Seguimiento y características clínicas de los pacientes con nódulos tiroideos en nuestra práctica clínica antes de 2015 / Follow-up and clinical characteristics of patients with thyroid nodules in our clinical practice before 2015

INTRODUCCIÓN: Los nódulos tiroideos son una consulta muy prevalente en Endocrinología. Las guías de la Asociación Americana de Tiroides (2015) animaban a realizar estudios a largo plazo. El objetivo de este estudio fue revisar las características, el seguimiento y la evolución de los nódulos de tiroides seguidos en nuestras consultas hasta 2015. MATERIAL Y MÉTODOS: Estudio retrospectivo de pacientes con al menos dos ecografías o cirugía. Los datos clínicos, ecográficos y de punción, así como la evolución y los resultados histológicos de aquellos operados, se analizaron con métodos descriptivos, bivariados y de regresión. RESULTADOS: 1.420 pacientes seguidos en Endocrinología a largo plazo fueron incluidos. 20 se excluyeron por tener una sola ecografía. El 71,2% presentaban normofunción, 9,6% hipertiroidismo subclínico, 9,5% hipotiroidismo subclínico, 5,7% hipotiroidismo clínico y 4% hipertiroidismo clínico. Del total de nódulos seguidos (n= 1400), 64,1%, 15,6% y 20,3% permanecieron estables, aumentaron y disminuyeron respectivamente. Los que crecieron no tuvieron más características sospechosas en las ecografías. De los intervenidos (457 casos (32,6% del total), 207 fueron malignos (45,2%). 57% de ellos fueron diagnosticados e intervenidos durante el primer año, en la primera evaluación. La aparición de nódulos malignos en el resto de pacientes fue de 89 casos (6,3% de todos los nódulos seguidos, 38,3% de ellos, incidentalomas). La ecografía y la citología empleadas antes de la homogenización de los criterios diagnósticos tuvieron una baja sensibilidad y especificidad en nuestro medio. CONCLUSIONES: Más de la mitad de los cánceres de tiroides fueron diagnosticados en la evaluación inicial del nódulo tiroideo. Más de la mitad de los nódulos no operados en el primer año mantienen el mismo tamaño a largo plazo. No encontramos predictores clínicos del aumento de tamaño. El valor diagnóstico de la ecografía y PAAF sin unos criterios estandarizados homogéneos es bajo.

INTRODUCTION: Thyroid nodules are a very prevalent consultation in endocrinology. Guidelines from the American Thyroid Association (2015) encouraged to conduct follow-up studies in the long term. This study object was to review the clinical characteristics, follow-up and evolution of thyroid nodules visited in our consultations till 2015. MATERIAL AND METHODS: Retrospective study of patients that had at least two thyroid ultrasounds or had been operated. Clinical, ultrasound and FNA (fine needle aspiration) data as well as the evolution and histology results of those operated, were analyzed with descriptive, bivariated and regression analyses. RESULTS: 1.420 patients followed in Endocrinology in the long term were included. 20 were excluded for having only one ecography. 71,2% had normal function, 9,6% subclinical hyperthyroidism, 9,5% subclinical hypothyroidism, 5,7% clinical hypothyroidism and 4% clinical hyperthyroidism. Of all the nodules followed (n=1400), 64,1%, 15,6% and 20,3% remained the same size, grew and decreased respectively. Nodules that grew didn´t have more suspicious sonographic characteristics. Of the operated nodules (457 cases (32,6% of all), 207 were cáncer (45,2%). 57% of them were diagnosed and intervened during the first year, in the first evaluation. Malignant nodules were detected in the rest of patients in 89 cases (6,3% of all the followed nodules, 38,3% of them were incidental cases). The ultrasound and citology diagnoses used before the homogenization of diagnoses criteria had a low senitivity and specificity in our clinical environment. CONCLUSIONS: More than half of the thyroid cancers were diagnosed in the initial evaluation of the thyroid nodule. More than half of nodules non operated in the first year remained the same size long term. We could not find clinical predictors of growth. The diagnostic value of the ultrasound and FNA is low without standardized and homogenous criteria.

Usos del láser terapéutico en Odontopediatría: Revisión de la literatura. Reporte de casos / Uses of Therapeutic Laser in Pediatric Dentistry: Review of the Literature. Case Reports

RESUMEN El término "LÁSER" es un acrónimo de "Light Amplification by the Stimulated Emission of Radiation" (en español "Amplificación de Luz por Emisión Estimulada de Radiación"). La utilización de la tecnología láser en Odontología ha tenido una constante evolución y desarrollo en los últimos 30 años. Se deben distinguir dos grandes grupos de láseres: De alta potencia o quirúrgicos y de baja potencia o terapéuticos. El más empleado en odontología pediátrica es el terapéutico o LLLT (o "blando"). El láser terapéutico está indicado para diversas anomalías tales como la hipersensibilidad, gingivitis, herpes, parestesias, neuralgias del trigémino, trismus, disfunción ATM, implantes, activación de químicos de blanqueamiento dental, entre otros. Este artículo pretende realizar una actualización de las aplicaciones del láser de baja potencia en el ámbito de la Odontología Pediátrica, así como la presentación de 4 casos clínicos representativos.

ABSTRACT The term "LASER" is an acronym for "Light Amplification by the Stimulated Emission of Radiation" (in Spanish "Amplificación de Luz por Emisión Estimulada de Radiación"). The use of laser technology in dentistry has had a constant evolution and development in the last 30 years. Two large groups of lasers should be distinguished: high-power or surgical and low-power or therapeutic. The most used in pediatric dentistry is the therapeutic or LLLT (or "soft"). The therapeutic laser is indicated for various anomalies such as hypersensitivity, gingivitis, herpes, paresthesias, trigeminal neuralgias, trismus, TMJ dysfunction, implants, activation of teeth whitening chemicals, among others. This article intends to perform an update of the applications of low power laser in the field of Pediatric Dentistry, as well as the presentation of 4 representative clinical cases.

Histopathologic findings in children diagnosed with cow's milk protein allergy.

BACKGROUND: Cow's milk protein allergy is the most common cause of food allergy. The challenge test, either open or doubled-blind with a placebo control, is regarded as the criterion standard. Endoscopy and histologic findings are considered a method that can aid in the diagnosis of this entity. AIMS: The aim of this study was to describe the histopathologic findings in children suspected of cow's milk protein allergy that were seen at our hospital. MATERIAL AND METHODS: A descriptive, observational study was conducted on 116 children clinically suspected of presenting with cow's milk protein allergy that were seen at the Department of Gastroenterology and Nutrition of the Instituto Nacional de Pediatría. Upper endoscopy and rectosigmoidoscopy with biopsies were performed and the findings were described. RESULTS: Of the 116 patients, 64 (55.17%) were girls and 52 (44.83%) were boys. The rectum was the site with the greatest presence of eosinophils per field in both groups, followed by the duodenum. In general, more than 15 eosinophils were found in 46% of the patients. CONCLUSIONS: Between 40 and 45% of the cases had the histologic criterion of more than 15 to 20 eosinophils per field and the rectosigmoid colon was the most affected site. Therefore, panendoscopy and rectosigmoidoscopy with biopsy and eosinophil count are suggested.

Brote de queratoconjuntivitis epidémica en un Servicio de Oftalmología / A nosocomial outbreak of epidemic keratoconjunctivitis

We describe a nosocomial outbreak of keratoconjunctivitis at the Ophthalmology Clinic in Hospital Carlos Van Buren, that affected 150 patients, during August and September of 2006. This outbreak was concomitant with a community outbreak produced by the same agent in the city of Valparaiso that affected 681 other patients. Although adenovirus was not isolated in the nosocomial cases, positive cultures were obtained from community cases, so the diagnosis was based on clinical and epidemiological criteria. The infection rate within the Clinic patients was 5.2 percent considering the population that attended the Clinic in this period. The evaluation of patient care practices showed that common risk factors among affected cases were measurement of ocular tension with a tonometer in the Ophthalmology Clinic (without disinfection of the tonometer between patients), contamination of work surfaces (equipment, furniture), and poor compliance of hand hygiene. Control measures adopted were cleaning, disinfection of tonometer, equipment and work surfaces, and reinforcement of hand hygiene measures. With these measures, it was possible to control the nosocomial outbreak, despite the continued outpatient care of community-acquired cases.

Se describe un brote nosocomial de queratoconjun-tivitis epidémica en la Policlínica de Oftalmología del Hospital Carlos Van Burén, que afectó a 150 pacientes, durante los meses de agosto y septiembre de 2006. Este brote se presentó en el contexto de un brote en la ciudad de Valparaíso que afectó a otros 681 pacientes. Aun cuando no se logró aislar adenovirus (ADV) en los casos nosocomiales, se aisló ADV en pacientes del brote comunitario, por lo que el diagnóstico de los casos nosocomiales se basó en criterios clínicos y epidemiológicos. La tasa de ataque del brote nosocomial fue de 5,2 por ciento considerando la población consultante del período. La evaluación de prácticas de atención directa mostró que los factores de riesgo de los casos serían la medición de la tensión ocular mediante tonómetro en la Policlínica de Oftalmología (sin desinfección del tonómetro entre paciente y paciente), contaminación de superficies de trabajo (equipos, mobiliario) y bajo cumplimiento de la higienización de manos. Las medidas de control fueron limpieza, desinfección del tonómetro, equipos y superficies de trabajo, junto a reforzamiento de lavado de manos. Con estas medidas se logró controlar el brote intrahospitalario a pesar de mantenerse las consultas provenientes del brote en la comunidad.

[A nosocomial outbreak of epidemic keratoconjunctivitis]. / Brote de queratoconjuntivitis epidémica en un Servicio de Oftalmología.

We describe a nosocomial outbreak of keratoconjunctivitis at the Ophthalmology Clinic in Hospital Carlos Van Buren, that affected 150 patients, during August and September of 2006. This outbreak was concomitant with a community outbreak produced by the same agent in the city of Valparaiso that affected 681 other patients. Although adenovirus was not isolated in the nosocomial cases, positive cultures were obtained from community cases, so the diagnosis was based on clinical and epidemiological criteria. The infection rate within the Clinic patients was 5.2% considering the population that attended the Clinic in this period. The evaluation of patient care practices showed that common risk factors among affected cases were measurement of ocular tension with a tonometer in the Ophthalmology Clinic (without disinfection of the tonometer between patients), contamination of work surfaces (equipment, furniture), and poor compliance of hand hygiene. Control measures adopted were cleaning, disinfection of tonometer, equipment and work surfaces, and reinforcement of hand hygiene measures. With these measures, it was possible to control the nosocomial outbreak, despite the continued outpatient care of community-acquired cases.

Inhibitory effect of nordihydroguaiaretic acid on the frequency of micronuclei induced by methyl methanesulfonate in vivo.

Nordihydroguaiaretic acid (NDGA) is an antioxidant originally obtained from plants of the genus Larrea. This chemical has shown antigenotoxic activity measuring gene mutations and sister-chromatid exchanges. The aim of this investigation was to determine if NDGA is also an antigenotoxic agent and can inhibit the induction of micronucleus (MN) formation by methyl methanesulfonate (MMS) in mouse. The frequency of micronucleated polychromatic erythrocytes (MPE) was scored for 4 days, and a MN induction curve by a single injection of MMS (40 mg/kg) was obtained. The results of this experiment showed that the highest MN incidence was reached at the second day of exposure with a mean of 13.2%+/-1.0. This value is more than 4 times the control mean. Thus, the modulatory study by NDGA was established at a 2-day exposure time using three doses (6.0, 11.0, and 17.0 mg/kg) against the damage induced by 40 mg/kg of MMS. The results of this study showed a significant reduction of the clastogenic damage at the two highest doses, where the inhibitory values corresponded to 62.2% and 66.7%, respectively. With respect to the ratio polychromatic erythrocytes/normochromatic erythrocytes, a marked toxicity was detected with 2 days of MMS exposure; however, the combination of the two high doses of NDGA plus MMS significantly reduced the cytotoxic damage produced by MMS alone.

In vivo and in vitro antigenotoxic effect of nordihydroguaiaretic acid against SCEs induced by methyl methanesulfonate.

Nordihydroguaiaretic acid (NDGA) is a phenolic lignan which has shown to cause a variety of actions potentially useful for human health; therefore, in this investigation we determined its capacity for inhibiting the rate of sister chromatid exchanges (SCEs) induced by methyl methanesulfonate (MMS). We tested the effect of 0.25, 0.50, 1.0, and 2.0 microM of NDGA on the damage exerted by 55 microM of MMS. Cultured human lymphocytes from two female donors were used for the experiment. The best result concerning its modulatory action was obtained with 1.0 microM of NDGA; with this dose the mean inhibitory index including both donors reached 68.2%. The values obtained for the mitotic and proliferative indexes were not significantly modified with respect to the basal data. We also used the mouse bone marrow in vivo system to evaluate the inhibitory effect of the chemical. In this study we tested 1.0, 6.0, and 11.0 mg/kg of NDGA intraperitoneally (i.p.) administered 1 h before an i.p. injection of MMS (40 mg/kg). The best inhibitory index in this model corresponded to the dose of 11 mg/kg of NDGA (86.9%). The mitotic index and the average generation time showed no significant variation with respect to the control data. Our study established that NDGA produces antigenotoxic action in mammalian cells in vitro and in vivo.

Containing health costs in the Americas.

In recent years, a series of policy measures affecting both demand and supply components of health care have been adopted in different Latin American and Caribbean countries, as well as in Canada and the United States. In applying these measures various objectives have been pursued, among them: to mobilize additional resources to increase operating budgets; to reduce unnecessary utilization of health services and consumption of pharmaceuticals; to control increasing production costs; and to contain the escalation of health care expenditures. In terms of demand management, some countries have established cost-recovery programmes in an attempt to offset declining revenues. These measures have the potential to generate additional operating income in public facilities, particularly if charges are levied on hospital care. However, only scant information is available on the effects of user charges on demand, utilization, or unit costs. In terms of supply management, corrective measures have concentrated on limiting the quantity and the relative prices of different inputs and outputs. Hiring freezes, salary caps, limitations on new construction and equipment, use of drug lists, bulk procurement of medicines and vaccines, and budget ceilings are among the measures utilized to control production costs in the health sector. To moderate health care expenditures, various approaches have been followed to subject providers to 'financial discipline'. Among them, new reimbursement modalities such as prospective payment systems offer an array of incentives to modify medical practice. Cost-containment efforts have also spawned innovations in the organization and delivery of health services. Group plans have been established on the basis of prepaid premiums to provide directly much or all health care needs of affiliates and their families. The issue of intrasectorial co-ordination, particularly between ministries of health and social security institutions, has much relevance for cost containment. In various countries, large-scale reorganization processes have been undertaken to eliminate costly duplications of resources, personnel, and services that resulted from the multiplicity of providers in the public subsector. Given the pluralistic character of the region's health systems, an important challenge for policy-makers is to find ways to redefine the role of state intervention in health from the simple provision of services to one that involves the 'management' of health care in the entire sector.

Alergia y parásitos: una asociación disociable / Alergy and parasities: an asociation dissoluble

Estudios epidemiológicos han intentado evaluar como las infecciones parasitarias por helmintos puede modular la respuesta alérgica, generando importantes controversias. En este estudio se observó una significativa prevalencia de enfermedades alérgicas (rinitis y asma bronquial en individuos infectados por helmintos)