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Climate changes evidenced by an increase in our planet's mean temperature, changes in rainfall, increased sea level and extreme weather conditions, favor air and soil contamination, ocean acidification, droughts, floods, heat waves and forest fires, which affect the health and wellbeing of exposed populations. These changes will exert negative effects on respiratory and cardiovascular systems, nutritional status, burden of infectious diseases, especially vector-borne infections, and human mental health. Moreover, environmental damages, such as loss of biodiversity, ecological collapse and deterioration of socioeconomic factors such as agricultural and fishery production, and the loss of habitable land, will impulse massive migrations. This article summarizes the impact that climate change is expected to have on respiratory, cardiovascular and infectious diseases and its repercussions on people of extreme ages. It is imperative to achieve the immediate commitment of worldwide national governments to control green-house gas emissions. The appropriate technology does exist, but political will is urgently needed to accomplish this goal.

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Climate changes evidenced by an increase in our planet's mean temperature, changes in rainfall, increased sea level and extreme weather conditions, favor air and soil contamination, ocean acidification, droughts, floods, heat waves and forest fires, which affect the health and wellbeing of exposed populations. These changes will exert negative effects on respiratory and cardiovascular systems, nutritional status, burden of infectious diseases, especially vector-borne infections, and human mental health. Moreover, environmental damages, such as loss of biodiversity, ecological collapse and deterioration of socioeconomic factors such as agricultural and fishery production, and the loss of habitable land, will impulse massive migrations. This article summarizes the impact that climate change is expected to have on respiratory, cardiovascular and infectious diseases and its repercussions on people of extreme ages. It is imperative to achieve the immediate commitment of worldwide national governments to control green-house gas emissions. The appropriate technology does exist, but political will is urgently needed to accomplish this goal.

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Resumen Introducción: El trasplante hepático (TH), es una terapia establecida en el tratamiento de diversas enfermedades del hígado agudas y crónicas terminales y del carcinoma hepatocelular (CHC). Las principales indicaciones en nuestro medio son la cirrosis de diferentes etiologías, el CHC, la atresia de vías biliares en niños y la falla hepática fulminante (FHF). Menos del 10% corresponden a indicaciones inhabituales, que incluyen pacientes con una miscelánea de enfermedades entre las cuales están la enfermedad poliquística hepática (EPH), enfermedades metabólicas (Niemann-Pick, otras), el síndrome hepato/portopulmonar, metástasis de diferentes tumores, etc. Objetivo: Describir y evaluar los resultados obtenidos con el trasplante hepático en estas indicaciones. Materiales y Método: Estudio de cohorte no concurrente que incluyó los TH por indicaciones inhabituales realizados entre marzo de 1997 y diciembre de 2016. De 295 TH realizados, 34 (11,5%) fueron por estas indicaciones. Resultados: Las causas más frecuentes fueron el síndrome porto/hepatopulmonar en 11 (40,7%) pacientes y la EPH en 9 (26,5%). Las enfermedades metabólicas representaron la tercera indicación, con 5 (14,7%) casos. Siete (20,6%) pacientes eran menores de 18 años. Las complicaciones más frecuentes fueron biliares y la trombosis de arteria hepática en 6 (17,6%) y 4 (11,8%) casos respectivamente; estos últimos eran portadores de una EPH masiva. Cuatro (12,5%) pacientes requirieron retrasplante. La mortalidad a 90 días fue de 2 (5,9%) enfermos. Conclusión: El TH es una opción factible en este grupo de pacientes con resultados similares a los obtenidos en las indicaciones clásicas.

Introduction: Liver transplantation (LT) is an established therapy in the treatment of several acute and chronic end-stage liver diseases and hepatocellular carcinoma (HCC). The main indications worldwide are cirrhosis of different etiologies, HCC, biliary atresia in children, and fulminant hepatic failure (FHF). Less than 10% concerns unusual indications which include patients with miscellaneous diseases among which are hepatic polycystic disease (HPD), metabolic diseases (Niemann-Pick, others), portal/hepatopulmonary syndrome, metastasis of different tumors, among others. Aim: The objective of the study is to describe and asses the results obtained with liver transplantation in these indications. Materials and Method: We performed a non-concurrent cohort study that included all LT due to unusual indications between March 1997 and December 2016 in a university medical center. Of 295 TH performed, 34 (11.75%) were due to these indications. Results: The most frequent causes were the portal/hepatopulmonary syndrome in 11 (40.7%) patients and HPD in 9 (26.5%). Metabolic diseases accounted for the third indication in 5 (14.7%) cases. Seven (20.6%) patients were less than 18 years old. The most frequent complications were biliary and hepatic artery thrombosis (HAT) in 6 (17.6%) and 4 (11.8%) cases, respectively. Patients complicated by a HAT suffered a massive EPH. Four (12.5%), required retransplantation. Mortality at 90 days was 2 (5.9%). Conclusión: LT is a feasible option in this group of patients with results similar to those obtained in classic indications of LT.

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The Chilean Academy of Medicine convened a commission to evaluate the status of HIV epidemic and the national response to it, regarding its achievements, gaps and challenges, aiming to recommend actions to optimize assessment quality and national response. This publication summarizes the agreed upon opinion of its members. The epidemic is overwhelmingly sexually transmitted, predominant in homo/bisexual men. Vertical transmission is very low. An increasing number of new diagnoses is occurring, with relative over representation of foreign people lately. There is a legal guarantee of confidentiality, nondiscrimination and treatment for those affected, both in the private and public sector. All public health services have active HIV care units. Modern antiviral drugs and monitoring tests are also available. Despite these clear achievements, insufficient, occasionally inadequate public policies and certain rigid regulations thwart optimal effectivity and efficiency of the programs, contributing to the slow and incomplete compliance with international commitments. Shortcomings worth highlighting are: suboptimal educational and preventive programs directed to youngsters, vulnerable and general population; persistent underdiagnosis of infected population; cumbersome requirements to request and inform diagnostic tests, thus discouraging testing; excessive centralization and long latency of diagnosis confirmation and monitoring tests; incomplete epidemiologic analysis and public reporting of findings; non flexibility and slow updating of therapeutic guidelines; insufficient adaptation of care and drug delivery modalities to patients' needs; excessive administrative requirements at care centers and restrictive legislation for outcome and interventional clinical research. Recommendations to deal with these issues were proposed.

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The Chilean Academy of Medicine convened a commission to evaluate the status of HIV epidemic and the national response to it, regarding its achievements, gaps and challenges, aiming to recommend actions to optimize assessment quality and national response. This publication summarizes the agreed upon opinion of its members. The epidemic is overwhelmingly sexually transmitted, predominant in homo/bisexual men. Vertical transmission is very low. An increasing number of new diagnoses is occurring, with relative over representation of foreign people lately. There is a legal guarantee of confidentiality, nondiscrimination and treatment for those affected, both in the private and public sector. All public health services have active HIV care units. Modern antiviral drugs and monitoring tests are also available. Despite these clear achievements, insufficient, occasionally inadequate public policies and certain rigid regulations thwart optimal effectivity and efficiency of the programs, contributing to the slow and incomplete compliance with international commitments. Shortcomings worth highlighting are: suboptimal educational and preventive programs directed to youngsters, vulnerable and general population; persistent underdiagnosis of infected population; cumbersome requirements to request and inform diagnostic tests, thus discouraging testing; excessive centralization and long latency of diagnosis confirmation and monitoring tests; incomplete epidemiologic analysis and public reporting of findings; non flexibility and slow updating of therapeutic guidelines; insufficient adaptation of care and drug delivery modalities to patients' needs; excessive administrative requirements at care centers and restrictive legislation for outcome and interventional clinical research. Recommendations to deal with these issues were proposed.

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BACKGROUND: The HIV epidemic reached Chile in late 1980s and as an early response, AIDS care centers were organized. Fundación Arriarán (FA) was the first center. Free antiretroviral therapy (ART) was later provided with progressive coverage and complexity over the years. AIM: To quantify evolution of mortality, retention and loss to follow up (LTFU) over 25 years according to different periods of access to ART, from no availability to full coverage with current drugs at FA center. MATERIAL AND METHODS: Retrospective analysis of FA database of 5,080 adults admitted between 1990 and 2014. The sample was distributed in 7 groups: A: no ART (1990-92), B: monotherapy, C: dual therapy, D: dual/triple ART, E: early triple therapy with incomplete coverage, F same as E but with complete coverage and G: contemporary ART (2008-14). Mortality, retention and LTFU were evaluated at 1, 3, 5, 7 and 10 years and at 31/12/2015. RESULTS: Mortality varied from 40% to 2%, and 62% to 7% at 1 and 5 years, for groups A and G respectively; from 71% to 16% at 10 years for groups A and E, respectively. Retention at 5 years were 28%, 23%, 39%, 62%, 75%, 75% and 77% for groups A to G, respectively. LTFU was 10%, 19%, 15%, 17%, 9% 12% and 10% at 5 years for same groups, respectively. At 12/31/2015 22% of patients had died, 11% were LTFU, 60% were retained in care and 6% had been transferred. CONCLUSIONS: There is a marked reduction in mortality and increase in retention of HIV patients' concomitant to expanded access to modern therapy, although LTFU remains a problem.

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Background: The HIV epidemic reached Chile in late 1980s and as an early response, AIDS care centers were organized. Fundación Arriarán (FA) was the first center. Free antiretroviral therapy (ART) was later provided with progressive coverage and complexity over the years. Aim: To quantify evolution of mortality, retention and loss to follow up (LTFU) over 25 years according to different periods of access to ART, from no availability to full coverage with current drugs at FA center. Material and Methods: Retrospective analysis of FA database of 5,080 adults admitted between 1990 and 2014. The sample was distributed in 7 groups: A: no ART (1990-92), B: monotherapy, C: dual therapy, D: dual/triple ART, E: early triple therapy with incomplete coverage, F same as E but with complete coverage and G: contemporary ART (2008-14). Mortality, retention and LTFU were evaluated at 1, 3, 5, 7 and 10 years and at 31/12/2015. Results: Mortality varied from 40% to 2%, and 62% to 7% at 1 and 5 years, for groups A and G respectively; from 71% to 16% at 10 years for groups A and E, respectively. Retention at 5 years were 28%, 23%, 39%, 62%, 75%, 75% and 77% for groups A to G, respectively. LTFU was 10%, 19%, 15%, 17%, 9% 12% and 10% at 5 years for same groups, respectively. At 12/31/2015 22% of patients had died, 11% were LTFU, 60% were retained in care and 6% had been transferred. Conclusions: There is a marked reduction in mortality and increase in retention of HIV patients' concomitant to expanded access to modern therapy, although LTFU remains a problem.

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The process of evaluation of candidate patients for liver transplantation should include the risk of infectious diseases in order to prevent the drop out of the waiting list due to infections or the occurrence of these in the post-transplant period. Cirrhotic patients in the pre-transplant stage are very ill and usually have severe infections. The most common is spontaneous bacterial peritonitis, but they can also present urinary infections and pneumonias. Mortality due to infectious causes has been reported up to 40% in patients on the transplant waiting list. The transplanted patients may have a poor immune response to vaccination, so the optimal immunization period is pre-transplant. In the post-transplant period, Gram-negative bacterial infections are one of the main complications. Invasive fungal infections and cytomegalovirus can also have a high impact on morbidity and mortality. Transplanted patients may also have mycobacterial infections in relation to a latent tuberculosis infection. In the following article we present the pre-transplant evaluations, vaccination schemes and antimicrobial prophylaxis that are used in liver transplantation.

El proceso de evaluación de pacientes candidatos para trasplante hepático debe incluir el riesgo de enfermedades infecciosas a fin de prevenir la salida de la lista por infecciones o la ocurrencia de éstas en el período post-trasplante. Los pacientes cirróticos en la etapa pre-trasplante están muy enfermos y suelen presentar infecciones graves. La más común es la peritonitis bacteriana espontánea, pero también pueden presentar infecciones urinarias y neumonías. La mortalidad por causa infecciosa se ha reportado hasta en 40% en pacientes en lista de espera de trasplante. Los pacientes trasplantados pueden tener una pobre respuesta inmune a la vacunación, por lo que el momento óptimo de inmunización es en el período pretrasplante. En el período post-trasplante las infecciones bacterianas por Gram negativos son una de las principales complicaciones. Las infecciones por hongos invasores y el citomegalovirus también pueden tener un alto impacto en morbilidad y mortalidad. Los pacientes trasplantados también pueden presentar infecciones por micobacterias en relación a una infección latente por tuberculosis. En el siguiente artículo se presentan las evaluaciones pre-trasplante, esquemas de vacunación y profilaxis antimicrobiana que se utilizan en trasplante hepático.

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BACKGROUND: Per-oral tacrolimus administration is not always practicable. Sublingual administration is a potential alternative, but its feasibility and effectiveness compared with oral route has not been established. AIM: To compare tacrolimus drug exposure after sublingual and oral administration in liver transplant recipients. METHODS: Experimental, open-label, non-randomised, cross-over study. Tacrolimus exposure was evaluated in 32 liver transplant recipients receiving oral administration. 12 h tacrolimus area-under-the-curve (AUC0-12 h ) was calculated using tacrolimus blood concentrations at 0-0.5-1-2-4-6-8-12 hrs post-dose. Recipients were switched to sublingual administration, and dose was adjusted to reach similar trough levels, new AUC0-12 h was calculated. Correlation between AUC0-12 h and trough levels was determined for both oral and sublingual phases. RESULTS: Similar trough levels were accomplished with oral and sublingual administration (6.68 ± 2 ng/mL vs. 6.62 ± 1.9 ng/mL (P = 0.8)). Although concentration 2 h post dose was higher in oral phase (15.36 ± 7.14 vs. 13.18 ± 5.64, P = 0.015), AUC0-12 h was similar in both phases (116.6 ± 34.6 vs. 111.5 ± 36.93 ng/mL* h, P = 0.19). Daily dose of tacrolimus required in sublingual phase was 37% lower than that used in oral phase (P < 0.0001), suggesting significantly increased bioavailability of tacrolimus when employing sublingual route. Good correlation between AUC0-12 h and trough levels was observed in sublingual phase (r2 = 0.74). Twenty-two recipients were maintained on sublingual administration after the end of study (mean follow-up: 18.7 ± 5.8 months). No difference in liver function tests or rejection rates was found during follow-up period. CONCLUSIONS: Sublingual administration of tacrolimus is feasible and provides similar drug exposure compared with oral administration. In our study, at long-term follow-up, sublingual administration was not associated with liver transplant rejection.

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