril formation and organization in neonatal rat ventricular myocites Biol Chem 1998 273 Wettschureck N Offermanns S Mammalian G proteins and their cell type specific functions Physiol Rev 2005 85 Satoh M Ogita H Takeshita K Requirement of Rac1 in the development of cardiac hypertrophy PNAS 2006 103 Auki H Izumo S Sadoshima J Angiotensin II activates RhoA in cardiac myocites Circ Res 1998 82 Satoh S Ueda Y Koyanagui M Kadokami T Sugano M Yoshikawa Y Makino N Chronic inhibition of Rho Kinase blunts the process of left ventricular hypertrophy leading to cardiac conctractile dysfunction in hypertensive - induced heart failure J Mol Cell Cardiol 2003 35 Frey N Katus H Olson E Hypertrophy of the heart Circulation 2004 109 Pimentel D Amin J Xiao L Miller T Viereck J Olivier-Krasinski J Reactive Oxygen Species mediate amplitud-dependant hypertrophic and apoptotic responses to mechanical stretch in cardiac myocites Circ Res 2001 89 Nojiri H Shimizu T Funakoshi M Yamaguchi O Zhou H Kawakami S Oxidative Stress causes heart failure with impaired mithocondrial respiration J Biol Chem 2006 281 Liu H Colavitti R Rovira I Finkel T Redox-Dependant transcriptional regulation Circ Res 2005 97 Giordano F Oxygen, oxidative stress, hypoxia, and heart failure J Clin Invest 2005 115 Cheng TH Cheng PY Shih NL Chen IB Ling D Chen JJ Involvement of reactive oxygen species in angiotensin II - induced endothelin - 1 gene expression in rat cardiac fibroblasts J Am Coll Cardiol 2003 42 Takimoto E Kass D Role of oxidative stress in cardiac hypertrophy and remodeling Hypertension 2007 49 Endemann D Schiffrin E Endothelial dysfunction J Am Soc Nephrol 2004 15 Taniyama Y Griendling K Reactive Oxygen Species in the Vasculature Hypertension 2003 42 López A Casado S Heart Failure, redox alterations, and endothelial dysfunction Hypertension 2001 38 Ramos-Esquivel A León-Céspedes C Efectos no hipolipemiantes de las estatinas Act Med Costarric 2007 49 Liao JK Isoprenoids as mediators of the biological effects of statins J Clin Invest 2002 110 Takemoto M Node K Nakagami H Liao Y Grimm M Takemoto Y Statins as antioxidant therapy for preventing cardiac myocite hypertrophy J Clin Invest 2001 108 Haendeler J Hoffman J Zeiher A Dimmeler S Antioxidant effect of statins via S-nitrosylation and activation of thioredoxin in endothelial cells Circulation 2004 110 Zhang H Schmeiber A Garlichs C Plötze K Damme U Mügge A Angiotensin II-induced superoxide anion generation in human vascular endothelial cells: Role of membrane-bound NADH-/ NADPH-oxidases Cardiovasc Res 1999 44 Wassmann S Laufs U Bäumer A Müller K Konkol C Sauer H Inhibition of geranylgeranylation reduces angiotensin II-mediated free radical production in vascular smooth muscle cells: involvement of angiotensin AT1 receptor expression and Rac1 GTPase Mol Pharmacol 2001 59 Dechend R Fiebeler A Park JK Müller D Theur J Mervaala E Amelioration of angiotensin II - induced cardiac injury by a 3hydroxy- 3-methyglutaryl coenzyme Areductase inhibitor Circulation 2001 104 Pliquett R Cornish K Zucker I Statin therapy restores sympathicovagal balance in experimental heart failure J Appl Physiol 2003 95 Pliquett R Cornish K Peuler JD Simvastatin normalizes autonomic neural control in experimental heart failure Circulation 2003 107 Gao L Wang W Li YL Shultz HD Liu D Cornish KG Simvastatin therapy normalizes sympathetic neural control in experimental heart failure Circulation 2005 112 Tousoulis D Antoniades C Bosinakou E Kotsopoulou M Pitsavos C Vlachopoulos C Effects of atorvastatin on reactive hyperemia and inflammatory process in patients with congestive heart failure Atherosclerosis 2005 178 Sola S Mir M Lerakis S Tandon N Khan B Atorvastatin improves left ventricular systolic function and serum markers of inflammation in nonischemic heart failure J Am Coll Cardiol 2006 47 May H Muhlestein J Carlquist J Horne B Campbell Kfoury A Relation of serum total cholesterol, c-reactive protein leveles and statin therapy to survival in heart failure Am J Cardiol 2006 98 Node K Fujita M Kitakaze M Hori M Liao J Short-term statin therapy improves cardiac function and symptoms in patients with idiopathic dilated cardiomyopathy Circulation 2003 108 Strey CH Young JM Lainchbury JH Frampton C Nicholls M Richards A Short term statin treatment improves endothelial function and neurohormonal imbalance in normocholesterolaemic patients with non - ischemic heart failure Heart 2006 92 Schäfer A Fraccarollo D Eigenthaler M Tas P Firnschild A Frantz A Rosuvastatin reduces platelet activation in heart failure Arterioscler Thromb Vasc Biol 2005 25 Horwich T Middlekauff H Potential autonomic nervous system effects of statins in heart failure Heart Fail Clin 2008 4 Tousoulis D Antoniades C Bosinakou E Kotsopoulou M Tsioufis C Tentolouris C Effects of atorvastatin on reactive hyperaemia and the thrombosis - fibrinolysis system in patients with heart failure Heart 2005 91 Strey CH Young JM Lainchbury JH Frampton CM Nicholls MG Richards AM Short-term statin treatment improves endothelial function and neurohormonal imbalance in normocholesterolaemic patients with non-ischaemic heart failure Heart 2006 92 Shanes JG Minadeo KN Moret A Grover M Tabaie SA Statin therapy in heart failure: Prognostic effects and potential mechanisms Am Heart J 2007 154 Bauersachs J Galuppo P Fraccarollo D Christ M Ertl G Improvement of left ventricular remodeling and function by hydroxymethylglutaryl coenzyme A reductase inhibition with cerivastatin in rats with heart failure after myocardial infarction Circulation 2001 104 Senthil V Chen S Tsybouleva N Halder T Naqueh SF Willerson J Prevention of cardiac hypertrophy by atorvastatin in a transgenic rabbit model of human hypertrophic cardiomyopathy Circ Res 2005 97 KjesKshus J Pedersen TR Olsson AG Faergeman A Pyörälä K The effects of simvastatin on the incidence of heart failure in patients with coronay heart disease J Card Fail 1997 3 Sacks FM Pfeffer MA Moye LA Rouleau J Rutherford J Cole TG The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels: Cholesterol and Recurrent Events Trial investigators N Engl J Med 1996 335 Horwich T MacLellan WR Fonarow G Statin therapy is associated with improved survival in ischemic and non-ischemic heart failure J Am Coll Cardiol 2004 43 Ray J Gong Y Sykora K Statin use and survival outcomes in elderly patients with heart failure Arch Intern Med 2005 165 Go A Lee W Yang J Lo J Gurwitz J Statin therapy and risks for death and hospitalization in chronic heart failure JAMA 2006 296 Foody JM Shah R Galusha D Masoudi FA Havranek EP Krumholz HM Statins and mortality among elderly patients hospitalizad with heart failure Circulation 2006 113 Ezekowitz J McAlister F Humphries K Norris C Tonelli M Ghali W The association among renal insufficiency, pharmacotherapy, and outcomes in 6,427 patients with heart failure and coronary artery disease J Am Coll Cardiol 2004 44 Mozaffarian D Nye R Levy W Statin therapy is associated with lower mortality among patients with severe heart failure Am J Cardiol 2004 93 Hognestad A Dickstein K Myhre E Snappin S Kjekshus J OPTIMAAL Investigators: Effect of combined statin and beta-blocker treatment on one-year morbidity and mortality after acute myocardial infarction associated with heart failure Am J Cardiol 2004 93 Krum H Bailey M Meyer W Verkenne P Dargie H Lechat P Impact of statin therapy on clinical outcomes in chronic heart failure patients according to beta-blocker use: results of CIBIS II Cardiology 2007 108 Krum H Caretta E Latini R Maggioni AP Anand I Masson S Statins and symptomatic chronic systolic heart failure: a post-hoc analysis of 5010 patients enrolled in Val-HeFT Int J Cardiol 2007 119 Krum H Ashton E Reid C Kalff V Roger J Amarena J Doubleblind, randomized, placebo-controlled study of high-dose HMG CoA reductase inhibitor therapy on ventricular remodeling, proinflammatory cytokines and neurohormonal parameters in patients with chronic systolic heart failure J Card Fail 2007 13 Khush K Waters D Bittner D Deedwania PC Kastelein JJ Lewis SJ Effect of high-dose atorvastatin on hospitalizations for heart failure: Subgroup analysis of the treating to new targets (TNT) study Circulation 2007 115 Kjieshus J Apetrei E Barrios V Böhm M Cleland J Cornel J Rosuvastatin for older patients with systolic heart failure N Engl J Med 2007 357 Tavazzi L Tognoni G Franzosi MG Latini R Maggioni A Marchioli R Rationale and design of the GISSI heart failure trial: a large trial to assess the effects of n-3 polyunsaturated fatty acids and rosuvastatin in symptomatic congestive heart failure Eur J Heart Fail 2004 6 Effects of rosuvastatin in patients with chronic heart failure (the GISSI-HF trial): a randomized, double-blind, placebo-controlled trial Lancet Rauchhuss M Coats AJ Anker S The endotoxin-lipoprotein hypothesis Lancet 2000 356 Littarru GP Langsjoen P Coenzyme Q10 and statins: biochemical and clinical implications Mithocondrion 2007 De Pinieux G Lipid-lowering drugs and mithochondrial function: effects of HMG-CoA reductase inhibitors on serum ubiquinone and blood lactate/pyruvate ratio Br J Clin Pharmacol 1996 42 van der Harst P Voors A van Gilst WH Böhm M van Veldhussein DJ Statin in the treatment of chronic heart failure: biological and clinical consideration Cardiovas Res 2006 Afsarmanesh N Horwich TB Fonarow GC Total cholesterol levels and mortality risk in nonischemic systolic heart failure Am Heart J 2006 152 Horwich TB Hamilton MA Maclellan WR Fonarow GC Low serum total cholesterol is associated with marked increase in mortality in advanced heart failure J Card Fail 2002 8 Rauchhaus M Clark AL Doehner W Davos C Bolger A Sharma R The relationship between cholesterol and survival in patients with chronic heart failure J Am Coll Cardiol 2003 42 Ramasubbu K Mann D The emerging role of statins in the treatment of heart failure J Am Coll Cardiol 2006 47 Mann D McMurray J Packer M Swedberg K Borer J Colucci W Targeted anticytokine therapy in patients with chronic heart failure: results of the randomized etanercept worldwide evaluation Circulation 2004 109 Ramasubbu K Mann D The emerging role of statins in the treatment of heart failure J Am Coll Cardiol 2006 47 Prevention of cardiovascular events with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels N Engl J Med 1998 339 Downs JR Clearfield M Weis S Whitney E Shapiro D Beere PA Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels JAMA 1998 279
S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200006 La pregunta de investigación Arguedas-Arguedas Olga ,Caja Costarricense de Seguro Social Hospital Nacional de Niños Dr. Carlos Sáenz Herrera 04 2009 2009 51 89 90 Gill J Design and analysis of experiments in the animal and medical sciences: Volumen 1 Design and analysis of experiments in the animal and medical sciences: Volumen 1 Arnes^eIA The Iowa State University Press
S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200007 Prevalencia del síndrome de desgaste en médicos residentes costarricenses Prevalence of Burnout Syndrome in Costarican Physician Residents Millán-González Ricardo Mesén-Fainardi Andrea ,Hospital Dr. Rafael Angel Calderón Guardia Servicio de psiquiatría ,Centro Costarricense de Investigaciones Médicas 04 2009 2009 51 91 97

Justificación y objetivo: determinar las características sociodemográficas del síndrome de desgaste en médicos residentes en Costa Rica durante el 2007 y validar localmente la escala de Maslach. Metodología: investigación aplicada, descriptiva y de corte transversal, en la que participaron 121 sujetos que cursaban primer y tercer año de las siguientes especialidades que imparte el CENDEISSS: anestesiología y recuperación, especialidades médicas y quirúrgicas, ginecología y obstetricia, pediatría y psiquiatría. Se aplicó el Maslach Burnout Inventory-Human Services Survey (versión validada en español) y una ficha de datos sociodemográfica que incluía especialidad médica, sede de residencia, sexo, estado civil, número de hijos, edad de los participantes, frecuencia mensual de guardias y año cursado de residencia. Resultados: El análisis final detectó alto agotamiento emocional en mujeres y en residentes de pediatría; bajo agotamiento emocional en quienes realizan en promedio 4 guardias por mes y en residentes de geriatría y psiquiatría; alta despersonalización en hombres; baja despersonalización en residentes de geriatría y medicina familiar así como en personas unidas; bajos niveles de realización personal en personas unidas; el síndrome de desgaste como tal fue mayor en mujeres, que cursaban el tercer año, sujetos unidos, personas con hijos, menores de 30 años y residentes de las especialidades médicas. Adicionalmente se validó la utilización de la escala en Costa Rica. Conclusión: existen subgrupos de médicos residentes que se encuentran en riesgo de presentar el síndrome de desgaste profesional o elevadas puntuaciones en algunas de sus 3 dimensiones. Algunos de ellos podrían ser propios del personal que mantiene una carga académica y laboral al mismo tiempo. Este hecho debe ser tomado en cuenta cuando se planifican las estrategias de bienestar mental en el sector salud.

Background and aim: to determine the socio-demographic characteristics of the burnout syndrome in residency trainees in Costa Rica in 2007 and to validate the Maslach Burnout Inventory-Human Services Survey (Spanish version). Materials and methods: The present is a descriptive and cross-sectional study. One hundred and 21 subjects were interviewed during the first and third year of specialization in anesthesiology, surgery and medical disciplines, gynecology and obstetrics, pediatrics and psychiatry. All of them completed the Maslach Burnout Inventory Human Services Survey (Spanish validated) and a socio-demographic questionnaire which included: medical specialty, residency center, sex, marriage status, number of children, age, number of on-call assignments per month and year of residency. Results: high levels of emotional exhaustion were found in women and pediatrics trainees; however the opposite was seen in those on-call 4 times a month on average, as well as in geriatrics and psychiatry residents. Depersonalization was elevated in men, but low in those living with someone, geriatrics and family medicine residents. Negative personal accomplishment was seen in those who lived with someone else. The Burnout Syndrome by itself was more frequent in women, third year residents, people living with someone else and with children, those below 30 years and those undergoing training in medical subspecialties. The inventory was validated for use its in Costa Rica. Conclusion: Subgroups undergoing residency training are at risk of developing Burnout Syndrome. Some of them could be related to the academic and occupational burden. When planning mental health strategies, this fact must be considered.

 síndrome de desgaste profesional agotamiento emocional realización personal despersonalización Maslach Burnout -Inventory burnout syndrome emotional exhaustion depersonalization negative personal accomplishment Maslach Burnout-Inventory Ministerial Round Tables: 54th World Health Assembly Ministerial Round Tables: 54th World Health Assembly Salud Mental y Violencia Intrafamiliar Salud Mental y Violencia Intrafamiliar Leiter MP Maslach C Banishing Burnout: Six strategies for improving your relationship with work Banishing Burnout: Six strategies for improving your relationship with work 2005 Prim. ed San Francisco^eCA Jossey-Bass Maslach C Jackson SE MBI Human Services Survey, Manual MBI Human Services Survey, Manual 1981 Palo Alto^eCA Consulting Psychologists Press Inc Maslach C Schaufeli WB Schaufeli WB Maslach C Marek T Historical and conceptual development of burnout Professional burnout: Recent developments in theory and research Professional burnout: Recent developments in theory and research 1993 Londres Taylor & Francis Kristensen T Borritz M Villadsen E Christensen K The Copenhagen burnout Inventory: A new tool for the assessment of desgaste Work & Stress 2005 19 Moriana J Burnout y cuidado de la salud en voluntarios Revista electrónica de Psicología Política y Comunitaria 2006 4 10 Gil-Monte P Validez factorial de la adaptación al español del Maslach Burnout Inventory General Survey Salud Pública de Méx 2002 44 Atance J Aspectos epidemiológicos del síndrome de desgaste en el personal sanitario Rev esp salud pub 1997 71 Woodside JR Miller MN Floyd MR McGowen KR Pfortmiller DT Observations on Burnout in Family Medicine and Psychiatry Residents Acad Psychiatry 2008 32 Días S Comportamiento del síndrome de desgaste profesional en médicos que laboraron en Coopesalud R.L, de agosto a octubre de 2004 Acta Med Costarric 2007 49 Madrigal M Síndrome de agotamiento profesional (Desgaste) en la psiquiatría costarricense Síndrome de agotamiento profesional (Desgaste) en la psiquiatría costarricense Madrigal M Burnout en médicos: aproximaciones teóricas y algunos diagnósticos diferenciales Rev de Med Legal de Costa Rica 2006 23 Salazar G Desgaste y satisfacción profesional de los médicos de atención primaria del Programa de Atención Integral de Salud del Convenio UCR-CCSS en el segundo trimestre del año 2002 Desgaste y satisfacción profesional de los médicos de atención primaria del Programa de Atención Integral de Salud del Convenio UCR-CCSS en el segundo trimestre del año 2002 Bianchini M El Síndrome del Desgaste en personal profesional de la salud Rev de Med Legal de Costa Rica 1997 13 Jiménez M González R Sell V Caracterización de algunos hábitos y enfermedades de los médicos costarricenses Acta Med Costarric 2000 42 Oficina Regional de la Organización Mundial de la Salud/Organización Panamericana de la Salud Oficina Regional de la Organización Mundial de la Salud/Organización Panamericana de la Salud Declaración de Helsinki sobre los principios éticos para las investigaciones en seres humanos Declaración de Helsinki sobre los principios éticos para las investigaciones en seres humanos Fórmula de consentimiento informado, versión FCI aprobada en sesión del Comité Ético Científico No. 53 realizada 03-09-03 Fórmula de consentimiento informado, versión FCI aprobada en sesión del Comité Ético Científico No. 53 realizada 03-09-03 15 d e no Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision Duty Hours Language Duty Hours Language Adams-Greenup R Editorial: The other side of the stethoscope Academic Psychiatry 2008 32 Dunn LB Iglewicz A Moutier C A Conceptual model of medical student well-being: promoting resilience and preventing burnout Acad Psychiatry 2008 32
S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200008 Acalasia, experiencia de 6 años. Hospital "Dr. Rafael Ángel Calderón Guardia" (2001-2007) Achalasia, a 6 Years Study at the Calderon Guardia Hospital Hernández-de Mezerville Viviana Izquierdo-Sandí Edgar Avendaño-Alvarado Gerardo Barahona-García Ricardo Ávalos-Giugliarelli Alessia Páez-Sáenz Rolando Salas-Aguilar Rigoberto ,Hospital Dr. Rafael Angel Calderón Guardia 04 2009 2009 51 98 102

Objetivos: Caracterizar la población de pacientes vistos con esta entidad en el Hospital "Dr. Rafael Angel Calderón Guardia" durante los últimos 6 años y determinar su presentación clínica, método(s) de diagnóstico utilizado (s), tratamiento brindado y evolución durante el primer año postratamiento. Materiales y métodos: Se analizaron los expedientes clínicos de hospitalización de los pacientes con acalasia atendidos desde enero de 2001 hasta enero de 2007; luego se revisaron las notas de evolución de la consulta externa de Gastroenterología durante el año posterior a la terapia brindada. Resultados: Durante el periodo se analizaron 30 pacientes en total. Hubo una discreta predominancia del género masculino y la edad promedio en el momento del diagnóstico fue de 50,37 años. El 100% de los pacientes presentó disfagia de larga data y los síntomas asociados más frecuentes fueron la pérdida de peso y el dolor torácico. Los métodos diagnósticos más utilizados fueron la manometría esofágica, la endoscopía y el esofagograma. El tratamiento que más se empleó fue la dilatación neumática seguida de la cirugía. El 50% de los pacientes reinició o persistió con disfagia durante el año siguiente a su tratamiento. La incidencia de complicaciones fue baja y no hubo perforación esofágica. Conclusiones: Las características generales y la presentación clínica de los pacientes coincidieron con lo descrito en la bibliografía. El tratamiento que más se brindó fue la dilatación neumática. La mitad de los pacientes presentaron o continuaron con síntomas postratamiento.

Objectives: To determine the general characteristics of patients with diagnosis of achalasia seen during the last 6 years at the Dr. Rafael Angel Calderon Guardia Hospital, their clinical presentation, diagnostic methods utilized, treatments given and the presence of disphagia within the following year after therapy. Methods: We analized the clinical records of patients with achalasia seen from january 2001 to january 2007. We also reviewed out patient clinic notes, looking for the persistence or recurrence of disphagia during the first year after therapy. Results: 30 patients were found and included in the study. There was a slight male gender predominance, and an average age of 50,37 years. All the patients had long standing dysphagia, the other most frequent symptoms were weight loss (43,33%) and chest pain (13,33%). The more commonly used diagnostic methods were esophageal manometry, endoscopy and barium esophagogram. Pneumatic dilation was the most frequently utilized treatment (46,67%) followed by surgery (26,67%). Half the patients recurred or continue having dysphagia during the year following treatment. The rate of complications was low and there were no esophageal perforations or mediastinitis. Conclusions: The general characteristics and clinical presentation of the patients agreed with those mentioned in the literature. Esophagic manometry was the most used diagnostic test and esophageal dilation was the preferred treatment. The rate of dysphagia within a year posttreatment was high.

 acalasia trastornos motores esofágicos disfagia achalasia esophagic motility disorders dysphagia Earlam R Cunha-Mejo JR Benign esophageal strictures: Historical and technical aspects of dilation Br J Surg 1981 68 Koshy SS Nostrant TT Pathophysiology and endoscopic/balloon treatment of esophageal motility disorders Surg Clin North Am 1997 77 Feldman M Friedman L Brandt L Sleisenger and Fordtran´s 8th gastrointestinal and liver disease Sleisenger and Fordtran´s 8th gastrointestinal and liver disease Saunders Elsevier Ellis FH Olsen AM Achalasia of the esophagus Achalasia of the esophagus 1969 Philadelphia^eToronto WB Saunders Company Kahrilas P Esophageal motility disorders: current concepts of pathogenesis and treatment Can J Gastroenterol 2000 14 Podas T Eaden J Mayberry M Mayberry J Achalasia: A critical review of epidemiological studies Am J Gastroenterol 1999 93 Perrier JP Fernández M Sosa MC Tratamiento quirúrgico de la acalasia y la opción de cirugía laparoscópica Cir Uruguay 2000 70 Gisbert J Losa C Barreiro A Pajares J Acalasia esofágica: Revisión de sus aspectos clínicos, diagnósticos y terapéuticos Rev Clin Esp 2000 200 Zaninotto G Constatntini M Rizzetto C Ancona E Acalasia: estrategias terapéuticas Cir Esp 2004 75 Italo Braghetto M Attila Csendes J Patricio Burdiles P Owen Korn B José Miguel Valera M 1066 Manejo actual de la acalasia del esófago: revisión crítica y experiencia clínica Rev Méd Chile 2002 130 Traube M Dubovik S Lange RC McCallum RW The role of nifedipine therapy in achalasia: Results of a randomized, double blind, placebo-controlled study Am J Gastroenterol 1989 84 Vantrappen G Hellemans J Deloof W Valembois P Vanderbroucke J Treatment of achalasia with pneumatic dilatation Gut 1971 12 Pasricha PJ Ravich WJ Kalloo AN Effects of intraesphinteric botulin toxin on the lower esophageal sphincter in piglets Gastroenterology 1993 105 Martínek J Siroky M Plottová Z Burest J Hep A Spicák J Treatment of patients with achalasia with botulinum toxin: a multicenter prospective cohort study Diseases of the esophagus 2003 16 Shimi S Nathanson LK Cuschieri A Laparoscopic cardiomyotomy for achalasia JR Coll Surg Edinb 1991 36 Bowrey DJ Peters JH Cirugía laparoscópica de esófago Surg Clin North Am 2000 80 Campos A Acalasia Acta Médic Costarric 1990 33 Mainieri-Hidalgo J Schmitz Gerstlauer I Mainieri-Breedy G Acalasia: estudio de 27 casos en el HCG Acta Médic Costarric 2003 45 Desai KM Soper NJ Laparoscopic management of idiopathic esophageal achalasia Rev. Gastroenterol Mex 2004 ^s69 Kozarek RA Yamada T Gastrointestinal dilation Textbook of Gastroenterology Textbook of Gastroenterology 1991 ^eNew York JB Lippincott Csendes A Braghetto I Henriquez A Cortes C Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia Gut 1989 30 Marks RD Richter JE Peptic strictures of the esophagus Am J Gastroeneterol 1993 88 Chiocca JC Salis GB Acalasia del esófago: qué hacer, ¿el balón o el bisturí? Acta Gastroent Latinoamer 1997 27 Khandelwal M Ouyang A Pneumatic dilation for achalasia: are all complications revealed? Gastrointest Endosc 1997 45 Hunter JG Richardson W Surgical management of achalasia Surg Clin North Am 1997 77
S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200009 Experiencia de la consulta homeopática de un programa docente en Costa Rica, 2003-2007. Un enfoque de atención holística Experience of a Homeopathy Consultation at a Teaching Program in Costa Rica, from 2003 to 2007 Brenes-Valverde Alejandro Ramírez -Salas Alcira Araya-Jiménez Lisbeth Vargas-Chavez Carolina Rodríguez-Canosa Patricia Montero-Chinchilla Giselle ,Director Programa Docente de la FMHC ,Comité Investigación COOPESALUD R.L ,Consejo Nacional de Cooperativas ,Comité Investigación COOPESALUD R.L ,INFOCOOP ,Comité Investigación COOPESALUD R.L 04 2009 2009 51 103 109

Objetivos: Describir la experiencia de la consulta homeopática, su metodología y caracterizar a los pacientes. Material y métodos: Estudio descriptivo de 83 expedientes; se analizaron variables cualitativas (sexo, estado conyugal, ocupación, escolaridad, residencia, credo, modo de acceso a la consulta, motivo de consulta, motivos de consulta físicos y psíquicos, dolor, síntomas psíquicos y físicos, diagnóstico o problemas) y cuantitativas (edad, duración de la primera consulta, número de motivos de consulta, número de diagnósticos /problemas principales, comparación del número de motivos de consulta con los diagnósticos /problemas, número total de consultas, número y costo de los medicamentos y resultado de la aplicación de la Glasgow Homoeopathic Hospital Outcome Scale. La información se recolectó del expediente clínico. Los datos se almacenaron y analizaron en el programa SPPS versión 12.0; se obtuvieron medidas de tendencia central, frecuencias y proporciones. Resultados: Se atendieron 83 personas, con un intervalo de edad entre 5 meses y 83 años, promedio 38 años. 79% adultos, predominó el sexo femenino. 57% accedió por demanda libre; 28% por referencia de médicos y enfermeros. 81% consultó por problemas físicos de salud; una vez realizado el diagnóstico, la proporción de estos disminuyó casi a la mitad y los físico-psíquicos se incrementaron ocho veces. El promedio de duración de la primera consulta fue de 66 minutos, del número de consultas fue de dos y el de medicamentos, de tres. El costo promedio de las prescripciones fue de ¢1.946ºº por paciente. Conclusiones: En el distrito de Pavas existe demanda por la consulta homeopática, que debe investigarse. Este enfoque terapéutico holístico identificó trastornos de salud no reportados por los pacientes como motivos de consulta iniciales. Los resultados obtenidos coinciden, en algunos aspectos, con otras investigaciones internacionales en el campo de la práctica clínica homeopática.

Objectives: To describe the experience, clinical methods and patients characteristics seen during homeopathic consultation. Methods: The present is a descriptive study of 83 total clinical records. The following qualitative variables were analyzed (sex, marriage status, occupation, education, residence, religion, referral manner, physical an psychic consultation reasons, diagnosis or problems). Quantitative variables were: age, duration of first consultation, number of complaints at consultation, comparison between number of complaints for consultation with diagnosis / problems, total number of consultations, number and cost of homeopathic medications and results of the application of the Glasgow Homoeopathic Hospital Outcome Scale. Data was obtained from the clinical records, and then analyzed with the SPPS software 12.0 version. Central tendency measures, frequencies and proportions were obtained. Results: 83 patients were seen, during the study period, ranging from 5 months to 83 years of age, average 38 years. There was female sex majority, and 79% were adult. Fifty seven percent attended on their own will, 28% were referred by physicians or nurses. Eighty one percent consulted because of physical problems, however after establishing a medical diagnosis, those diminished around 50% but psycho-physical health problems increased 8 times. The average of the first consultation was 66 minutes; the number of consultations was 2 and 3 the medications per person. The average cost of the prescriptions was ¢ 1 946.00 (aprox. 3 US dollars) per patient. Conclusions: There is a demand for homeopathic consultation in Pavas district that should be investigated. The holistic therapeutic approach identified health problems in patients, that they did not report at the initial consultation. The results obtained coincidence in some aspects, with other international investigations in the field of clinical homeopathic practice.

 homeopatía modelo holístico atención primaria programa docente homeopathy holistic model primary care teaching program Lyon A The fifth wave The fifth wave 2003 Edinburgh Scottish Council Foundation Kayne S The origin of holism Br Hom J 1999 88 Jeammet P Reynaud M Consoli SM Psicología médica Psicología médica 1999 Barcelona Masson Dorland’s Illustrated Medical Dictionary Dorland’s Illustrated Medical Dictionary 1994 Philadelphia W.B. Saunders Company Amador S Del fijismo del siglo XVIII al holismo del siglo XXI Revista Girasol 2003 5 Hasegawa H Reilly D Mercer S Bikker A Holism in primary care: the views of Scotland’s general practitioners Primary Health Care Research and Development 2005 6 Madel TL The incorporation of homoeopathy into public health programmer Br Hom J 1992 81 Reilly D Harrison T Creative consulting: psiconeuroimmunology, the mindbody. Student BMJ 2002 10 Menéndez E Intencionalidad, Experiencia y Función: la articulación de los saberes médicos Revista de Antropología Social 2005 14 Köehler G The hanbook of homoeopathy The hanbook of homoeopathy 1987 New Delhi Aristeguieta A Homeopatía y psicología: consideraciones de actualidad Homeopatía y psicología: consideraciones de actualidad 1989 San José Litografía Artex Abecassis J Barbancey J Bastide M Baur J Belon P Belot J Tratado de homeopatía Tratado de homeopatía 2000 Barcelona Paidotribo Leckridge B Homeopatía en atención primaria Homeopatía en atención primaria 2000 Barcelona Mathie R The research evidence base for homeopathy: a fresh assessment of the literature Homeopathy 2003 92 Wayne J Kaptchuk J Linde K A critical overview of homeopathy Ann Intern Med 2003 138 Jacobs J Springer A Crothers D Homeopathic treatment of acute otitis media in children: a preliminary randomized placebo-controlled trial Pediatr Infect Dis J 2001 20 Jacobs J Herman P Heron K Olsen S Vaughters L Homeopathy for menopausal symptoms in breast cancer survivors: a preliminary randomized controlled trial J Alter Compl Med 2005 11 Van Wassenhoven M Priorities and methods for developing the evidence profile of homeopathy: Recommendations of ECH General Assembly and XVIII Symposium of GIRI Homeopathy 2005 94 2 Hahnemann S Ensayo sobre un principio nuevo para descubrir los poderes curativos de las sustancias medicinales, junto con algunas miradas actuales (1796) Escritos médicos menores Escritos médicos menores 1996 New Delhi B Jain Publisher Hahnemann S Organón de la medicina (1810) Organón de la medicina (1810) 1983 Caracas Ediciones de la Biblioteca Poitevin B Integrating homoeopathy in health systems Bulletin of the World Health Organization 199 77 Brenes A Medicina Homeopática en Costa Rica Medicina Legal de Costa Rica 1990 7 Departamento Farmacoterapia, Informe Final Departamento Farmacoterapia, Informe Final 4 de m ay San José Comisión institucional para el análisis de la homeopatía como medicina alternativa Brenes A Terapéutica homeopática y Seguridad Social en Costa Rica: Conferencia, Foro de Prestaciones Sociales del Adulto Mayor y Medicina no Tradicional Terapéutica homeopática y Seguridad Social en Costa Rica: Conferencia, Foro de Prestaciones Sociales del Adulto Mayor y Medicina no Tradicional Conferencia Interamericana de Seguridad Social 2-4 de julio, 2003 San José Reilly D Duncan R Bikker A Heirs M Development of the GHHOS, the IDCCIM Action Research, & The PC-HICOM Project: Developing a scale relating outcome to impact on daily living, modelled on daily clinical care and piloted in an action research cycle in NHS General Practice. Interim Report February 2003 Development of the GHHOS, the IDCCIM Action Research, & The PC-HICOM Project: Developing a scale relating outcome to impact on daily living, modelled on daily clinical care and piloted in an action research cycle in NHS General Practice. Interim Report February 2003 Manual diagnóstico y estadístico de los trastornos mentales, texto revisado DSM-IV-TR®: AP-Atención Primaria Manual diagnóstico y estadístico de los trastornos mentales, texto revisado DSM-IV-TR®: AP-Atención Primaria 2004 Barcelona Masson Jacobs J Jiménez L Gloyd S Gale J Crothers D Treatment of acute childhood diarrhea with homeopathic medicine: a randomized clinical trial in Nicaragua Pediatrics 1994 93 Trichard M Chaufferin G Nicoloyannis N Study of the practice of homeopathic general practitioners in France Homeopathy 2003 92 Vithoulkas G Las leyes y principios de la homeopatía en su aplicación práctica Las leyes y principios de la homeopatía en su aplicación práctica 1997 26 Barcelona Paidós -Ibérica Robinson T Responses to homeopathic treatment in National Health Service general practice Homeopathy 2006 95 Pomposelli R Andreoni C Costini G Dedor B Mariani M Castellini M Opinions and self-reported health status of italians seeking homeopathic treatment Homeopathy 2006 9 Mercer S Reilly D Watt G Enablement and the therapeutic Alliance: an evaluation of the consultation at the Glasgow Homoeopathic Hospital. Report February 2001 Enablement and the therapeutic Alliance: an evaluation of the consultation at the Glasgow Homoeopathic Hospital. Report February 2001 Asha J Does homeopathy reduce the cost conventional drug prescribing?: A study of comparative prescribing costs in General Practice Homeopathy 2003 92 Vincent C Furnham A Why do patients turn to complementary medicine?: An empirical study Br J Clin Psicol 1996 35 Riley D Fischer M Singh B Haidvogl M Herger M Homeopathy and conventional Medicine: an outcomes study comparing effectiveness in a primary care -setting J Alter Compl Med 2001 7 2
S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200010 Medicina darwiniana de Céspedes Montealegre Carlos ,Hospital Nacional de Niños Dr. Carlos Sáenz Herrera 04 2009 2009 51 110 113 Neese Randolph M Williams George C Why We Get Sick: The New Science of Darwinian Medicine Why We Get Sick: The New Science of Darwinian Medicine Darwin’s Gifts The Lancet dici em br Número especial
S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200011 Osteogénesis imperfecta con manifestaciones en el periodo neonatal Neonatal Presentation of Osteogenesis Imperfecta Rodríguez-Herrera Gilberto Navarro-Charpantier María Jesús ,Hospital Nacional de Niños ,Hospital Nacional de Niños Servicio de Neonatología 04 2009 2009 51 114 118

Se reporta un caso de un paciente masculino de un día de vida extrauterina; producto de una madre de 20 años, primigesta, prima segunda de su pareja. Nace por cesárea por presentación pélvica, con líquido amniótico meconizado, con un peso al nacer de 2275 gramos (RNTPEG). Al examen físico el niño se encontraba flácido, con cianosis leve, fontanelas amplias con comunicación de la anterior con la posterior, ausencia de escama occipital, escleras azules, retrognatia, extremidades cortas y con crepitación al movimiento. En las radiografías óseas con fracturas múltiples, formación de callo óseo y cambios displásicos en metáfisis. Se diagnostica por parte de los genetistas una osteogénesis imperfecta (OI) y se da consejo genético a los padres. La OI es un conjunto de trastornos genéticos que afectan la integridad del tejido conectivo, debido a que se presentan mutaciones en la síntesis del colágeno, ya sean autosómicas dominantes o recesivas. En vista de que el diagnóstico es predominante-mente clínico y radiológico, se debe profundizar en los patrones óseos, ya que los pacientes pueden desarrollar cambios quísticos, densos o frágiles. A partir de este caso de OI tipo 2 severa se pretende discutir las diferencias entre los diferentes grupos.

We report the case of a male patient with one day of life, his mother is a 20-yr-old gravida 1 para 1 male, there is parental consanguinity (second cousin). This patient born alive by Caesarean section in breech presentation with meconium stained amniotic fluid and birthweight 2275 g (small for gestational age term infant). Physical examination findings in this case are hypotonia, mild cyanosis, large anterior fontanelle, absence of occipital scale, blue sclera, retrognathia and shortening of the long bones whit crepitation. The radiografphic findings show numerous fractures, hyperplastic callus formation and dysplastic changes in metaphyses. He was diagnosed by the geneticists with OI and given genetic counseling to parents. The osteogenesis imperfecta has a genetic background that affects connective tissue integrity, associated with collagen synthesis mutations, being dominant or recessive autosomic inheritance. In the majority of cases, diagnosis of IO is easy on the basis of clinical and radiological findings; for this reason must be important to emphasize on bone structure studies, because patients may develop cystic, dense or fragile changes. This case presents a patient who has osteogenesis imperfecta type II; we pretend to discuss the differences between Ol’s types.

 osteogénesis imperfecta neonatos protocolágeno tipo I osteogenesis imperfecta neonates type I protocollagen Hoffman Jodi D Estrella E Newborn: Presentation of connective tissue disorders NeoReviews 2007 8 Niyibizi C Smith P Zhibao M Robbins P Evans C Potential of gene terapy for treating osteogenesis imperfecta Clin Otrthop and Relat Reser 2000 379 Mihran O Tachdjlan M Pediatric Orthopedics Pediatric Orthopedics 1990 II 2 Saunders Company Paterson Colin R McAllion Susan J Classical Osteogenesis Imperfecta and Allegations of Nonaccidental Injury Clin Orthop and Relat Reser 2006 452 Devogelaer J New uses of biphosphonates: osteogenmesis imperfecta Current Opinion in Pharmacol 2002 2 Byers Peter H Osteogenesis imperfecta: perspectives and opportunities Current Opinion in Pediatrics 2000 12 Astrom E Soderhall S Beneficial effect of biphosphonate during five years of treatment of severe osteogenesis imperfecta Acta Paedriatr 1998 87 Jones K Smit´s: Recognizable Patterns of Human Malformation Smit´s: Recognizable Patterns of Human Malformation 1997 5 Saunders Company Hanscom DA Winter RB Lutter L Lonstein JE Osteogenesis imperfecta: Radiographic classification, natural history, and treatment J Bone Joint Surg Am 1992 74
S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200012 Tuberculosis extrapulmonar en embarazada: Primer caso en el Área de Salud de Pavas Extra pulmonary tuberculosis in a pregnant woman: First case seeing at the Pavas Health Area González- Vizcaíno Adriana Ramírez -Salas Alcira ,COOPESALUD R.L Clínica de Pavas 04 2009 2009 51 119 120

La tuberculosis es la segunda causa de muerte por enfermedades infecciosas en el mundo, precedida solo por el Virus de Inmunodeficiencia Humana y Síndrome de Inmunodeficiencia Adquirida (sida), y es la primera causa de muerte por enfermedades infecciosas en las mujeres. La presentación de la tuberculosis en la mujer embarazada es similar a la de la no embarazada, pero el diagnóstico puede retardarse por la naturaleza no específica de los primeros síntomas y la frecuencia de malestar y fatiga en el embarazo. Este es el primer caso de tuberculosis en una embarazada documentado en el Área de Salud de Pavas.

Tuberculosis is the world’s second commonest cause of death from infectious disease, after HIV/AIDS and is the first infectious cause of death among women. The clinical presentation of tuberculosis does not differ in pregnant and not pregnant women, but the diagnosis can be delayed because of increased rates of malaise and fatigue in noninfected pregnant women. This is the first case of pregnant woman with extra pulmonary tuberculosis documen-ted in the Area of Health of Pavas.

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S0001-600220090002 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022009000200013 Costa Rica en el exterior , 04 2009 2009 51 109 118