Hever Krüger

The placenta and the newborn infant at high altitudes

Abstract A comparative study of the placenta and the newborn infant at Rio Pallanga (altitude 15,100 feet) and Lima (500 feet) is presented. Three parameters were analyzed, the weight of the newborn infant, the weight of the placenta, and the ratio of the weight of the placenta to the weight of the newborn infant (placental coefficient). The mean values of these parameters were analyzed according to Fishers t test. The results showed that: (1) at high altitudes, the newborn infants weighed significantly less than those born at sea level; (2) the placentas at high altitude weighed more than the placentas at sea level; (3) the value for the placental coefficient at high altitudes was significantly higher than at sea level; (4) the number of cotyledons in high-altitude placentas was half that of sea level placentas, indicating a lesser degree of septation and probably a greater proportion of functioning parenchyma; and (5) no differences were found in the volumes of the placentas. The physiologic role of the placenta at high altitudes is discussed.

Verruga peruana mimicking malignant neoplasms.

We have shown that in some cases fully developed florid verruga peruana nodules, as well as late-resolving, deeply situated lesions, can histologically suggest a variety of tumors to experienced pathologists. The compact proliferation of endothelial cells characteristic of florid verruga lesions can give rise to two pseudoneoplastic histologic patterns. One consists of sheets or islands of cells arranged in an epithelioid or pseudoepithelioid pattern (cases 1 and 2) in which the following histologic diagnoses were considered: squamous carcinoma, sweat gland carcinoma, epithelioid hemangioendothelioma, epithelioid sarcoma, melanoma and metastatic carcinoma. The other pattern of the florid lesion is characterized by a predominantly spindle cell arrangement (case 3) and in it the following diagnoses were made: Kaposis sarcoma, fibrosarcoma, melanoma and leiomyosarcoma. The dense lymphoplasmacytic and histiocytic infiltrates of the late-resolving, deeply situated nodules (case 4) suggested the following histologic conditions: malignant lymphoma, nodular Hodgkins disease, reticuloendotheliosis, and reticulosarcomatosis. Some histologic features thought to be of value to help in the differential diagnoses are discussed. It is emphasized that only the finding of Rocha-Limas inclusions on light-microscopic studies and/or the demonstration of bartonella organisms in the lesions by electron-microscopic studies can objectively establish a diagnosis in a given lesion. However, knowledge of the epidemiologic data and particularly the presence of other lesions in the patient make it relatively easy to rule out neoplasia.

The heart and pulmonary vasculature of the llama (Lama glama)

Heath, D., Smith, P., Williams, D., Harris, P., Arias-Stella, J., and Krüger, H. (1974).Thorax, 29, 463-471. The heart and pulmonary vasculature of the llama (Lama glama). A qualitative and quantitative histological study was made of the pulmonary trunk and muscular pulmonary arteries of a male and a pregnant female llama born and living at an altitude of 4,720 m above sea-level in the Peruvian Andes. A similar study was made on the fetal llama. The individual cardiac chambers of the two adults were weighed. Our results show that in the adult llama there is no hypertrophy of the right ventricle or of the media of the pulmonary trunk or small pulmonary arteries. This appears to be of evolutionary significance in respect of survival at high altitude and suggests that the llama does not have a sustained significant pulmonary hypertension. The pulmonary arteries of the fetal llama are thick-walled and we associate this with the physiological pulmonary hypertension of fetal life.

Association of major depressive episode with negative outcomes of tuberculosis treatment.

Background Pulmonary tuberculosis (TB) persists an important contributor to the burden of diseases in developing countries. TB control success is based on the patient’s compliance to the treatment. Depressive disorders have been negatively associated with compliance of therapeutic schemes for chronic diseases. This study aimed to estimate the significance and magnitude of major depressive episode as a hazard factor for negative outcomes (NO), including abandon or death in patients receiving TB treatment. Methodology/Principal Findings A longitudinal study was conducted to evaluate the association of major depressive episode (MDE), as measured by a 5-item version of the Center for Epidemiological Studies Depression Scale (CES-D) with NO to TB treatment. Patients with confirmed TB were enrolled before the start of TB treatment. Baseline measurements included socio-demographic variables as well as the CES-D, which was also applied every month until the end of the treatment. Death and treatment default were assessed monthly. Survivor function (SF) for NO according to MDE status (CES-D≥6) at baseline (MDEb) was estimated. Cox’s Regression was performed for bivariate analyses as well as for the multivariate model. A total of 325 patients accepted to participate in the study, of which 34 where excluded for diagnosis of MDR-TB. NO was observed in 24 patients (8.2%); 109 (37%) presented MDEb. Statistically significant difference was found on the SF of patients with and without MDEb (0.85 vs. 0.96, p-value = 0.002). The hazard ratio for NO, controlled for age, sex, marital status and instruction level was 3.54 (95%CI 1.43–8.75; p-value = 0.006). Conclusion The presence of MDE at baseline is associated to NO of TB treatment. Targeting detection and treatment of MDE may improve TB treatment outcomes.

Pathology of chronic mountain sickness.

Arias-Stella, J., Krüger, H., and Recavarren, S. (1973).Thorax, 28, 701-708. Pathology of chronic mountain sickness. Pathological data on chronic mountain sickness are scarce due to the fact that the disease is ameliorated or cured by descent to a low altitude. In this report we describe a case of chronic mountain sickness occurring in a woman of 48 years at Cerro de Pasco (4,300 m above sea level). The necropsy findings are compared with the limited pathological observations reported by others. It is apparent from our findings that in fatal cases the main changes are located within the pulmonary circulation. So far histological studies have been reported only in cases of the secondary form of chronic mountain sickness. The basic pathology of the primary form (Monges disease) remains to be defined.

Excessive sleepiness prevalence in public transportation drivers of a developing country

Objective: To determine the prevalence of excessive sleepiness (ES) in bus and auto-rickshaw drivers from Lima, Peru. Methods: We conducted a cross-sectional study of Limas bus and auto-rickshaw drivers to estimate ES prevalence in this population. Survey sites were private transportation companies, systematically selected with a snowball approach. ES was assessed with the Spanish-validated version of the Epworth sleep questionnaire (ESQ) with a cutoff score >10. We obtained relevant demographic information. Results: Four hundred and thirty-four bus and auto-rickshaw drivers were eligible for analysis. The overall ES prevalence was 32.7 percent (95% confidence interval [CI]: 28–37.2). ES prevalence was higher in bus drivers than in auto-rickshaw drivers, 38 percent (95% CI: 31.7–44.2) and 26.9 percent (95% CI: 20.6–33.1), respectively (P = .01). We used data from all subjects to obtain regression equations for ESQ score with several predictors. Being a bus driver, working additional nighttime hours per week, having depression or anxiety, and alcohol abuse had small but significant associations with ESQ scores. Conclusion: ES prevalence in Limas public transportation drivers is in a medium range as suggested by previous regional studies.

Common Mental Disorders in Public Transportation Drivers in Lima, Peru

Background Traffic related injuries are leading contributors to burden of disease worldwide. In developing countries a high proportion of them can be attributed to public transportation vehicles. Several mental disorders including alcohol and drug abuse, psychotic disorders, mental stress, productivity pressure, and low monetary income were found predictors of high rates of traffic related injuries in public transportation drivers. The goal of this study was to estimate the prevalence of common mental disorders in the population of public transportation drivers of buses and rickshaws in Lima, Peru. Methodology/Principal Findings Cross sectional study. A sample of bus and rickshaw drivers was systematically selected from formal public transportation companies using a snowball approach. Participants completed self-administered questionnaires for assessing major depressive episode, anxiety symptoms, alcohol abuse, and burnout syndrome. Socio demographic information was also collected. The analyses consisted of descriptive measurement of outcomes taking into account both between and within cluster standard deviation (BCSD and WCSD). A total of 278 bus and 227 rickshaw drivers out of 25 companies agreed to participate in the study. BCSD for major depressive episode, anxiety symptoms and burnout syndrome was not found significant (p>0.05). The estimated prevalence of each variable was 13.7% (IC95%: 10.7–16.6%), 24.1% (IC95%: 19.4–28.8%) and 14.1% (IC95%: 10.8–17.4%) respectively. The estimated prevalence of alcohol abuse was 75.4% (IC95%: 69–81.7%, BCSD = 12.2%, WCSD = 41.9%, intra class correlation (ICC): 7.8%). Conclusion Common mental disorders such as alcohol abuse, major depressive episode, anxiety symptoms and burnout syndrome presented higher rates in public transportation drivers than general population.

Nail haemorrhages in native highlanders of the Peruvian Andes

Nail haemorrhages are of interest to the chest physician and cardiologist. While the common type in the distal part of the nail is produced by the minor trauma of daily life, the rarer form—scattered through the nail substance—appears to be related to hypoxaemia brought about by heart and lung disease. We thought it would be of interest to study a population which was naturally hypoxaemic because of living at high altitude. Accordingly we have studied the frequency and types of nail haemorrhage in Quechua Indians who are permanently exposed to the hypobaric hypoxia of the Andes. We found the haemorrhages to be common both in mestizos living on the coastal plain and in the native highlanders. They appeared to increase in frequency with altitude but were of the distal type and would thus seem to be the result of minor trauma as at sea level. However, just as in cases of cyanotic congenital heart disease at low altitude, those with exaggerated hypoxaemia and pronounced elevation of haematocrit—namely, subjects with Monges disease (chronic mountain sickness)—had scattered haemorrhages in the nail substance.