Aspectos quirúrgicos en deformidades congénitas de la columna vertebral: clínico y radiológico / Surgical aspects in congenital spinal deformities: clinical and radiological

El tratamiento quirúrgico de las deformidades congénitas de la columna vertebral ha evolucionado en los últimos años desde fusiones in situ, hemiepifisiodesis hasta hemivertebrectomía y sustracción pedicular. En la actualidad no hay concenso cual es el procedimiento idóneo. Objetivo: Determinar la eficacia y utilidad de la Hemivertebrectomía y Sustracción Pedicular de los pacientes con Escoliosis Congénita y Cifoescoliosis. Métodos: se estudiaron 18 pacientes intervenidos en el período de enero 2013- diciembre del 2014, en un análisis estadístico retrospectivo. En 12 (66%) pacientes se realizó hemivertebrectomía y a 6 (33%) pacientes sustracción pedicular. Se evaluó edad, sexo, tipo de defecto, grado de corrección, niveles de resección y fusión, evolución neurológica, pérdida de sangre, tiempo quirúrgico y complicaciones. Resultados: se observó un ángulo de Cobb preoperatorio de 46º con escoliosis y 8 casos con ángulo de cifosis de 75º. Los porcentajes de corrección promedio de la escoliosis y la cifosis fueron 59 y 60% respectivamente, y el ángulo en el postoperatorio fue de 23º y 45º. La resección de la hemivertebra fue en un nivel (75%), dos niveles (33%). Se presentaron complicaciones en 8 pacientes, fístula de LCR, infección de la herida, pseudoartrosis, con pérdida de sangre de 528 ml, tiempo quirúrgico de 8 horas, y fusión 70%. Conclusiones: la hemivertebrectomía y la sustracción pedicular, constituyen una alternativa que permiten la corrección de la deformidad y estabilidad de la columna(AU)

Surgical treatment of congenital deformities of the spine has evolved in recent years from mergers in situ, hemiepiphysiodesis to hemivertebrectomy and pedicle subtraction. At present there is no consensus on the appropriate procedure. Objective: To determine the effectiveness and usefulness of the Hemivertebrectomía and Subtraction Pedicular of patients with congenital scoliosis and Kyphoscoliosis. Methods: in a retrospective statistical analysis 18 patients treated in the period January 2013-December 2014, were studied. In 12 (66%) patients a hemivertebrectomy was performed and a pedicle subtraction was performed on the other 6 (33%) patients. Age, sex, type of defect, degree of correction, resection and fusion levels, neurologic outcome, blood loss, operative time and complications were evaluated. Results: The preoperative Cobb angle of 46º with scoliosis and 8 cases with kyphosis angle of 75 ° were observed. The percentages of average correction of scoliosis and kyphosis were 59% and 60% respectively, and the postoperatively angle was 23º and 45º. Hemivertebra resection was on a level (75%); two levels (33%). There were complications in 8 patients, fistula LCR, wound infection, nonunion, with blood loss of 528 ml, operating time of 8 hours, and 70% merger. Conclusions: hemivertebrectomy pedicle subtraction are an alternative that allows the correction of the deformity and column stability(AU)

Algoritmo del tratamiento para el trastorno por déficit de atención con hiperactividad en niños y adolescentes

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Summary The diagnostic criteria for the Attention Deficit Hyperactivity Disorder (ADHD) have been changing according to international classifications. It is currently included in the ICD-10 as an hyperkinetic disorder and in the DSM-IV as a disorder having its onset during childhood and adolescence. The reported prevalence for ADHD is between 3% and 6%; up to 60% of the patients remain symptomatic through adolescence and adulthood. Population-based surveys of physicians who treat children and adolescents reveal that the rate and the proportion of office visits associated with ADHD are high and have increased over the past decade. This fact points to the need of elaborating clinical guidelines for the treatment of this disorder. Evidence from controlled clinical trials confirms the superiority of medication management for ADHD over behavioral therapy and the combination of medication and behavioral treatment. Stimulants are the most studied drugs for ADHD and constitute the first treatment of choice. Methylphenidate (MPH) is the only stimulant available in Mexico. Its mechanism of action is based on the blocking of the dopamine reuptake, which increases the availability of this neurotransmitter in the synaptic cleft. Based on the dopaminergic theories of ADHD, dopamine genes have been the initial candidates for molecular studies regarding response to MPH. Variations of the dopamine D4 receptor gene (DRD4) and the dopamine transporter gene (DAT1) have been related with the response to MPH. The short half life of this drug (less than three hours) supports the shift from once-a-day to twice-a-day or thrice-a-day dosing. The Osmotic Release Oral System (OROS) of MPH allows to maintain therapeutic plasmatic doses with once-a-day dose. Its efficacy and tolerability have been shown in clinical trials. Regarding the long-term effects of MPH, this drug has demonstrated efficacy in a two-year follow-up controlled study. In addition, animal models have shown that the chronic exposure to MPH during developmental periods produces changes in the function of brain dopaminergic cells, as well as changes in behavior. The association between MPH and substance abuse has also been explored. The pharmacokinetic and pharmacodinamic differences between MPH and cocaine, which also acts by blocking the dopamine transporter, were examined: When administered intravenously, MPH, like cocaine, has a reinforcing effects at doses that exceed a 60% dopamine transporter blockade threshold. When administered orally at clinical doses, the pharmacological effects of MPH also exceed this threshold, but reinforcing effects rarely occur. So, the pharmacokinetic properties of MPH in brain differ for oral and intravenous routes of administration, suggesting that the oral administration of MPH mimics the tonic dopamine cell firing, which may be a critical factor associated with clinical effects. In addition, therapeutic doses of MPH do not act at the nucleus accumbens, a brain structure highly associated with reinforcing. These data suggest that oral administration of MPH does not lead to abuse. Follow-up studies have also shown that stimulant therapy is not associated with increased risk of substance abuse. Since 30% of the patients do not respond to stimulant treatment, the efficacy and safety of other drugs have been evaluated. Among them, tricyclic antidepressants (TCAs) are considered a good choice for the management of ADHD and conduct disorders. Their half life is longer than that of MPH, which allows a once-a-day or twice-a-day dosing. It has also been described that TCAs are effective for the treatment of comorbid tics. The main disadvantage of these drugs is their effect on cardiac conduction, which has been associated with sudden death. Bupropion is another antidepressant having an effect on dopamine activity. It has shown efficacy for the treatment of ADHD in children, adolescents, and adults, particularly in patients with nicotine dependence, patients with comorbid conduct disorder, or depression. Bupropion is available in a extended-release, once-daily formulation (XL). The main side effects of this antidepressant are the increased risk of seizure development, rash and mild elevation of blood pressure. This drug is not recommended for the treatment of patients with comorbid eating disorders. Venlafaxine (a serotonin and norepinephrine reuptake inhibitor) and reboxetine (a norepinephrine reuptake inhibitor) are recently introduced antidepressants which have shown efficacy in open label trials on patients with and without comorbid depressive disorder. Atomoxetine is another non-stimulant medication; its main mechanism of action is the inhibition or the reuptake of norepinephrine. Several clinical trials have shown its efficacy for the treatment of ADHD in children, adolescents and adults. This drug can also be administered in a single dose; in addition, it has a low potential for cardiotoxicity and a reduction of tic frequency and severity has been reported with its use. It is also recommended for the ADHD comorbid with anxiety or depression. Nausea and decreased appetite are the most common side effects of atomoxetine. Modafinil is another non-stimulant drug which was initially described for the treatment of narcolepsy. This drug increases the dopamine and norepinephrine activity through its direct effect on glutamate and GABA, among other neuromodulators. Some clinical trials have shown its superiority over placebo on ADHD symptoms. The main side effects of modafinil are gastrointestinal distress and insomnia. Clonidine and risperidone are drugs considered as second treatment of choice or adjunctive treatments for patients with comorbidity. Although medication is the first treatment of choice, patients often get benefits from psychosocial interventions, particularly parent training in contingency management methods and classroom applications of contingency management techniques. The value of these measurements lies in the temporary reduction of symptom levels and/or in the reduction of related behavioral and emotional difficulties, such as defiance and conduct problems, depression, low self-esteem, or academic underachievement. Parents' training focus on general contingency management tactics, such as contingent application of reinforcement or punishment following appropriate/inappropriate behaviors. Reinforcement procedures have typically relied on praise or tokens, while punishment methods have usually been the loss of tokens or time-out from reinforcement. The classroom management include a continuous communication with teachers, in order to maintain them informed about the illness and its treatment, as well as training on contingency management tactics. The aforementioned information was used in the elaboration of clinical guidelines for the treatment of youngsters with ADHD, either alone or comorbid with internalizing or externalizing disorders. Another guideline for the management of preschool children with ADHD is included. Psychoeducation follows the assessment of the children in each case. The pharmacological treatment recommendations give priority to monotherapy. Stimulants are the first treatment of choice in each guideline. The use of non-stimulant medications as second choice will depend on the age and comorbidity of patients.

Evaluación de las aplicaciones locales de una solución limpiadora suave con Dinafitol de Bardana y pH8: estudio realizado en consulta privada / Evaluation of the local application of a mild cleansing solution: study carried out in private consultation

Estudio realizado en consulta privada de los 17 médicos participantes, en 150 pacientes con vulvovaginitis, de los que se reportan 148 casos provenientes de tres principales ciudades del Ecuador (Guayaquil, Quito y Cuenca).Tipo de estudio: Abierto, multicéntrico, no comparativo.Objetivo: Evaluar la eficacia y tolerancia de una solución limpiadora suave con contenido de Bardana, en el período previo al tratamiento específico, como ayuda en el control del prurito y eritema presentes en las vulvovaginitis.Material y método: Se utilizó una solución limpiadora suave con contenido de Dinafitoles de Bardana y nivel de pH 8. Fueron reclutadas 150 pacientes de acuerdo a los criterios de inclusión, no inclusión y exclusión. La sintomatología fue evaluada al inicio y al final del estudio. Se recomendó el uso del producto en higiene local dos veces al día por siete días mientras se esperaba el resultado del examen cito bacteriológico vaginal.Resultados:•98.0% de mejoría y desaparición del prurito.•96.5% de mejoría y desaparición del eritema.En cuanto a la tolerancia al producto utilizado, el 95.3% reportó la calificación de “buena”.Conclusión: Se logró demostrar la utilidad de la solución limpiadora suave con pH8 y contenido de Dinafitol de Bardana, concluyendo que su utilización está justificada en los casos de vulvovaginitis y que, gracias a la tolerancia y aceptación de las pacientes se puede recomendar también su uso cotidiano en la higiene íntima y corporal. Por los resultados obtenidos, podemos considerar el uso de esta solución limpiadora como de primera elección en el manejo de las patologías relacionadas con el prurito y eritema y como un excelente coadyuvante en el tratamiento etiológico de las vulvovaginitis en las que con frecuencia advertimos la presencia de esta sintomatología.

Study carried out in the private consultation of 17 doctors selected to participate in the study that included 150 patients with vulvovaginitis, of which 148 cases are reported from in the three main cities of the Ecuador, (Guayaquil, Quito and Cuenca). Type of study: Open, multicentral, not comparative. Objective: To evaluate the effectiveness and tolerance of a mild cleansing solution, containing Bardana, during the period prior to a specific treatment, in order to help the control of pruritus and erythema present in the vulvovaginitis. Material and method: A mild cleansing solution with a pH level 8 was used. 150 patients were recruited according to the inclusion and exclusion criteria of the study. The symptoms were evaluated at the beginning and at the end of the study. The use of the product was recommended twice a day for seven days while expecting the results of the bacteriological vaginal exam.Results:•98.0% of improvement and disappearance of pruritus.•96.5% of improvement and disappearance of erythema. As for the tolerance to the use of product, 95.3% of the patients reported it as “good”. Conclusion: It was possible to demonstrate the how important is the use of the mild cleansing solution with a pH 8. We conclude that its use is justified in the case of vulvovaginitis and that thanks to its tolerance and the patients' acceptance, it may also be recommended to be used daily in the intimate and corporal hygiene. With the reported results, one can consider the use of this mild cleansing solution as the first election in the handling of pathologies related with pruritus and erythema and as an excellent help for etiological treatment of the vulvovaginitis in those that frequently notice the presence of this symptoms.

¿El Pandas es un subtipo de trastorno obsesivo compulsivo de los niños? / Is Pandas a subtype of obsessive-compulsive disorder in children?

La prevalencia del trastorno obsesivo compulsivo (TOC) en la población clínica de niños y adolescentes es de 0.2 por ciento a 5 por ciento. Aunque el TOC de los niños comparte algunas características, como la severidad y la respuesta al tratamiento, con el trastorno de los adultos, su etiología y su fisiopatología no están bien establecidas. El acrónimo PANDAS agrupa a las entidades neurológicas y psiquiátricas (el TOC y el síndrome de Tourette) que se presentan como una reacción autoinmune posterior a la infección por estreptococo. La principal característica de este grupo de enfermedades es que los pacientes presentan inicio o exacerbación de sus síntomas en forma abrupta, cuya duración coincide con la aparición de una infección por estreptococo.Los síntomas comórbidos (ansiedad, hiperactividad, trastornos de la conducta)también se presentan en forma abrupta y desaparecen al resolverse la infección. Para evaluar a estos pacientes se requiere determinar si presentan otros síntomas psiquiátricos, y descartar la presencia de enfermedades físicas concomitantes, y hacerles un examen físico completo. La determinación de antiestreptolisinas y el anticuerpo monoclonal, llamado D8/17, son de utilidad para hacer el diagnóstico. Los pacientes con PANDAS responden poco a los tratamientos tradicionalmente utilizados en el TOC. La inmunoterapia (plasmaféresis y aplicación de inmunoglobulina) parece ser una buena opción para controlar los síntomas.

Fusión lumbar: status funcional postoperatorio / Lumbar cualition: postoperatorio functional status

Fueron estudiados 60 pacientes intervenidos quirúrgicamente de la columna vertebral lumbar. La cirugía primaria y en algunos casos de revisión, fueron durante el período 1988-1998. El seguimiento promedio del estudio fue de 10 años. La espondilosis lumbar junto a la enfermedad degenerativa discal representaron los más frecuentes diagnósticos pre-operatorio. El procedimiento quirúrgico consistió en la artrodesis de los segmentos involucrados, a través de un abordaje posterior convencional de la columna lumbar. Se analizó el estatus funcional postoperatorio del paciente y su relación con distintas variables como: sexo, edad, diagnóstico, ocupación, compensación laboral y tipo de cirugía. Se concluye en el trabajo que el 100 por ciento de los pacientes mostraron distintos grados de mejoría clínica, sin importar el método escogido de fusión intervertebral lumbar

Adenoma monomórfico de glándulas salivares menores en paladar duro: presentación de un caso y revisión de la literatura / Salivary gland monomorphic adenoma minors in hard palate: presentation of case and review of literature

Los tumores de glándulas salivares representan el 3 por ciento de las neoplasias de cabeza y cuello, de éstos, el 85 por ciento corresponden a la glándula parótida y el 15 por ciento al resto de las glándulas salivares. De los tumores de glándulas salivares. el Adenoma Monomórfico constituye menos del 2 por ciento y se caracteriza histológicamente por presentar una marcada eosinofilia, con tejido hialino alrededor de los vasos sanguíneos, islotes de epitelio, y abundantes células picnóticas, esta entidad tumoral benigna tiene predilección por glándulas salivares mayores (80 por ciento se originan en parótida) y si se originan en glándulas salivares menores tiene preferencia por el labio superior. En este trabajo presentamos un caso de Adenoma Momomórfico de glándulas salivares menores en paladar duro, encontrado en un paciente masculino de 44 años de edad, con historia de hemialgia facial de 14 años de evolución.