Características clínico-oftalmológicas y evolución de los pacientes con oftalmopatía tiroidea activa moderada severa tratados con bolos de metilprednisolona que acuden al Hospital Central del Instituto de Previsión Social, Paraguay / Clinical-ophthalmological characteristics and evolution of patients with moderately severe active thyroid ophthalmopathy treated with methylprednisolone boluses who attended the Central Hospital of the Instituto de Previsión Social, Paraguay

Introducción: La oftalmopatía tiroidea (OT) es un trastorno debilitante en pacientes con enfermedad tiroidea autoinmune, principalmente enfermedad de Graves, que se desarrolla entre el 30 a 50% de los casos. Objetivos: Describir las características clínico-oftalmológicas y la evolución de los pacientes con oftalmopatía tiroidea activa moderada severa tratados con bolos de metilprednisolona que acuden al Hospital Central del Instituto de Previsión Social en el tiempo comprendido entre enero de 2018 y setiembre de 2021. Materiales y métodos: Investigación de diseño observacional, con estudio descriptivo, retrospectivo. Resultados: Se revisaron fichas de 34 pacientes con OT activa moderada severa que recibieron bolos de metilprednisolona basado en las guías EUGOGO 2016, de los cuáles se excluyeron 3 pacientes por tener fichas incompletas y otros 3 pacientes ya que requirieron tratamiento de segunda línea previo al término del esquema de 12 sesiones. De los 28 pacientes estudiados, la edad promedio fue de 43,6 ±13,1 años, el 89% de sexo femenino y el 28,5%, fumadores. En cuanto a la función tiroidea de la población previo al tratamiento, se constató hipertiroidismo en el 82%, hipotiroidismo en el 11% y eutiroidismo en el 7%; y posterior al tratamiento, se constató hipertiroidismo en el 78,6% (subclínico), eutiroidismo en el 17,9% e hipotiroidismo en el 3,5%. La mayoría (92.6%) contaba con anticuerpos contra el receptor de TSH positivo, con un promedio de 18 ± 9,9 mIU/Ml. Respecto a la actividad de la oftalmopatía según la escala CAS, se constató un promedio de 4,1 ±1,0 previo al tratamiento y posterior 1,2 ±1,4; de ellos el 46,4% presentó un estado leve según escala de gravedad, 39% sin criterios de gravedad y 14 % persistió en moderada -severa. Se constató mejoría de la agudeza visual tras el tratamiento (57,1%), el promedio de exoftalmía previo al tratamiento fue 22,2 mm y posterior 21,1 mm; se presentó diplopía en el 7,1% previo al tratamiento y en el 3,6% posterior al tratamiento. Conclusión: El tratamiento con glucocorticoides endovenosos en la oftalmopatía de Graves moderada-severa (esquema EUGOGO 2016) fue muy efectivo, revirtiendo la actividad y consecuentemente ayudando a disminuir la gravedad, en la gran mayoría de nuestros pacientes. Esto podría explicarse porque la oftalmopatía era incipiente y por el alto grado de adherencia de los pacientes en el contexto de un manejo multidisciplinar bien protocolizado.

Introduction: Graves' orbitopathy (GO) is a debilitating disorder in patients with autoimmune thyroid disease, mainly Graves' disease, which develops in 30 to 50% of cases. Objectives: To describe the clinical-ophthalmological characteristics and evolution of patients with moderate-to- severe active GO treated with methylprednisolone boluses who attended the Central Hospital of the Institute of Social Security between January 2018 and September 2021. Materials and methods: Observational design research, descriptive, retrospective study. Results: Records of 34 patients with active moderate-to-severe GO who received boluses of methylprednisolone based on the EUGOGO 2016 guidelines, were reviewed, of which 3 patients were excluded due to having incomplete records and another 3 patients since they required second-line treatment prior to end the 12-session scheme. Of the 28 patients studied, the average age was 43.6 ±13.1 years, 89% were female and 28.5% were smokers. Regarding the thyroid function of the population prior to treatment, hyperthyroidism was found in 82%, hypothyroidism in 11% and euthyroidism in 7%; and after treatment, hyperthyroidism was found in 78.6% (subclinical), euthyroidism in 17.9% and hypothyroidism in 3.5%. The majority (92.6%) had positive thyrotropin receptor antibodies, with an average of 18 ± 9.9 mIU/Ml. Regarding the activity of orbitopathy according to the CAS scale, an average of 4.1 ±1.0 was found before treatment and 1.2 ±1.4 after; Of them, 46.4% presented a mild condition according to the severity scale, 39% without severity criteria and 14% persisted in moderate-severe. Improvement in visual acuity was noted after treatment (57.1%), the average exophthalmia before treatment was 22.2 mm and after 21.1 mm; Diplopia occurred in 7.1% before treatment and in 3.6% after treatment. Conclusion: Treatment with intravenous glucocorticoids in moderate-severe Graves' orbitopathy (EUGOGO 2016 scheme) was very effective, reversing the activity and consequently helping to reduce the severity, in the vast majority of our patients. This could be explained because the orbitopathy was incipient and by the high degree of patient adherence in the context of well-protocolized multidisciplinary management.

Metastases-directed stereotactic body radiotherapy in combination with targeted therapy or immunotherapy: systematic review and consensus recommendations by the EORTC-ESTRO OligoCare consortium.

Stereotactic body radiotherapy (SBRT) for patients with metastatic cancer, especially when characterised by a low tumour burden (ie, oligometastatic disease), receiving targeted therapy or immunotherapy has become a frequently practised and guideline-supported treatment strategy. Despite the increasing use in routine clinical practice, there is little information on the safety of combining SBRT with modern targeted therapy or immunotherapy and a paucity of high-level evidence to guide clinical management. A systematic literature review was performed to identify the toxicity profiles of combined metastases-directed SBRT and targeted therapy or immunotherapy. These results served as the basis for an international Delphi consensus process among 28 interdisciplinary experts who are members of the European Society for Radiotherapy and Oncology (ESTRO) and European Organisation for Research and Treatment of Cancer (EORTC) OligoCare consortium. Consensus was sought about risk mitigation strategies of metastases-directed SBRT combined with targeted therapy or immunotherapy; a potential need for and length of interruption to targeted therapy or immunotherapy around SBRT delivery; and potential adaptations of radiation dose and fractionation. Results of this systematic review and consensus process compile the best available evidence for safe combination of metastases-directed SBRT and targeted therapy or immunotherapy for patients with metastatic or oligometastatic cancer and aim to guide today's clinical practice and the design of future clinical trials.

Visibilización y Atención Socio-Sanitaria a la Diversidad Sexual, Corporal y de Género / Visibility and Socio-Health Care for Sexual, Corporal and Gender Diversity

La escasa formación del personal sanitario sobre las necesidades y desigualdades en salud de las personas LGBTIAQ+(lesbianas, gays, bisexuales, trans, intersex, asexuales, queer y otras) hace necesaria la celebración de sesiones de formación específicas en materia de despatologización y derechos humanos. La aprobación de la Ley 2/2014, de 8 de julio, integral de no discriminación por motivo de identidad de género y reconocimiento de los derechos de las personas transexuales en Andalucía y la publicación de los Procesos Asistenciales Integrados Atención sanitaria a personas transexuales adultas / en la infancia y adolescencia tienen el objetivo de garantizar el derecho a la autodeterminación de género. Junto con la Ley 8/2017, de 28 de diciembre, para garantizar los derechos, la igualdad de trato y no discriminación de las personas LGTBI y sus familiares en Andalucía, se establece una protección de personas deorientaciones sexuales, expresiones / identidades de géneros y características sexuales diversas en el ámbito andaluz. El objetivo de esta sesión es la de formar y concienciar a profesionales de las Ciencias de la Salud del cambio de paradigma en la atención sanitaria a personas LGTBIAQ+, además de proporcionar estrategias para una atención sanitaria basada en la despatologización y los derechos humanos. (AU)

Enfermedad periodontal en Latinoamérica: enfoque regional y estrategia sanitaria

La periodontitis es una enfermedad crónica de tipo no transmisible, caracterizada por ser inflamatoria, infecciosa y multifactorial. Es una de las enfermedades más prevalentes en cavidad oral hasta el punto de ser considerada una epidemia. Esta condición se puede prevenir y tratar; sin embargo, las medidas sanitarias siguen siendo insuficientes para lograr un control efectivo en la práctica clínica. La progresión de la periodontitis se basa en la presencia de un microbioma disbiótico que desencadena una respuesta inflamatoria del huésped, lo cual se traduce clínicamente en la pérdida del tejido de soporte dental y provoca su pérdida. Cabe destacar la importancia del conocimiento sobre la relación existente entre la enfermedad periodontal y la salud sistémica, la bidireccionalidad y la necesidad del manejo multidisciplinario. La periodontitis representa un problema para la salud pública de los países de Latinoamérica y es responsabilidad que los estados gubernamentales, así como de todo el personal sanitario, ejecutar estrategias de salud con el fin de reducir el impacto de la enfermedad en las poblaciones más vulnerables. El objetivo del presente ensayo es analizar los factores por los cuales la enfermedad periodontal sigue siendo altamente prevalente y, así mismo, promover la prevención de la enfermedad y medidas de control.

Periodontitis is a chronic, non-communicable disease characterized by being inflammatory, infectious, and multifactorial. It is one of the most prevalent diseases in the oral cavity to the point of being considered an epidemic. This condition can be prevented and treated; however, sanitary measures are still insufficient to achieve effective control in clinical practice. The progression of periodontitis is based on the presence of a dysbiotic microbiome that triggers an inflammatory response in the host, which translates clinically into the loss of dental support tissue, in turn causing its loss. It is worth highlighting the importance of knowledge about the relationship between the periodontal disease and systemic health, bidirectionality and the need for multidisciplinary management. Periodontitis represents a public health problem in Latin American countries and it is the responsibility of government states, as well as all health workers, to implement health strategies in order to reduce the impact of this disease on the most vulnerable populations. The aim of this essay is to analyze the factors by which periodontal disease continues to be highly prevalent in Latin America and, furthermore, to promote disease prevention and control measures.

Riesgo de recurrencia y factores de riesgo de invasión del cáncer diferenciado de tiroides / Risk of recurrence and risk factors for invasion of differentiated thyroid cancer

Introducción: El cáncer diferenciado de tiroides (CDT) se encuentra representado por el carcinoma papilar y el carcinoma folicular. Comprende la gran mayoría (>90%) de todos los cánceres de tiroides. Objetivos: Estratificar el riesgo de recurrencia inicial de los pacientes con CDT. Relacionar la edad, sexo y tamaño tumoral con el riesgo de recurrencia, invasión capsular, ganglionar, vascular y de tejido peritiroideo. Materiales y métodos: Estratificar el riesgo de recurrencia inicial de los pacientes con CDT. Relacionar la edad, sexo y tamaño tumoral con el riesgo de recurrencia, invasión capsular, ganglionar, vascular y de tejido peritiroideo. Resultados: El 87% fueron del sexo femenino. La edad media fue de 43±14 años. Predominó el riesgo de recurrencia bajo en el 49% de los pacientes, seguido del riesgo intermedio (33%) y riesgo alto (18%). El tamaño tumoral ˃1cm confiere mayor riesgo de ser estratificado como riesgo de recurrencia intermedio/alto (OR 5,7 IC 95% 3,6-9). El sexo masculino representó mayor riesgo de invasión ganglionar (OR 2,8 IC 95% 1,2-6,6); la edad ≥55 años lo fue en la invasión vascular (OR 2,1 IC 95% 1,1-4,1); el tamaño >1cm constituyó un mayor riesgo de manera significativa de invasión capsular (OR 10,5 IC 95% 6,5-17), invasión ganglionar (OR 10,2 IC 95% 3,8-26,9), invasión vascular (OR 30,7 IC 95% 4,2-224) e invasión de tejido peritiroideo (OR 5,2 IC 95% 3,3-8,2). Conclusión: El riesgo de recurrencia inicial más frecuente fue el riesgo bajo. El sexo masculino, la edad ≥55años y el tamaño >1cm constituyen factores de riesgo de invasión a estructuras vecinas.

Introduction: Differentiated thyroid cancer (DTC) is represented by papillary carcinoma and follicular carcinoma. It comprises the vast majority (> 90%) of all thyroid cancers. Objectives: Stratify the risk of initial recurrence of patients with DTC. Relate age, sex, and tumor size to the risk of recurrence, capsular, nodal, vascular, and perithyroid tissue invasion. Materials and methods: Observational, descriptive, retrospective, cross-sectional study with an analytical component. A total of 432 patients with a diagnosis of DTC from Hospital de Clínicas, Instituto de Previsión Social and Instituto Nacional del Cáncer between 2011 and 2015 were included. Results: 87% were female. The mean age was 43 ± 14 years. Low recurrence risk predominated in 49% of patients, followed by intermediate risk (33%) and high risk (18%). Male sex, age ≥55 years and tumor size ˃1cm confer a higher risk of being stratified as intermediate / high recurrence risk, but only size> 1cm was significantly (OR 5.7 95% CI 3.6-9). Male sex represented a higher risk of lymph node invasion (OR 3.1 95% CI 1.4-2.8) and vascular invasion (OR 2.3 95% CI 1.1-4.8); age ≥55 years was in the vascular invasion (OR 2.6 95% CI 1.4-4.9); size> 1cm constituted a significantly higher risk of capsular invasion (OR 10.7 95% CI 6.7-17.3), nodal invasion (OR 10.5 95% CI 4-27.7), vascular invasion (OR 33 95% CI 4.5-244) and invasion of perithyroid tissue (OR 5.1 95% CI 3.2-8.1). Conclusion: The most frequent initial recurrence risk was low risk. Male sex, age ≥55 years, and size> 1cm are risk factors for invasion of neighboring structures.

Análisis Microbiológico del Fluido Crevicular para Determinar Presencia de Candida albicans en Bolsas Periodontales de Sujetos Adultos

RESUMEN: El objetivo de este trabajo fue establecer la asociación entre la profundidad de bolsa periodontal y la presencia de Candida albicans en el fluido crevicular de sujetos adultos con salud gingival y periodontitis, recibidos en el área de la Maestría en Periodoncia de un Centro Odontológico. El estudio estuvo conformado por 81 muestras de fluido crevicular obtenidas con un cono de papel Nº 40. Fueron distribuidas en tres grupos: G1: 20 muestras del grupo control (salud gingival), G2: 32 muestras de bolsas con profundidad de 4-6 mm y G3: 29 muestras de bolsas con profundidad >6mm; que fueron colocadas en Caldo Sabouraud Dextrosa para su trasporte al laboratorio, donde fue cultivado en Agar Sabouraud Dextrosa por 48 h a 37 ºC. Posteriormente se realizó tinción a las colonias y prueba de tubo germinal para la confirmación de la presencia de Candida albicans. Del total de muestras, 12 (14,8 %) evidenciaron presencia de Candida albicans, de las cuales 6 (18,8 %) pertenecían al grupo de bolsas con profundidad de 4-6 mm y las otras 6 (20,7 %) pertenecían al grupo de bolsas con profundidad >6mm. En el grupo control, no se observó presencia de Candida albicans. Los pacientes con salud gingival no presentaron Candida albicans. Sin embargo, la Candida albicans estuvo presente en pacientes con bolsas periodontales de 4-6 mm y >6 mm (14,8 %). No se encontró diferencia estadísticamente significativa entre presencia de Candida albicans con profundidad de bolsa periodontal (p=0,849).

ABSTRACT: The aim of this work was to establish the association between the depth of the periodontal pocket and the presence of Candida albicans in the crevicular fluid of adult subjects with gingival health and periodontitis, received in the area of the Master in Periodontology of a Dental Center. The study consisted of 81 samples of crevicular fluid obtained with a No. 40 paper cone. They were distributed into three groups: G1: 20 samples from the control group (gingival health), G2: 32 samples from pockets with depth of 4-6 mm and G3: 29 samples from pockets with depth >6 mm; which were placed in Sabouraud Dextrose Broth for transport to the laboratory, where it was cultivated in Sabouraud Dextrose Agar for 48h at 37 ºC. Subsequently, colony staining and a germ tube test were performed to confirm the presence of Candida albicans. Of the total samples, 12 (14.8 %) showed the presence of Candida albicans, of which 6 (18.8 %) belonged to the group of pockets with depth of 4-6 mm and the other 6 (20.7 %) belonged to the group of bags with depth> 6mm. In the control group, no presence of Candida albicans was observed. The patients with gingival health did not present Candida albicans. However, Candida albicans was present in patients with periodontal pockets of 4-6 mm and >6 mm (14.8 %). No statistically significant difference was found between the presence of Candida albicans with depth of the periodontal pocket (p=0.849).

Histiocitosis de células de langerhans. Un hallazgo poco común en la glándula tiroides. A propósito de un caso / Langerhans cell histiocytosis. A rare finding in the thyroid gland. About a case

La histiocitosis de células de Langerhans (HCL) es una neoplasia mieloide, poco común, se caracteriza por la proliferación de células histiocíticas CD1a+/Langerina+. La incidencia en adultoses1 a 2 casos por millón,unpoco más frecuente en niños. La presentación es variable, como una única lesión en un órgano hasta una enfermedad multisistémica con toque de órganos vitales. Los tejidos de mayor afinidad son: huesos, piel, pulmones e hipófisis y raramente tiroides.El retraso en el diagnóstico o en el tratamiento puede provocar un deterioro de la función de los órganos afectados. El objetivo de la comunicación es reportar un caso de HCL, de presentación aún menos frecuente, en forma aislada en la glándula tiroides de un adulto, hallazgo hecho tras una tiroidectomía total, realizándose el diagnóstico luego de la histología.

Langerhans cell histiocytosis (LCH) is a rare myeloid neoplasm characterized by the proliferation of CD1a+/Langerin+ histiocytic cells. The incidence in adultsis1 to 2 cases per million, a little more frequent in children. The presentationis variable, as a single lesion in an organ to a multisystemic disease with touch of vital organs. The tissues with the highest affinity are: bones, skin, lungs and pituitary and rarely thyroid. Delay in the diagnosis or in the treatment can cause a deterioration in thefunction of the affected organs. The objective of the communication is to report a case of LCH, with an even less frequent presentation, isolated formin the thyroid gland of an adult, a finding made after a total thyroidectomy, the diagnosis being made after histology.

Interrupción del tallo hipofisario como causa poco frecuente de amenorrea primaria / Pituitary stalk disruption as a rare cause of primary amenorrhea

El síndrome de interrupción del tallo hipofisario es una anomalía congénita de probable origen genético causante de hipopituitarismo, que radiológicamente se caracteriza por hipoplasia de la adenohipófisis, neurohipófisis ectópica e interrupción del tallo hipofisario. Suele presentarse con baja estatura y deficiencia de hormonas adenohipofisarias. El retraso en el diagnóstico se relaciona con alta morbimortalidad. Se reporta el caso de una mujer de 24 años que consulta por amenorrea primaria. Presentaba talla baja y ausencia de caracteres sexuales secundarios, con genitales infantiles. Los exámenes paraclínicos mostraron compromiso de dos ejes hipofisarios. Una resonancia magnética nuclear mostró hallazgos consistentes con síndrome de interrupción de tallo hipofisario.

Pituitary stalk disruption syndrome is a congenital abnormality of probable genetic origin that causes hypopituitarism, which is radiologically characterized by adenohypophysis hypoplasia, ectopic neurohypophysis, and pituitary stalk disruption. It usuallypresents with short stature and adenohypophyseal hormone deficiency. The delay in diagnosis is related to high morbidity and mortality. The case of a 24-year-old woman who consulted for primary amenorrhea is reported. She had short stature and no secondary sexual characteristics, with infantile genitalia. Paraclinical examinations showed involvement of two pituitary axes. An MRI scan showed findings consistent with pituitary stalk disruption syndrome.

Síndrome de Hirata, causa poco frecuente de hipoglucemia / Hirata syndrome, a rare cause of hypoglycemia

Mujer de 32 años, asmática en tratamiento irregular con prednisona (ultima dosis hace 1 mes), Enfermedad de Graves Basedow desde hace 3 años, reiniciótratamiento hace 3 meses (metimazol 40 mg/día), antecedente de aborto dos semanas previas al ingreso. Acude por pérdida del conocimiento, constatándose hipoglucemia. Al persistir el cuadro de hipoglucemia a pesar del tratamiento instaurado y descartadas otras causas etiológicas, la evaluación endocrinológica confirma hipoglucemia autoinmune, niveles de autoanticuerpos contra la insulina e insulina extremadamente elevados.

A 32-year-old woman, asthmatic on irregular treatment with prednisone (last dose 1 month ago), Graves Basedow's disease for 3 years, restartedtreatment 3 months before(methimazole 40 mg / day).History of abortion two weeks prior to admission. She came for loss of consciousness, finding hypoglycemia. As hypoglycemia persists despite the treatment instituted and other etiological causes ruled out, the endocrinological evaluation confirms autoimmune hypoglycemia,autoantibody levelsagainst insulinandextremely high insulin.

Correlación entre el Diagnóstico Clínico y Radiográfico de Sujetos Adultos con Erupción Pasiva Alterada

RESUMEN: El objetivo de este estudio fue determinar la correlación entre el diagnóstico clínico y radiográfico de sujetos adultos con erupción pasiva alterada. La muestra estuvo conformada por los incisivos centrales del cuadrante I de 30 sujetos adultos. Se registraron 2 mediciones clínicas: longitud de corona clínica y distancia del margen gingival (MG) a la unión cemento esmalte (UCE); y 2 mediciones radiográficas: longitud de corona anatómica y distancia del MG-UCE. Para diagnosticar EPA, se comparó el promedio de la resta entre corona anatómica y corona clínica; con el valor hipotético ( ³ 2,5 mm según Zucchelli). La muestra estuvo conformada por: 36,7 % incisivos de sujetos de sexo masculino y 63,3 % de sexo femenino; con la edad media de 25,17 años. Clínicamente, se obtuvo la media de 8,5 mm para longitud de corona clínica y 2,267 mm para sondaje MG-UCE. Radiográficamente, se obtuvo la media de 10,767 mm para longitud de la corona radiográfica y 2,47 mm para MG-UCE. Según la Rho de Spearman, el sondaje MG-UCE (clínico) con MG-UCE (radiográfico) no muestra una correlación estadísticamente significativa (p=0,227), sin embargo, al comparar la media (2,48 mm) con el valor hipotético (³2,5 mm) según la prueba t de una muestra, se determina que no existe diferencia estadísticamente significativa (p=0,864) entre ambos resultados. La radiografía con técnica paralela de Zucchelli es una excelente alternativa para un adecuado diagnóstico diferencial de la erupción pasiva alterada; de manera simple, económica y reproducible para el beneficio de clínicos y pacientes.

ABSTRACT: The aim of the study was to determine the correlation between the clinical and radiographic diagnosis of adult subjects with altered passive eruption. The population consisted of the central incisors of quadrant I of 30 adult subjects. Two clinical measurements were recorded: length of clinical crown and distance from the gingival margin (GM) to the cementum enamel junction (CEJ); and 2 radiographic measurements: length of anatomical crown and distance from the GM-CEJ. To diagnose APE, the average of the subtraction between anatomical crown and clinical crown was compared; with the hypothetical value (³ 2.5 mm according to Zucchelli). The population were: 36.7 % incisors of male subjects and 63.3 % female; with the average age of 25.17 years. Clinically, the average was 8.5 mm for clinical crown length and 2,267 mm for GM-CEJ probing. Radiographically, the average 10.767 mm was obtained for the length of the radiographic crown and 2.47 mm for GM- CEJ. According to Spearman's Rho, the GM-CEJ (clinical) probing with GM-CEJ (radiographic) does not show a statistically significant correlation (p = 0.227), however, when comparing the average (2.48 mm) with the hypothetical value (³ 2.5 mm) according to the t-test of a sample, it is determined that there is no statistically significant difference (p = 0.864) between both results. The radiography with Zucchelli technique is an excellent alternative for an adequate differential diagnosis of altered passive eruption; in a simple, economical and reproducible way for the benefit of clinicians and patients.

Caracterización de pacientes con pie diabético en el servicio de urgencias del Hospital de Clínicas, Paraguay. Periodo 2015-2016 / Characterization of patients with diabetic foot in the emergency service of the Hospital de Clínicas, Paraguay. Period 2015-2016

Objetivo: determinar las características de los pacientes con diagnóstico de Pie Diabético en un servicio de Urgencias. Materiales y métodos: estudio retrospectivo, descriptivo, basado en la revisión de 525 historias clínicas de pacientes que acudieron al servicio de Urgencias-Adultos del Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Paraguay entre los años 2015 y 2016. Se recopilaron los siguientes datos: edad, sexo, comorbilidades, tratamiento, tipo de amputaciones, identificación del mecanismo y lugar de inicio de lesiones; destino de los pacientes luego de Urgencias y mortalidad. Resultados: La frecuencia de Pie Diabético fue del 40% de 2718 pacientes con Diabetes;60% era del sexo masculino, el promedio de edad 63 años (±10);34 (65,3%) tenían antecedentes de hipertensión arterial; amputación previa 99 (18,9%);cardiopatía isquémica 56 (10,7%);accidente cerebro vascular 21(4%);tabaquismo 18 (3,4%). Recibieron tratamiento quirúrgico 274 (52%), de ellos 199 fueron amputaciones (73%); el 56% fueron amputaciones mayores;256 de 356 pacientes (72%) no identificaron un traumatismo causal de la lesión; 270 (51%) refirieron a los dedos como el lugar de inicio de lesiones. Hubo336 altas (64%) y 14 (2,67%) fallecieron. Conclusión: Se observó una alta frecuencia de pacientes con pie diabético en Urgencias, lo cual urge establecer programas estructurados para prevención y tratamiento multidisciplinario.

Objective: to determine the characteristicsof patients diagnosed with Diabetic Foot in an emergency service. Materials and methods: a retrospective, descriptive study, based on the review of 525 medical records of patients who attended the Emergency-Adult service of the Hospital de Clínicas, Faculty ofMedicine, National University of Asunción, Paraguay between the years 2015 and 2016. The following data were collected: age, sex, comorbidities, treatment, type of amputations, identification of the mechanism and place of initiation of injuries; destination of patients after emergencies and mortality. Results:The frequency of Diabetic Foot was 40% of 2718 patients with Diabetes, 60% were male, average age was 63 years (± 10),34 (65.3%) had a history of high blood pressure, previous amputation 99 (18.9%),ischemic heart disease 56 (10.7%), stroke 21 (4%), smoking 18 (3.4%),274 (52%) received surgical treatment, of which 199 were amputations (73%); 56% major amputations,256 of 356 patients (72%) did not identify a traumatic cause of the injury; 270 (51%) referred to the fingers as the place of initiation of lesions. There were 336 discharges (64%) and 14 patients (2.67%) died. Conclusion:High frequency of patients with diabetic foot in the Emergency Department, which makes it urgent to establish structured programs for prevention and multidisciplinary treatment.

Causa poco frecuente de insuficiencia suprarrenal. A propósito de un caso / A rare cause of adrenal insufficiency. A case report

Se presenta un caso de sarcoidosis que presentó afectación suprarrenal. Hombre de 44 años fue diagnosticado de sarcoidosis pulmonar y ganglionar según hallazgos clínicos, laboratoriales y anatomopatológicos. Tres años después acude por debilidad generalizada, náuseas, hiponatremia persistente, hipotensión arterial, pérdida de peso e hiperpigmentación cutánea. La evaluación endocrinológica confirma insuficiencia suprarrenal primaria, lo que sugiere la infiltración de la sarcoidosis en las glándulas suprarrenales.

We present a case of sarcoidosis that presented adrenal involvement. A 44-year- old man was diagnosed with pulmonary and lymph node sarcoidosis based on clinical, laboratory, and pathological findings. Three years later, he presented with generalized weakness, nausea, persistent hyponatraemia, arterial hypotension, weight loss, and skin hyperpigmentation. Endocrinologic evaluation confirms primary adrenal insufficiency, suggesting infiltration of sarcoidosis into the adrenal glands.

Factores de riesgo asociados a Pérdida de Sensibilidad Protectora en pacientes con Diabetes en la Unidad Multidisciplinaria de Pie Diabético / Risk factors associated with Loss of Protective Sensitivity in Diabetes patients in the Multidisciplinary Unit of Diabetic Foot

Introducción: Identificar factores de riesgo para pérdida de la sensibilidad protectora es fundamental para prevenir el Pie Diabético. Objetivos: Analizar los factores de riesgo asociados a la pérdida de la sensibilidad protectora en pacientes con diabetes mellitus y sus complicaciones. Materiales y métodos: diseño observacional, de casos y controles. Se incluyó pacientes de ambos sexos, con diabetes mellitus; ≥ 18 años, a quienes se realizó el Test de monofilamento en la Unidad Multidisciplinaria Hospital de Clínicas, de enero 2014 a julio 2019. Factores de riesgo considerados: edad, años de diabetes mellitus, Hba1c, HTA, dislipidemia; se tuvo en cuenta las complicaciones: retinopatía, enfermedad arterial periférica = ITB <0,9 derecho e izquierdo, enfermedad renal= ClCr <60 ml/min/m2 (MDRD), amputaciones (mayores y menores). Resultados: De 100 pacientes; 33% con pérdida de la sensibilidad protectora; edad 59±9,7 años; 55% masculino. Factores de riesgo: edad: 57,7±1,0 años sin pérdida de la sensibilidad protectora y 61,2±9 años con pérdida de la sensibilidad protectora, p=0.08; años de diabetes mellitus 9,4±8,4 vs 11,5± 8,7 p=0,20; HbA1C 8,8± 2,7% vs 9,1±2% p=0,50; HTA 63,5% vs 75,6% p=0,20; dislipidemias 75,9% vs 57,69%, p=0,09; complicaciones con pérdida de la sensibilidad protectora: retinopatía 88% vs 57,5% OR=1,67, p=0,02. ClCr 84±40,3 ml/min vs 90,9±30,4, p=0,40. Enfermedad arterial periférica derecha 27,78% vs 11,1% OR=0,1, p=0,10; enfermedad arterial periférica izquierda 20% vs 7 15,5% OR=1 p=0,60; amputación 17,5% vs 7,9% OR=2,01, p=0,06. Conclusión: con pérdida de la sensibilidad protectora: la edad, años de diabetes mellitus fueron mayores. HTA fue más frecuente y Hba1c más elevada; nefropatía, enfermedad arterial periférica y amputación con mayor frecuencia, todas no significativas. La retinopatía fue más frecuente en forma significativa.

Introduction: Identifying risk factors for loss of protective sensitivity is essential to prevent Diabetic Foot. Objectives: To analyze the risk factors associated with the loss of protective sensitivity in patients with diabetes mellitus and its complications. Materials and methods: observational, case-control design. Patients of both sexes were included, with diabetes mellitus; ≥ 18 years, who underwent the Monofilament Test in the Multidisciplinary Unit Hospital de Clínicas, from January 2014 to July 2019. Risk factors considered: age, years of diabetes mellitus, Hba1c, HT, dyslipidemia; Complications were taken into account: retinopathy, peripheral arterial disease = ABI <0.9 right and left, kidney disease = CrCl <60 ml / min / m2 (MDRD), amputations (major and minor). Results: Of 100 patients; 33% with loss of protective sensitivity; age 59 ± 9.7 years; 55% male. Risk factors: age: 57.7 ± 1.0 years without loss of protective sensitivity and 61.2 ± 9 years with loss of protective sensitivity, p = 0.08; years of diabetes mellitus 9.4 ± 8.4 vs 11.5 ± 8.7 p = 0.20; HbA1C 8.8 ± 2.7% vs 9.1 ± 2% p = 0.50; HTN 63.5% vs 75.6% p = 0.20; dyslipidemias 75.9% vs 57.69%, p = 0.09; complications with loss of protective sensitivity: retinopathy 88% vs 57.5% OR = 1.67, p = 0.02. CrCl 84 ± 40.3 ml / min vs 90.9 ± 30.4, p = 0.40. Right peripheral arterial disease 27.78% vs 11.1% OR = 0.1, p = 0.10; left peripheral arterial disease 20% vs 7 15.5% OR = 1 p = 0.60; 17.5% amputation vs 7.9% OR = 2.01, p = 0.06. Conclusion: with loss of protective sensitivity: age, years of diabetes mellitus were older. HBP was more frequent and Hba1c higher; nephropathy, peripheral arterial disease and amputation with greater frequency, all not significant. Retinopathy was significantly more frequent.

Prevalencia de Cáncer de Tiroides en Centros de Referencia del Paraguay / Prevalence of Thyroid Cancer in Reference Centers of Paraguay

Introducción: El Cáncer de tiroides es la neoplasia maligna más frecuente del sistema endócrino. Durante las últimas décadas se ha observado un aumento de su incidencia de forma progresiva en numerosos países y regiones del mundo. Objetivos: Determinar la prevalencia de Cáncer de tiroides y, los tipos histológicos, en 3 hospitales de referencia en Paraguay. Materiales y métodos: Estudio observacional, descriptivo, retrospectivo, de corte transversal. Se incluyó a todos los pacientes sometidos a tiroidectomía parcial o total en el Hospital de Clínicas, Instituto de Previsión Social e Instituto Nacional del Cáncer, entre los años 2011 y 2015. Resultados: La prevalencia de cáncer de tiroides fue de 23,7% de 1913 pacientes sometidos a tiroidectomía. El 85,7% fueron del sexo femenino. La edad media fue de 43±14 años. El 85,4 % de los pacientes presentó Carcinoma Papilar; el 9,5% Carcinoma Folicular; el 3,1% Carcinoma Medular; el 1,6% Carcinoma Anaplásico y el 0,4% Carcinoma Papilar + Carcinoma Folicular en el mismo paciente. El sexo femenino fue más frecuente en todos los tipos histológicos y, el Carcinoma Medular resultó igual en ambos sexos. La edad media de los pacientes con Carcinoma Papilar fue de 42±13 años, Carcinoma Medular 49±15 años, del Carcinoma Folicular 50±18 años y Carcinoma Anaplásico 69±11 años. El tamaño promedio del Carcinoma Papilar fue de 19±17 mm, del Carcinoma Folicular 53±24 mm, del Carcinoma Medular 40±22 mm, y el Carcinoma Anaplásico 50±35 mm. Conclusión: Aproximadamente 1 de cada 4 pacientes sometidos a tiroidectomía presentó cáncer de tiroides, siendo más frecuente en el sexo femenino y, el Carcinoma Papilar es el tipo histológico más frecuente.

Introduction: Thyroid cancer is the most frequent malignant neoplasm of the endocrine system. During the last decades, an increase in its incidence has been observed progressively in many countries and regions of the world. Objectives: To determine the prevalence of thyroid cancer and its histological types in thyroidectomies carried out in reference hospitals in Paraguay. Materials and methods: Observational, descriptive, retrospective, cross-sectional study. All patients undergoing partial or total thyroidectomy at the Hospital de Clínicas, Instituto de Previsión Social and Instituto Nacional del Cáncer between 2011 and 2015 were included. Results: The prevalence of thyroid cancer was 23.7% of 1913 patients undergoing thyroidectomy. 85.7% were female. The mean age was 43 ± 14 years. 85.4% of the patients presented Papillary Carcinoma; 9.5% Follicular Carcinoma; 3.1% Medullary Carcinoma; 1.6% Anaplastic Carcinoma and 0.4% Papillary Carcinoma + Follicular Carcinoma in the same patient. The mean age of the patients with Papillary Carcinoma was 42 ± 13 years, Medullary Carcinoma 49 ± 15 years, Follicular Carcinoma 50 ± 18 years, and Anaplastic Carcinoma 69 ± 11 years. The average size of Papillary Carcinoma was 19 ± 17 mm, Medullary Carcinoma 40 ± 22 mm, Anaplastic Carcinoma 50 ± 35 mm, and Follicular Carcinoma 53 ± 24 mm. Conclusion: About 1 in 4 patients undergoing thyroidectomy has thyroid cancer, it is more frequent in women, and the most frequent histological type is Papillary Carcinoma.

Effect of a family and interdisciplinary intervention to prevent T2D: randomized clinical trial.

BACKGROUND: Lifestyle changes can reduce the risk of T2D; however, no study has evaluated the effect of a lifestyle intervention involving patients´ family. The aim of this study was to compare the impact of an interdisciplinary family (FI) Vs individual intervention (II) on glucose metabolism, insulin resistance (IR), pancreatic ß-cell function and cardiovascular risk markers in patients with prediabetes, as well as to measure the impact on their families' metabolic risk. METHODS: Randomized Clinical Trial (RCT) to compare the impact of FI and II on IR and pancreatic ß-cell function in subjects with prediabetes. There were 122 subjects with prediabetes (and 101 family members) randomized to FI or II. Data were collected in 2015-2016 and analyzed in 2017-2018. FI group had the support of their family members, who also received personalized diet and exercise recommendations; patients and their family members attended monthly a lifestyle enhancement program. II group received personalized diet and exercise recommendations. The follow-up was for 12 months. Glucose, IR, pancreatic ß-cell function and secondary outcomes (body composition and lipid profile) were assessed at baseline, 6 and 12 months. RESULTS: FI group improved area under the glucose curve (AUC) (from 18,597 ± 2611 to 17,237 ± 2792, p = 0.004) and the Matsuda index (from 3.5 ± 2.3 to 4.7 ± 3.5, p = 0.05) at 12 months. II group improved Disposition Index (from 1.5 ± 0.4 to 1.9 ± 0.73, p < .0001) at 12 months. The improvements achieved in weight and lipids at 6 months, were lost in II group at 12 moths, whereas in FI persisted. Adherence up to 12 months was not different between the study groups (FI 56% Vs II 60%). CONCLUSIONS: FI intervention was more effective by improving glucose AUC, insulin sensitivity and lipid profile, besides that, metabolic risk in family members of the FI group was maintained, while the risk of II group was increased. TRIAL REGISTRATION: This study was retrospectively registered at clinicaltrials.gov on December 15, 2015 (NTC026365646).

The combination of linagliptin, metformin and lifestyle modification to prevent type 2 diabetes (PRELLIM). A randomized clinical trial.

BACKGROUND: Prediabetes is a highly prevalent health problem with a high risk of complications and progression to type 2 diabetes (T2D). The goals of this study were to evaluate the effect of the combination of lingaliptin + metformin + lifestyle on glucose tolerance, pancreatic ß-cell function and T2D incidence in patients with prediabetes. METHODS: A single center parallel double-blind randomized clinical trial with 24 months of follow-up in patients with impaired glucose tolerance plus two T2D risk factors which were randomized to linagliptin 5 mg + metformin 1700 mg daily + lifestyle (LM group) or metformin 1700 mg daily + lifestyle (M group). Primary outcomes were regression to normoglycemia and T2D incidence; glucose levels and pancreatic ß-cell function were secondary outcomes. RESULTS: Subjects were screened for eligibility by OGTT and 144 patients with prediabetes were randomized to LM group (n = 74) or M group (n = 70); 52 and 36 participants in the LM group and 52 and 27 participants in the M group, completed the 12 and 24 months of treatment, respectively; average follow-up was 17 ±â€¯6 and 18 ±â€¯7 months in M and LM group, respectively. Glucose levels during OGTT improved more in LM group. OGTT disposition index (DI) improved significantly better during the first months in LM group, increasing from 1·31 (95% CI: 1·14-1·49) to 2·41 (95% CI: 2.10-2.72) and to 2.07 (95% CI: 1.82-2.31) at 6 and 24 months in LM group vs from 1.21 (95% CI: 0.98-1.34) to 1.56 (95% CI: 1.17-1.95) and to 1.72 (95% CI: 1.45-1.98) at 6 and 24 months in M group (p < .05). T2D incidence was higher in M group in comparison to LM group (HR 4.0, 95% CI: 1.24-13.04, p = .020). The probability of achieving normoglycemia was higher in LM group (OR 3.26 CI 95% 1.55-6.84). No major side effects were observed during the study. CONCLUSIONS: The combination of linagliptin, metformin and lifestyle improved significantly glucose metabolism and pancreatic ß-cell function, and reduced T2D incidence in subjects with prediabetes as compared to metformin and lifestyle.

Pancreatic ß-cell dysfunction in normoglycemic patients and risk factors.

AIMS: To evaluate pancreatic ß-cell function (ßf) in patients with normoglycemia (NG) and normal glucose tolerance (NGT) and related risk factors. METHODS: An observational and comparative study in 527 patients with NG and NGT that were divided by quartiles of ßf according to the disposition index derived from OGTT. Anthropometrical, clinical, nutritional, and biochemical variables were measured and associated with ßf. RESULTS: Quartiles of ßf were Q1 = DI < 1.93 n = 131, Q2 = DI 1.93-2.45 n = 134, Q3 = DI 2.46-3.1 n = 133, and Q4 = DI > 3.1 n = 129. There was a progressive reduction in pancreatic ß-cell function and it is negatively correlated with age, weight, BMI, total body fat and visceral fat, waist circumference, total cholesterol, LDL, and triglycerides (p < 0.01). Glucose levels during OGTT had a negative correlation with ßf; the product of fasting glucose by 1-h glucose had the best correlation with ßf (r = 0.611, p < 0.001) and was the best predictor of ßdf (AUC 0.816, CI 95% 0.774-0.857), even better than 1-h glucose (r = 0.581, p < 0.001). Energy, fat, and carbohydrate intake were negatively correlated with ßf (p < 0.05). Glucose levels at 1-h OGTT > 110 mg/dl were positively associated with pancreatic ßdf (OR 6.85, CI 95% 3.86-12.4). In the multivariate analysis, glucose levels during OGTT, fasting insulin, and BMI were the main factors associated with ßf. CONCLUSIONS: A subgroup of patients with NG and NGT may have a loss of 40% of their ßf. Factors related to this ßdf were age, adiposity, glucose during OGTT, and the product of fasting and 1-h glucose, as well as food intake.

Eficacia de la terapia periodontal no quirúrgica en una periodontitis agresiva / Efficaccy therapy in a nonsurgical periodontal treatment in aggressive periodontitis

La terapia periodontal no quirúrgica es la clave para el control y el mantenimiento de la enfermedad periodontal logrando evitar la fase quirúrgica en muchos casos. Paciente de sexo masculino de 46 años de edad con diagnóstico de periodontitis agresiva generalizada se realizó el control mecánico de placa bacteriana, motivación e instrucción de higiene oral, raspado y alisado radicular manual por cuadrantes, clorhexidina al 0.12% en colutorio 15 ml por 30s dos veces al día por siete días; se complementó con terapia antibiótica sistémica clindamicina de 300mg tres veces al día por siete días. Durante un año de seguimiento con tratamiento periodontal de soporte se observó una reducción de los parámetros clínicos como sangrado al sondaje, disminución de la perdida de inserción y estabilidad del nivel óseo.

Non-surgical periodontal therapy is the key to controlling and maintaining achieving periodontal disease avoid surgical phase in many patients with periodontal disease. Male patient 46 years of age diagnosed with generalized aggressive periodontitis mechanical dental plaque control, motivation and oral hygiene instruction, periodontal debridement quadrant, 0.12% chlorhexidine mouthwash 15 ml 30s performed by two times a day for seven days; It was supplemented with systemic antibiotic therapy Clindamycin 300mg three times daily for seven days. During a year of monitoring and treatment of periodontal maintenance reduced clinical parameters such as bleeding on probing, reduced attachment loss and stability of bone level was observed.

BASAL-BOLUS REGIMEN WITH INSULIN ANALOGUES VERSUS HUMAN INSULIN IN MEDICAL PATIENTS WITH TYPE 2 DIABETES: A RANDOMIZED CONTROLLED TRIAL IN LATIN AMERICA.

OBJECTIVE: Few randomized studies have focused on the optimal management of non-intensive care unit patients with type 2 diabetes in Latin America. We compared the safety and efficacy of a basal-bolus regimen with analogues and human insulins in general medicine patients admitted to a University Hospital in Asunción, Paraguay. METHODS: In a prospective, open-label trial, we randomized 134 nonsurgical patients with blood glucose (BG) between 140 and 400 mg/dL to a basal-bolus regimen with glargine once daily and glulisine before meals (n = 66) or Neutral Protamine Hagedorn (NPH) twice daily and regular insulin before meals (n = 68). Major outcomes included differences in daily BG levels and frequency of hypoglycemic events between treatment groups. RESULTS: There were no differences in the mean daily BG (157 ± 37 mg/dL versus 158 ± 44 mg/dL; P = .90) or in the number of BG readings within target <140 mg/dL before meals (76% versus 74%) between the glargine/glulisine and NPH/regular regimens. The mean insulin dose in the glargine/glulisine group was 0.76 ± 0.3 units/kg/day (glargine, 22 ± 9 units/day; glulisine, 31 ± 12 units/day) and was not different compared with NPH/regular group (0.75 ± 0.3 units/kg/day [NPH, 28 ± 12 units/day; regular, 23 ± 9 units/day]). The overall prevalence of hypoglycemia (<70 mg/dL) was similar between patients treated with NPH/regular and glargine/glulisine (38% versus 35%; P = .68), but more patients treated with human insulin had severe (<40 mg/dL) hypoglycemia (7.6% versus 25%; P = .08). There were no differences in length of hospital stay or mortality between groups. CONCLUSION: The basal-bolus regimen with insulin analogues resulted in equivalent glycemic control and frequency of hypoglycemia compared to treatment with human insulin in hospitalized patients with diabetes.

Aislamiento de trichomonas tenax en pacientes con periodontitis crónica al medio de cultivo de tioglicolato modificado / Isolation of trichomonas tenax in patients with chronic periodontitis in the modified thioglycolate culture médium

Objetivo. Establecer la asociación entre la presencia del protozoario flagelado de la cavidad bucal Trichomonas tenax y la periodontitis crónica en los pacientes atendidos en la clínica especializada en odontología de la universidad de San Martín de Porres (USMP). Material y métodos. Fueron seleccionados 53 pacientes con periodontitis crónica y 41 pacientes periodontalmente sanos, los cuales acudieron a la clínica entre los meses de setiembre a diciembre de 2011, tomándose muestras de cálculo dental y placa dental subgingival respectivamente. Las muestras fueron depositadas en un tubo de vidrio conteniendo el medio de cultivo de Tioglicolato modificado para Trichomonas tenax, los cuales fueron incubados a 35ºC por 4 a 5 días en el laboratorio. Resultados. Se encontró presencia del parásito de Trichomonas tenax en 9 pacientes con periodontitis crónica (17,0%) y 10 pacientes periodontalmente sanos (24,4 %), con un valor de p =0,781, por ser un estudio de casos y controles, el OR= 0,634. Conclusiones. Se determinó que no existe asociación entre la presencia de Trichomonas tenax y la periodontitis crónica. Asimismo, la presencia del parásito no se vio condicionada por la edad, el sexo y el índice de higiene oral de los pacientes atendidos en el mencionado recinto.

Objective. To establish the association between the presence of the flagellated protozoan of the oral cavity Trichomonas tenax and chronic periodontitis in patients treated at the specialized clinic in dentistry of San Martin de Porres University (SMPU). Material and methods. 53 patients with chronic periodontitis and 41 periodontal healthy patients were selected, who attended to the clinic during the months of September to December 2011, taking of them samples of dental calculus and subgingival dental plaque, respectively. The samples were placed in a glass tube containing the culture medium of modified thioglycollate to Trichomonas tenax, which were incubated at 350 grades centigrades for 4 or 5 days in the laboratory. Results. We found the presence of Trichomonas tenax in 9 patients with chronic periodontitis (17,0%) and in 10 periodontal healthy patients (24,4%), with a p-value =0,781. Conclusions. We conclude that there is no association between the presence of Trichomonas tenax and chronic periodontitis. Also the presence of the parasite was not influenced by age, sex and oral hygiene index of patients seen in the clinic.