Medicina (Buenos Aires)

Risk markers of follicular neoplasms in thyroid nodules

Los n�dulos tiroideos de origen folicular abarcan procesos no neopl�sicos y neopl�sicos. No existen m�todos de diagn�stico ni rasgos citol�gicos por punci�n con aguja fina (PAF) que los delimiten, constituyendo un dilema su diagn�stico diferencial. Analizamos la asociaci�n existente entre variables cl�nicas y m�todos de diagn�stico prequir�rgicos en n�dulos tiroideos de estirpe folicular, con el objetivo de definir riesgo de neoplasia.Se estudiaron 92 pacientes con bocios nodulares de estirpe folicular por citolog�a, tratados con tiroidectom�a. Las variables analizadas fueron: sexo, edad, tama�o del n�dulo, caracter�sticas ecogr�ficas, diagn�stico citol�gico, nivel de TSH y resultados del centellograma. De los 92 casos, 74 fueron neopl�sicos (56 adenomas y 18 carcinomas diferenciados) y 18 n�dulos no neopl�sicos, hiperpl�sicos o adenomatosos. Los marcadores que se relacionaron con alto riesgo de neoplasia folicular correspondieron al diagn�stico citol�gico de proliferaci�n folicular de alto grado, en n�dulos iso o hipoecog�nicos, e hipocaptantes con I131. Los carcinomas presentaron citolog�a de proliferaci�n folicular de alto grado en n�dulos hipoecog�nicos, de bordes irregulares con microcalcificaciones e hipocaptantes, en pacientes varones o menores de 20 a�os. La presencia de macrocalcificaciones e hipercaptaci�n estar�an a favor de n�dulo de origen benigno.La correlaci�n de los m�todos de diagn�stico y variables cl�nicas en n�dulos tiroideos de estirpe folicular nos permitir�an delimitar el riesgo de neoplasia y carcinoma para planificar un tratamiento quir�rgico selectivo.

Thyroid nodules of follicular origin include neoplastic and non neoplastic processes. No methods of diagnosis or cytological features (obtained by fine-needle aspiration, FNA) may differentiate both types, and therefore differential diagnosis still constitutes a dilemma.We analyzed the existing association between clinical variables and methods of diagnosis in thyroid nodules of follicular type with the aim of defining risk of neoplasm. Ninety two patients with nodular goiters, of follicular origin by cytology, previously submitted to surgical treatment were analyzed. The studied variables were: sex, age, size of the nodule, ultrasound characteristics, cytological diagnosis, TSH level and results of the scintigraphy. Of 92 cases, 74 were neoplastic nodules (56 adenomas and 18 differentiated thyroid cancer) and 18 were non neoplastic nodules. Markers, that were related to high risk of follicular neoplasm corresponded to the cytological diagnosis of proliferation of high follicular degree, in iso or hypoechoic, and hypofunctioning nodules with I131. The carcinomas presented cytology of follicular proliferation of high degree, in hipoechoic nodules, of irregular edges with microcalcifications and hypofunctioning, in male patients or patients younger than 20 years. The presence of macrocalcifications and hypercaptation would be in favor of nodules of benign origin.The correlation of diagnostic methods and clinical variables in thyroid nodules of follicular type would allow us to differentiate the risk of neoplasm or carcinoma, and plan surgical selective treatments.

Antinuclear antibodies, patterns and characteristics obtained by immunofluorescence: The importance of the IgA, IgM and IgG isotypes

La t�cnica de elecci�n para el screening de anticuerpos antinucleares (ANA) es la inmunofluorescencia indirecta que utiliza como sustrato una l�nea de c�lulas epiteliales de carcinoma de laringe humano (IFI-HEp2), y como antisuero, anti-IgG o anti-Ig totales. Los ANA-IgG son los m�s importantes para el diagn�stico y monitoreo de las enfermedades del tejido conectivo (ETC), mientras los ANA-IgM son de menor relevancia cl�nica en estos pacientes. Sin embargo, poco se sabe de los ANA-IgA ya que estos Ac han sido menos investigados. El objetivo de este trabajo fue estudiar la prevalencia de los diferentes isotipos de inmunoglobulinas de anticuerpos antinucleares en los pacientes con ETC y evaluar la conveniencia de utilizar conjugados monovalentes o polivalentes. Se procesaron 100 sueros de pacientes con diversas ETC empleando IFI-HEp2, en los cuales se detect� 38% de ANA-IgA (t�tulos ≥ 1:80) y 12% de ANA-IgM (t�tulos ≤ 1:160). En 29 casos se detect� IgA en ausencia de IgM, en 3 casos IgM en ausencia de IgA. En todos los casos los ANA-IgG estuvieron presentes. En 6 sueros se observ� un cambio de imagen con conjugado anti-IgA y en 3 con conjugado anti-IgM. Debido a la alta prevalencia de ANA-IgA detectada por IFI-HEp2, se destaca la conveniencia de utilizar conjugado anti-Ig totales en lugar de anti-IgG, mientras se desconozca la relevancia de los ANA-IgA en el diagn�stico, pron�stico y seguimiento de las enfermedades reum�ticas sist�micas.

The indirect immunofluorescence with epitelial cell line from human laryngeal carcinoma as substrate (IIF-HEp2) and anti-IgG or anti-total Ig as antisera, is the technique currently used for the detection of antinuclear antibodies. The most important antibodies for the diagnosis and follow-up of connective tissue diseases (CTD) are the IgG-ANA, while the IgM-ANA have no clinical relevance. However the IgA-ANA have not been thoroughly investigated so far. The aim of this work was to study the prevalence of different ANA isotypes of Ig antibodies in CTD patients and to evaluate the convenience of the use of monovalent or polyvalent conjugate. We examined the sera of 100 patients with different CTD by IIF-HEp2 and detected a prevalence of 38% IgA-ANA (titles ≥ 1:80) and 12% IgM-ANA (titles ≤ 1:160). In twenty nine cases we detected IgA-ANA in absence of IgM-ANA, and in 3 cases IgM-ANA in absence of IgA-ANA. In all the cases IgG-ANA were present. In 6 sera a change in the immunofluorescence pattern was observed while using anti-IgA conjugate, whereas in 3 the change was observed with the use of anti-IgM conjugate. Because of the high prevalence of ANA-IgA detected by IIF-HEp2, we emphasize the convenience of employing anti-total Ig in spite of anti-IgG conjugated until the role of ANA-IgA is dilucidated in CTD patients, in order to establish its relevance in the diagnosis, prognosis and follow-up of systemic rheumatic diseases.

Transient expiratory flow interruptions (TEFI) increase expiratory flow in acute asthma exacerbation

We have shown that expiratory flows increase when expirations are rapidly interrupted in stable asthmatic patients. We hypothesized that a similar increase could be obtained in patients with acute exacerbation of bronchial asthma treated in the Emergency Room. A total of 30 asthmatic patients were randomly allocated into two groups, the study and the control groups. Patients in the study group were connected to a device with an inspiratory line designed to administer pressurized aerosols. The expiratory line passed through a valve completely interrupting flow at 4 Hz, with an open/closed time ratio of 10/3. The control group patients were also connected to the device, but with the valve kept open. Mean expiratory flow at tidal volume (MEFTV) was measured under basal conditions and at 4, 8 and 12 minutes after connecting the patients to the device. All patients received standard treatment throughout the procedure. At all time points MEFTV increased more in the study than in the control group (p < 0.003 by two-way ANOVA). There was no residual effect after disconnection from the device. We conclude that TEFI can rapidly improve expiratory flows in patients with acute exacerbations of asthma, while pharmacologic interventions proceed.

Demostramos que el flujo espiratorio m�ximo, en pacientes asm�ticos en estado estable, se incrementaba cuando se generaban r�pidas y transitorias interrupciones del flujo. Formulamos la hip�tesis de que un incremento similar podr�a ser observado en pacientes con exacerbaci�n aguda de asma tratados en la sala de emergencias. Un total de 30 pacientes asm�ticos fueron distribuidos al azar en dos grupos. Los pacientes del grupo en estudio fueron conectados a un aparato con una v�a inspiratoria dise�ada para la administraci�n de aerosoles. La v�a espiratoria pasaba por una v�lvula que interrump�a el flujo completamente a 4 hz, con una relaci�n tiempo abierta/tiempo cerrada de 10/3. Los pacientes del grupo control tambi�n fueron conectados al aparato pero con la v�lvula siempre abierta. Se midi� el flujo medio de la espiraci�n a volumen circulante en condiciones basales y a los 4, 8 y 12 minutos despu�s de conectado el paciente al equipo. Todos los pacientes recibieron el tratamiento farmacol�gico est�ndar a lo largo del ensayo. Se observ� un incremento significativamente mayor del flujo espiratorio medio a volumen circulante en el grupo en estudio en comparaci�n al grupo control (p < 0.003 ANOVA de dos v�as) durante todo el ensayo. No hubo efecto residual despu�s de la desconexi�n del equipo. Concluimos que las interrupciones transitorias del flujo espiratorio pueden incrementar r�pidamente el flujo espiratorio en pacientes con exacerbaciones agudas de asma dando tiempo a que el tratamiento farmacol�gico comience a actuar.

Pyogenic vertebral osteomyelitis

La osteomielitis vertebral pi�gena (OVP) es una localizaci�n poco frecuente (2-7%) Se confirma con el aislamiento de un microorganismo de una v�rtebra, disco intervertebral, absceso epidural o paravertebral. Se describe una serie de casos por la infrecuente presentaci�n de esta enfermedad, que puede ser consulta inicial en los servicios de cl�nica m�dica y por su sintomatolog�a inespec�fica que supone una dificultad diagn�stica. Tanto la columna lumbar como la dorsal fueron los sitios m�s afectados. El dolor dorsolumbar y la paraparesia fueron los s�ntomas m�s frecuentes de presentaci�n. En ocho pacientes se aislaron Staphylococcus aureus, en uno Escherichia coli y en el restante Haemophylus sp. Se observ� leucocitosis s�lo en tres pacientes, y en dos velocidad de sedimentaci�n globular mayor de 100 mm/h. Los diez pacientes presentaron im�genes caracter�sticas de osteomielitis vertebral pi�gena en la resonancia nuclear magn�tica. Dentro de las complicaciones, los abscesos paravertebrales y epidurales fueron los m�s frecuentes (en cinco enfermos). Adem�s, un paciente present� empiema pleural. De los diez pacientes de esta serie, siete recibieron inicialmente tratamiento m�dico emp�rico y luego espec�fico para el germen aislado. En los restantes el tratamiento fue guiado de acuerdo al antibiograma. A dos enfermos fue necesario realizarles laminectom�a descompresiva por compromiso de partes blandas y a otros dos estabilizaci�n quir�rgica por inestabilidad espinal, observ�ndose buena evoluci�n en todos los casos. Esta serie demuestra que, ante un paciente con dolor dorsolumbar y s�ntomas neurol�gicos se deber� tener en cuenta esta entidad para evitar un retraso en el tratamiento.

Pyogenic osteomyelitis seldom affects the spine (2-7%). It is diagnosed by the isolation of a bacterial agent in the vertebral body, the intervertebral disks or from paravertebral or epidural abscesses. We report a retrospective study of ten patients who attended a medical clinic with this disease to emphasize its unusual presentation and difficult diagnosis. Lumbar and dorsal spine were the most common sites affected. Dorsolumbar pain and paraparesis were the most frequent symptoms. Staphylococcus aureus were isolated in eight patients, Escherichia coli in one and Haemophilus sp. in other Leukocytosis was observed in only three patients. Erythrocyte sedimentation rate was higher than 100 mm in the first hour in two patients. Typical images of pyogenic vertebral osteomyelitis were observed in all these patients with magnetic resonance imaging. The main complications were paravertebral and epidural abscesses that were found in five patients. One patient also presented an empyema, seven of them initially received empiric medical treatment, and later specific antibiotics according to the culture and sensitivity results. The rest of the patients were initially treated according to the sensitivity of the isolated germ. Surgical intervention was performed in two patients to drain soft tissue involvement, and in two other to stabilize the spine. All four surgical patients had a full recovery. This report is intended to point out that in patients with dorsolumbar pain and neurological symptoms pyogenic vertebral osteomyelitis is a possible diagnosis and has to be treated without delay.

Caregivers of palliative care home patients

Diversos estudios coinciden en se�alar que el hogar es el �mbito que pacientes y familiares prefieren para el cuidado del enfermo terminal y donde transcurre la mayor parte del �ltimo a�o de vida. Los cuidadores informales se han convertido en un importante componente de los cuidados paliativos. Los objetivos de este estudio fueron: 1) identificar y describir aspectos relevantes relativos a las tareas del cuidado de pacientes con enfermedades terminales en el hogar, desde la perspectiva de los propios cuidadores y 2) proponer una clasificaci�n de los diferentes tipos de cuidados provistos, elaborando perfiles de cuidadores. Se realiz� una investigaci�n cualitativa mediante un cuestionario auto-administrado, con un dise�o flexible de alcance exploratorio-descriptivo que incorpor� t�cnicas cuantitativas para medir determinados aspectos analizados con el paquete estad�stico SPSS (12.01). La unidad de an�lisis estuvo constituida por 50 cuidadores de pacientes con enfermedades terminales atendidos en el Servicio de Cuidados Paliativos del Instituto de Investigaciones M�dicas A. Lanari (Ciudad de Buenos Aires) durante los a�os 2007 y 2008. Tres aspectos fueron evaluados: a) el cuidado cotidiano del paciente, b) las percepciones sobre los deseos del enfermo y c) las reflexiones sobre el propio papel del cuidador. Fueron identificados cuatro perfiles de cuidadores: 1) los satisfechos con la provisi�n de la atenci�n dada, con soporte en una red organizada de amigos y familiares involucrados, 2) los potencialmente vulnerables, con aparente control de la situaci�n pero con factores de riesgo de deterioro, 3) los que se sent�an desbordados en estas tareas y que expl�citamente expresaban las dificultades de cuidar y 4) los aislados en su rol, compuesto por esposas solas que prefer�an no molestar ni pedir ayuda.

Research suggests that patients spend most of the last year of their life at home and that this is the place where they often choose to stay. Family caregiving has become an important issue of palliative care. The purposes of this study were: 1) to identify salient issues of caregiving for family members of palliative care patients and 2) to propose a classification based on different profiles of caregivers. The research was exploratory-descriptive, based on a flexible design, specifically case studies. Caregivers (n=50) were selected randomly among relatives of home. Palliative care patients attended in the Lanari Institute (University of Buenos Aires, Argentina) during 2007-2008. Qualitative data were gathered through unstructured, open ended interviews in the home setting. Quantitative data were collected with a self-completion questionnaire and were analyzed with SPSS (12.01). Three dimensions were evaluated: a) attitudes of the caregiver towards the treatments, b) perceptions of the caregivers of the needs and wishes of the patient and c) evaluation of their own role as caregiver. Four types of informal caregivers were identified: 1) satisfactory carers, based on a well-organized system of relatives and friends involved in the caring situation, 2) potentially vulnerable carers, those involved in situations apparently controlled, but with factors which could trigger a spiral of deterioration, 3) overwhelmed carers, who explicitly express difficulties in being able to achieve the daily goals for the patients� comfort and 4) isolated carers, composed by lonely wives wishing "not to bother" others.

TIMI risk score validation for patients with acute coronary syndrome without ST elevation

Los s�ndromes coronarios agudos sin elevaci�n del segmento ST (SCA-SST) son causa frecuente de hospitalizaci�n, siendo responsables del 10 al 15% de infartos de miocardio (IM) o muertes al a�o. El objetivo fue evaluar eventos cardiovasculares a 6 meses de seguimiento y validar el score de riesgo TIMI (Thrombolysis in Myocardial Infarction) en nuestra poblaci�n. Se analizaron retrospectivamente pacientes con diagn�stico de SCA-SST. Se realiz� seguimiento telef�nico a los 6 meses del ingreso. Los puntos finales evaluados fueron la combinaci�n de muerte, internaci�n por s�ndrome coronario agudo y necesidad de revascularizaci�n. Se incluyeron 204 pacientes. El 70.2% eran hombres, edad promedio de 64.5 � 11.8 a�os. Luego de la evaluaci�n inicial, se hizo diagn�stico de angina inestable en el 34.6%, IM en 38.9% y el 26.4% fueron catalogados como "dolor no coronario". Al aplicar el score de TIMI, 52 (25.5%) pacientes ten�an riesgo bajo, 106 (52%) riesgo intermedio, y 46 (22.5%) riesgo alto. La mortalidad global fue 12.6%. Se encontr� un incremento progresivo y significativo en la tasa de eventos combinados a medida que aumentaba el score de TIMI (p < 0.001). Concluimos que, en nuestra poblaci�n, encontramos de gran utilidad al score de riesgo TIMI, ya que los pacientes con score intermedio y alto se correlacionaron con nuevos eventos cardiovasculares a 6 meses de seguimiento.

Non-ST elevation acute coronary syndromes (NSTE-ACS) are frequent cause of hospitalization, being responsible for 10-15% of infarcts or deaths per year. The study was designed to analyze 6 months follow-up of cardiovascular events as well as to validate the Thrombolysis in Myocardial Infarction (TIMI) risk score for patients hospitalized for NSTE-ACS. We retrospectively analyzed patients admitted with NSTE-ACS. Telephone follow-up were performed at 6 month. Combination of death, re-admission for acute coronary syndrome and revascularization were considered as end point. Two hundred and four patients were included for the analysis. There were 70.2% males, with a mean age of 64.5 � 11.8 years. After the initial evaluation, we diagnosed unstable angina in 34.6% of cases, MI in 38.9% of cases, and 26.4% of patients were categorized as "non coronary chest pain". Applying the TIMI risk score, 52 (25.5%) patients had low risk, 106 (52%) intermediated risk, and 46 (22.5%) high risk. The global mortality was 12.3%. We found a progressively and significant increase in the rate of combined events as the TIMI score increase (p < 0.001). We conclude that in our population, the intermediated and high TIMI risk score was well related to newer cardiovascular events at 6 month follow-up.

Maternal fetal-transmission of Trypanosoma cruzi in Argentina

El diagn�stico de la transmisi�n cong�nita del T. cruzi en hijos de mujeres infectadas se realiza por detecci�n de la parasitemia y/o de anticuerpos espec�ficos no transferidos por la madre, en ausencia de transfusi�n sangu�nea y transmisi�n vectorial. En la etapa temprana, aproximadamente hasta el 7� mes de vida, cuando es posible la presencia de inmunoglobulinas maternas, el diagn�stico depende de la detecci�n del par�sito. Luego, en la etapa tard�a, a partir del 8� mes de vida, la detecci�n de anticuerpos espec�ficos con por lo menos 2 de 3 pruebas serol�gicas permiten el diagn�stico del ni�o. En el INP hemos realizado el seguimiento de los ni�os de un grupo de mujeres embarazadas sero-reactivas que concurrieron para el diagn�stico de la infecci�n. El 11% de ellas (29 de 267) transmitieron la infecci�n a sus ni�os. Los hijos de 20 de estas mujeres fueron diagnosticados en la etapa temprana, con 1 o 2 controles parasitol�gicos, en 14 y 6 casos respectivamente. En las 9 madres restantes los ni�os fueron diagnosticados principalmente por la serolog�a en la etapa tard�a de la infecci�n. Nuestro an�lisis de los datos publicados anteriormente enfatizan que el porcentaje de la transmisi�n madre-hijo depende principalmente del tiempo de seguimiento diagn�stico del ni�o. En estos trabajos, cuando el diagn�stico del ni�o se realiz� s�lo en la etapa temprana se notific� aproximadamente un 2% de transmisi�n materno-fetal, mientras que cuando tambi�n se estudiaron a los ni�os en la etapa tard�a se encontr� un promedio de 9% de casos de transmisi�n cong�nita.

In the neonates born to T. cruzi infected mothers, the diagnosis of the congenital transmission relays on the detection of the parasites and/or the specific antibodies non-transferred by their mothers, in the absence of blood transfusion and vectorial transmission. In the early stage, approximately until the 7th month of life, when maternal immunoglobulins could be present, the diagnosis depends on the detection of the parasite. Then, in the late stage, from the 8th month, the detection of specific antibodies by at least 2 of 3 serological tests confirms the infection in the neonates. The diagnostic follow up of the children born to a group of sero-reactive pregnant women was carried out in the INP. The 11% of the mothers (29 out of 267) transmitted the infection to their children. The neonates of 20 of these mothers were diagnosed in the early stage, 14 and 6 in one or two controls, respectively. In the 9 remaining mothers the children were diagnosed in the late stage of the infection, mainly serologicaly. Our analisis of previously published reports stressed that the maternal-fetal transmission rate depends on the time of diagnostic follow up of the child. In this reports, mean values of mother to child transmission reported was 2% and 9% when the diagnosis of the neonates born to sero-reactive mothers was carried out only in the early stage or in the early and also the late stage, respectively.

Cutaneous melanoma associated with previous nevus

El melanoma maligno es una neoplasia originada en los melanocitos de la piel y otras localizaciones. No existe informaci�n en nuestro pa�s acerca de su incidencia y prevalecencia, s� se sabe cu�les son los factores de riesgo m�s importantes. El melanoma puede originarse de novo o a partir de lesiones melanoc�ticas previas. La noci�n de que un nevo melanoc�tico pueda servir como lesi�n precursora es sustentada por evidencias cl�nicas e histol�gicas. Realizamos en el Hospital Privado de C�rdoba un estudio observacional, retrospectivo y anal�tico. El objetivo de este trabajo fue conocer cu�l es la frecuencia de asociaci�n de melanomas malignos que se desarrollan sobre nevos previos. Fueron analizados un total de 134 melanomas. En 32 pacientes (24%), los melanomas estuvieron histol�gicamente asociados con nevos, con espesores de Breslow mayores de 1 mm el porcentaje de asociaci�n fue de 16.3%, y con Breslow menores de 1 mm, 38.1%. Al evaluar los melanomas en relaci�n a la clasificaci�n de Breslow y Clark, se objetiv� que el grupo de melanomas asociados a nevos present� un espesor de Breslow y niveles de Clark bajos y en el an�lisis estad�stico fueron predictores significativos en la probabilidad de hallar esta asociaci�n (p < 0.027). Este estudio demuestra que s�lo el espesor del tumor es un factor predictivo independiente en la asociaci�n melanoma-nevo, el resto de las variables estudiadas no arrojaron resultados significativos desde el punto de vista estad�stico. Los pacientes deben ser educados para el control de nuevas lesiones pigmentadas as� como para la modificaci�n de nevos preexistentes.

The malignant melanoma is a neoplasia originated from the melanocytes located in the skin and other locations. Even though there is not information regarding its incidence and prevalence in our country, its most important risk factors are known. The melanoma can originate de novo or from previous melanocytic lesions. The concept that a melanocytic nevus can serve as a precursor lesion is supported by clinical and histological evidence. An observational, retrospective and analytical study was carried out in the Hospital Privado de C�rdoba. The objective was to determine which is the frequency of association of malignant melanomas that develop on previous nevus. A total of 134 melanomas were analyzed. In 32 cases (24%), the melanomas were histologically associated with nevus, in individuals with Breslow's depth bigger than 1 mm the percentage of association was 16.3% while in those exhibiting Breslow smaller than 1 mm the percentage of association was 38.1%. Having evaluated the melanomas in relation to the Breslow and Clark classification, we observed that the nevus associated melanoma group showed less Breslow thickness and low Clark levels, which, by statistical analysis were shown to be significant predictors of the probabilty of finding this association (p < 0.027). This study demonstrates that the tumor thickness by itself is an independent predictive factor of the association melanoma-nevus. However, the rest of the variables studied did not throw significant results from the statistical point of view. In conclusion, patients must be educated for the control of new pigmented injuries as well as for the modification of preexisting nevi.

Glomerular filtration rate, cardiovascular risk factors and insulin resistance

The aim of this paper was to study the estimated glomerular filtration rate (eGFR), its changes with age, and its association with systolic blood pressure (SBP) and diastolic BP (DBP), indicators of obesity, dyslipemia, insulin resistance and inflammation on a random population sample. BP, weight, size and waist circumference (WC) were recorded at home. Fasting morning blood samples were analysed. The eGFR was calculated with MDRD (eGFR-MDRD), Cockroft-Gault (eGFR-CG) adjusted to 1.73 m� and reciprocal of serum creatinine (100/serum cretinine). A total of 1016 individuals, 722 females (41.97 � 0.66 years old) and 294 males (42.06 � 0.99 years old), completed the laboratory tests. The mean of 100/Scr was 115.13 � 0.60 (dl/mg), the mean eGFR-CG was 98.48 � 0.82 ml/min/1.73 m�; the mean eGFR-MDRD was 85.15 � 0.58 ml/min/1.73 m�. The eGFR-MDRD decreased with age and with the number of risk factors in both sexes. The eGFR-MDRD < 60 ml/min/1.73 m� adjusted prevalence was 6.2 per 100 inhabitants (CI 95%, 4.7-7.7), 3.6 (CI 95%, 1.5-5.7) in males and 8.6 (CI 95%, 6.6-10.6) in females. The bivariate analysis showed that the eGFR-MDRD correlates inversely with age, SBP, DBP WC, BMI, serum glucose, serum total cholesterol, LDL cholesterol, serum triglycerides, serum uric acid and, in males, with C-reactive-protein. There was no correlation with either insulinemia or HOMA.The mean eGFR value, its association with cardiovascular risk factors and the prevalence of eGFR < 60 ml/min/1.73 m� found in a rural population of Argentina are similar to those found in other parts of the world.

El objetivo fue evaluar en una muestra poblacional aleatoria el filtrado glomerular estimado (FGe), sus cambios con la edad y su asociaci�n con presi�n arterial sist�lica (PAS) y diast�lica (PAD), indicadores de obesidad, dislipemia, resistencia a la insulina e inflamaci�n. En cada domicilio fueron medidos presi�n arterial, peso y talla y per�metro de la cintura (PC). Se analizaron muestras de sangre en ayunas y fue calculado el FGe usando las f�rmulas de MDRD (FGe-MDRD) y Cockroft-Gault (FGe-CG) ajustado a 1.73 m�, y la inversa de la creatinina s�rica (100/CrS). Completaron el protocolo de laboratorio 1016 sujetos, 722 mujeres (41.97 � 0.66 a�os) y 294 varones (42.06 � 0.99 a�os). La media de 100/Crs fue 115.13 � 0.60 (dl/mg), la del FGe-CG 98.48 � 0.82 ml/min/1.73 m� y la del FGe-MDRD 85.15 � 0.58 ml/min/1.73 m� (CI 95% 84.00-86.29). El FGe-MDRD disminuy� con la edad y con el n�mero de factores de riesgo cardiovascular en ambos sexos. La prevalecencia ajustada de FGe-MDRD < 60 ml/min/1.73 m� fue 6.2 por 100 habitantes (CI 95%, 4.7-7.7); 3.6 (CI 95%, 1.5-5.7) en varones y 8.6 (CI 95%, 6.6- 10.6) en mujeres. El an�lisis bivariado mostr� correlaci�n inversa del FGe-MDRD con edad, PAS, PAD, PC, IMC, glucemia, colesterolemia total, colesterol-LDL, trigliceridemia, uricemia y, en varones, con la proteina-C-reactiva. No hubo correlaci�n con insulinemia u HOMA. La media del FGe, su asociaci�n con factores de riesgo cardiovascular y la prevalecencia de FGe < 60 ml/min/1.73 m� fueron similares a los hallados en otras partes del mundo.

Respiratory domain of revised amyotrophic lateral sclerosis: Functional Rating Scale

Virtualmente todos los pacientes con esclerosis lateral amiotr�fica tendr�n disnea, que es quiz� el s�ntoma m�s penoso de esta devastadora enfermedad. El objetivo de este estudio fue correlacionar la dimensi�n respiratoria de la escala ALSFRS-R, la capacidad vital forzada y las presiones est�ticas m�ximas bucales. Se estudiaron prospectivamente 20 pacientes consecutivos sin disnea durante 24 meses. El puntaje total de la escala ALSFRS-R disminuy� de 34.3 � 10.3 a 22.1 � 8.0 (p = 0.0325); la contribuci�n de la dimensi�n respiratoria fue insignificante. En quienes refirieron disnea (n: 12), la capacidad vital forzada cay� un 41 � 21 % del valor inicial pero con similar ca�da (46 � 23%), 8 pacientes no refirieron disnea. La correlaci�n entre la escala ALSFRS-R con la capacidad vital forzada (litros) fue r: 0.73, (p = 0.0016) y con la presi�n inspiratoria m�xima (cm H2O), r: 0.84, p = 0.0038. La correlaci�n entre la capacidad vital forzada (%) con la disnea fue r s: 0.23, p = 0.1400. La correlaci�n de la disnea con la presi�n inspiratoria m�xima (%) fue r s: 0.58, p = 0.0300 y con la presi�n espiratoria m�xima (%), r s: 0.49, p = 0.0400. La dimensi�n respiratoria de la escala ALSFRS-R no permiti� predecir el grado de deterioro funcional respiratorio. Esto sugiere que dicha dimensi�n no reemplaza a las mediciones funcionales respiratorias y, debido a que la insuficiencia respiratoria puede no ser evidente, la realizaci�n de dichas pruebas provee una base objetiva de seguimiento y permite planear medidas con anticipaci�n.

Virtually all patients with amyotrophic lateral sclerosis will complain of dyspnea, which is perhaps the most distressing symptom of this devastating disease. The objective was to correlate respiratory domain of ALSFRS-R with forced vital capacity and maximal static pressures in the mouth. We designed a prospective study in 20 consecutive patients without dyspnea during 24 months. The global decline of ALSFRS-R was from 34.3 � 10.3 to 22.1 � 8.0 (p = 0.0325), the contribution of respiratory domain was irrelevant. Those who referred dyspnea (n: 12), forced vital capacity fell 41 � 21% of the initial value but with similar value of fall (46 � 23%) 8 patients did not referred dyspnea. Total score of ALSFRS-R correlated with forced vital capacity (litres), r: 0.73, p = 0.0016 and maximal inspiratory pressure (cm H2O), r: 0.84, p = 0.0038, but the fall of the forced vital capacity (%) did not correlate with dyspnea (r s: 0.23, p = 0.1400). There was a moderate correlation between dyspnea and maximal inspiratory pressure (%), r s: 0.58, p = 0.0300 and between dyspnea and maximal expiratory pressure (%), r s: 0.49, p = 0.0400. We concluded that the respiratory functional deterioration could not be predicted using respiratory domain of ALSFRS-R. This suggests that respiratory domain of this scale does not replace to respiratory function testing measurements and, due to the respiratory insufficiency could not be clinically evident; performing pulmonary function tests provides an objective view and permit to make anticipatory actions.

Mesenchymal hamartoma of the liver in an elderly man

El hamartoma mesenquimatoso hep�tico es un tumor benigno poco frecuente, formado por alteraciones de la placa hiliar y compuesto por tejidos mixomatoso, mesenquim�tico y conductos biliares anormales en proporciones variables. Habitualmente son formaciones hep�ticas m�ltiples, qu�sticas y sin comunicaci�n con la v�a biliar. Es m�s frecuente en ni�os, es raro en adultos. El primer caso fue publicado por Yamamura et al en 1976, y se encuentran pocos en la bibliograf�a. Presentamos el caso de un paciente de 87 a�os con un hamartoma hep�tico qu�stico de 20 cm.

The mesenchymal hamartoma of the liver is a non frequent benign tumor with a ductal plate malformation, consisting of myxoid mesenchymal tissue and abnormal bile ducts in different proportion. Usually it presents as multiple liver cyst formations without communication with the principal bile duct. They are frequent in children, being rare in adults. The first case was reported by Yamamura et al in 1976, and very few cases are reported in the bibliography. We present the case of an elder 87 year old male who presented a 20 cm mesenchymal hamartoma liver cyst.

Complex regional pain syndrome type 1: An elusive diagnosis

El s�ndrome doloroso regional complejo tipo 1 es una afecci�n que puede complicar traumatismos, en especial de los miembros. Es infradiagnosticado y potencialmente muy incapacitante. El diagn�stico se realiza reuniendo una serie de criterios cl�nicos. No existe un m�todo de diagn�stico complementario que pueda considerarse patr�n de oro. Su tratamiento debe ser multidisciplinario (f�rmacos, terapia f�sica, terapia psicol�gica y en casos seleccionados, procedimientos invasivos). Se han comunicado resultados favorables con m�ltiples tratamientos farmacol�gicos, siendo la terapia con corticosteroides una de las que han alcanzado altos niveles de evidencia a favor de su utilidad. Presentamos el caso de un paciente masculino de 47 a�os de edad que fue internado en nuestro servicio por dolor intenso en su extremidad inferior derecha de caracter�sticas neurop�ticas de larga evoluci�n. Hab�a realizado m�ltiples consultas previas y cumplido diversos tratamientos. Se le realiz� centellograma �seo de tres fases con 99Tc que result� compatible con el diagn�stico propuesto. Se trat� con metilprednisona 60 mg/d�a con disminuci�n progresiva hasta completar 15 d�as, obteni�ndose una mejor�a significativa de la sintomatolog�a. Se le otorg� el alta hospitalaria para proseguir la rehabilitaci�n ambulatoria.

Complex regional pain syndrome type 1 is a painful disorder that may complicate a traumatic lesion especially in extremities. It is infradiagnosed and potentially very disabling. Its diagnosis consists of a few clinical criteria. It does not exist a complementary diagnostic study which can be considered as gold standard. Its treatment must be multidisciplinary (e.g. medicines, physical therapy, psychological therapy and, in selected cases, invasive procedures). There have been communicated some favorable results using multiple pharmacological treatments in which corticosteroid therapy was among the ones that have reached highest levels of evidence in favor of its utility. Here we present the case of a forty-seven male patient who presented severe pain in his right lower extremity with neuropathic characteristics and a long time of evolution. He had had multiple previous consultations and he had carried out many other treatments. It has been performed a 99Tc three- phase bone scintigraphy that was compatible with the proposed diagnosis. He was treated with methyl prednisone 60 mg q24h with progressive lowering doses during fifteen days with a significant improvement of signs and symptoms. Finally he received hospital discharge for ambulatory rehabilitation treatment.

Macrolitiasis vesical

Comunicaciones sinusoidales coronario-ventriculares

Caveat lector

Treatment recommendations based on best evidences

Las recomendaciones de tratamiento exigen un an�lisis sistematizado de las distintas variables que las convertir�n en una recomendaci�n fuerte, aquella en que los beneficios superan a los perjuicios, o en una d�bil, aquella en que los beneficios y perjuicios est�n balanceados. La medicina basada en las mejores pruebas propone analizar: 1) la calidad de la bibliograf�a; 2) la importancia del efecto cl�nico; 3) la magnitud del efecto; 4) los riesgos de la enfermedad a tratar; 5) los riesgos de la prescripci�n; 6) los costos; 7) las preferencias de los pacientes; 8) las molestias para los pacientes; 9) el m�nimo y m�ximo efecto y 10) si la recomendaci�n es fuerte o d�bil. Consideramos necesarios estos diez pasos en la estrategia que lleva a la construcci�n de una recomendaci�n cient�ficamente sustentada.

The fact of making recommendations about treatments demands for a systematic analysis of the different variables involved. The direction of these variables will become a recommendation into a strong one, when the benefits outweigh the harms, or into a weak one, when profits and losses are balanced. In this way, evidence based medicine analyzes this variables: 1) the quality of the literature; 2) the importance of clinical effect; 3) the magnitude of the effect; 4) the risks of the disease to treat; 5) the risks of treatment; 6) the costs; 7) the preferences of the patients; 8) the inconvenience to patients; 9) the minimum and maximum effect and 10 ) if the recomendation is strong or weak. This ten steps strategy will lead us to the construction of a scientifically based recommendation.

FRAX^TM: A new instrument for calculating 10-year absolute fracture risk

La eficacia de nuevos agentes farmacol�gicos para la prevenci�n de fracturas osteopor�ticas y la decisi�n de intervenci�n con la misma finalidad en la pr�ctica cl�nica han sido guiadas por la evaluaci�n de la densitometr�a �sea (DMO). Sin embargo, reconociendo la naturaleza multifactorial de ese desenlace, recientemente se dio a conocer el calculador Fracture Risk Assessment Tool (FRAX™) que persiguiendo los mismos objetivos de modelos previos, integra y combina varios de esos factores ponderadamente para estimar el riesgo absoluto de fractura de cadera o un combinado de fracturas osteopor�ticas para los siguientes 10 a�os. El mismo ser�a ajustable a cualquier pa�s incorporando al modelo la incidencia de fractura de cadera y las expectativas de vida edad- y sexo-espec�ficas para la poblaci�n a que pertenece el individuo. Este instrumento es presentado como un nuevo paradigma para ayudar en la toma de decisiones terap�uticas, especialmente farmacol�gicas. En la presente revisi�n se discuten algunas de sus caracter�sticas, como ser: la pretendida aplicabilidad a poblaciones de distintos pa�ses, la conveniencia de utilizar el riesgo absoluto a 10 a�os para todo el espectro etario de inter�s y si la eficacia de los tratamientos farmacol�gicos para la prevenci�n de fracturas �seas en pacientes osteopor�ticos podr� comprobarse tambi�n en pacientes seleccionados para tratamiento en base a este modelo. Finalmente, se llama la atenci�n sobre el hecho de que a�n no est�n claramente determinados los umbrales de riesgo orientadores para la toma de decisiones, los que obviamente tendr�n un relevante impacto en el n�mero de pacientes pasibles de tratamiento.

The efficacy of new pharmacological agents for the prevention of osteoporotic fractures and the clinical decision to intervene with that purpose in daily medical practice have been guided by the evaluation of bone mineral density (BMD). However, given the multifactorial nature of the proposed endpoint, a new calculator has been proposed: Fracture Risk Assessment Tool FRAX TM, which follows the same objectives of previous models, but integrates and combines several of those factors according to their relative weight. It can estimate absolute risk of hip fracture (or a combination of osteoporotic fractures) for the following 10 years. The calculator could be adapted for use in any country by the incorporation of hip fracture incidence and age- and sex-adjusted life expectancy in the same country. This instrument has been presented as a new paradigm to assist in clinical and therapeutic decision-making. In the present review some of its characteristics are discussed, such as: the purported applicability to different populations, the convenience of using 10-year absolute fracture risk for the whole age range under consideration, and whether the efficacy of pharmacological treatment for the prevention of bone fractures in osteoporotic patients can be expected to be equally effective among patients selected for treatment on the basis of this model. Finally, we would like to call attention to the fact that risk thresholds for intervention are not yet clearly defined; those thresholds can obviously be expected to have a profound impact on the number of patients amenable to treatment.

Bestiario biom�dico y el principio de Krogh

Hitos en la historia de la inmunolog�a: Apogeo y ca�da de la teor�a de la red

Carlos Chagas: a cien a�os de un trabajo genial