Dos casos de liquen plano con tratamiento de hipnosis: Report of two cases / Lichen planus submitted to hypnosis treatment

El liquen plano es una alteración que afecta la piel, mucosas oral y genital, el cuero cabelludo y uñas. Su etiología incluye factores genéticos, inmunológicos y estrés; puede evolucionar por años y adquirir carácter crónico, presenta alta resistencia a los tratamientos de todo tipo. Se presentan dos casos con diagnósticos de liquen plano múltiple, sometidos a tratamiento de hipnosis con sugerencias terapéuticas directas, en tres direcciones: eliminación de las lesiones, marcas y prevención de nuevos brotes. Se administró una sesión por semana. El tratamiento fue de diez y seis sesiones, respectivamente. Se logró la remisión de los síntomas en ambos casos, el seguimiento no fue suficiente para evaluar la eliminación de las máculas residuales. Aún cuando el control de variables y el número de casos, no permite asegurarlo de manera científica, la hipnosis se perfila como un proceder que puede ser efectivo, en el tratamiento del liquen plano crónico.

Lichen planus is an alteration that affects the skin, oral and genital mucous membranes, the scalp and nails. Its etiology is imprecise, it includes genetic, immunological and stress-related factors, it can evolve for years and acquire the characteristic of a chronic disorder, it has a high resistance to treatments, psychotherapeutic methods have not shown efficiency either. Two cases with a diagnosis of multiple lichen planus submitted to hypnosis treatment with direct therapeutic suggestions, in three directions: elimination of lesions, marks, and prevention of new outbreaks are presented. One session per week was administered. The treatment lasted ten and six sessions respectively, the evolution was favorable, the remission of the symptoms was achieved in both cases, which had not been achieved with any previous treatment. The follow-up was not long enough to evaluate the elimination of residual spots. The importance of the cases presented lies in the favorable evolution of both under hypnotherapy, if taken into account their chronic nature and the lack of response to other treatments. Although it can not be ensured scientifically, by the small sample and by the impossibility of controlling variables, that the evolution is a result of the intervention performed, hypnosis is emerging as a procedure that can be effective in the treatment of chronic lichen planus, used as a single procedure or combined with other treatments.

Microcalcificaciones y focos ecogénicos puntiformes, ¿qué tan bien sabemos lo que estamos viendo? / Microcalcifications and punctate echogenic foci, how well do we know what we are seeing?

Resumen: La presencia de microcalcificaciones en nódulos tiroideos es un signo muy específico de malignidad, al corresponder a cuerpos de Psammoma. No existen suficientes estudios que demuestren una correlación entre su presencia histológica y su aspecto ecográfico real. Materiales y Métodos: Se seleccionaron todos los nódulos con tamaño mayor a 3 cm puncionados en el Hospital Clínico Universidad Católica entre los años 2010-2015 y se clasificó el aspecto ecográfico según la presencia de 3 tipos de focos ecogénicos con una definición más estricta a lo usual. Se correlacionó lo anterior con hallazgos en biopsias. Resultados: 44 nódulos correspondieron a cáncer papilar de tiroides. Hubo relación estadísticamente significativa entre una nueva definición ecográfica de las microcalcificaciones (focos ecogénicos puntiformes) y la presencia histológica de cuerpos de psamomma. Discusión: Habría una buena correlación entre una definición más estricta y la presencia real de microcalcificaciones en histología, mejorando la alta tasa de sobrediagnóstico advertido recientemente por algunos autores.

Abstract: The presence of microcalcifications in thyroid nodules is a very specific sign of malignancy, as it corresponds to Psammoma bodies. There are not enough studies that demonstrate a correlation between their histological presence and their actual ultrasound appearance. Materials and Methods: All nodules larger than 3 cm punctured at the Universidad Católica Clinical Hospital between 2010-2015 were selected, and the sonographic appearance was classified according to the presence of 3 types of echogenic foci according to a stricter definition than usual. The above was correlated with findings in biopsies. Results: 44 nodules corresponded to papillary thyroid cancer. There was a statistically significant relationship between a new ultrasound definition of the microcalcifications (punctate echogenic foci) and the histological presence of psamomma bodies. Discussion: There would be a good correlation between a stricter definition and the actual presence of microcalcifications in histology, improving the high rate of over diagnosis recently noticed by some authors.

Tratamiento multidisciplinario del Síndrome de Goldenhar: reporte de caso / Multidisciplinary treatment Goldenhar Syndrome: case report

Los síndromes polimalformativos se refieren a un patrón de anomalías multiples con relación patogénica entre sí, sin que representen una secuencia; el Síndrome Goldenhar es de rara aparición, ha sido identificado como una displasia óculo-aurículo-vertebral, su severidad y pronóstico están directamente relacionados con problemas derivados de las malformaciones. Se reporta el caso de un paciente masculino de 13 años de edad con diagnóstico de Síndrome Goldenhar, y antecedente de labio y paladar fisurado pre-foramen unilateral derecho (clasificación de Spina), ausencia de pabellón auricular izquierdo y parálisis facial leve del lado izquierdo. Se planteó un tratamiento multidisciplinario ortodoncico-quirúrgico, La atencion de pacientes sindrómicos requiere del análisis de las características del síndrome para que el clínico pueda establecer sus objetivos y limitaciones en cuanto a planificación de tratamiento. El abordaje de las malformaciones asociadas a un síndrome debe realizarse en una secuencia lógica y bien analizada con el fin de brindar al paciente un tratamiento eficaz y eficiente.

Polymalformation syndromes refer to a pattern of multiple anomalies pathogenic relationship with each other, without representing a sequence; the Goldenhar syndrome is very rare and has a weak genetic component, it has been identified as an oculo-auriculo-vertebral dysplasia and its severity and prognostic is related to the malformations problems. This case describes a 13 years old male patient diagnosed with Goldenhar syndrome which records show a history of cleft lip and palate right unilateral pre-foramen, no left ear and slight left facial paralysis. For treatment was planned a multidisciplinary approach with an ortho-surgical fase. The attention of syndromic patient requires the analysis of each syndrome's characteristics so the clinician can establish his goals and limitations. The approach of anomalies associated to a syndrome must have a logical sequence and well analyzed so the patient can receive an efficient and effective treatment.

Incidencia de granulomas en el lecho tiroideo con el uso de bisturí ultrasónico en pacientes sometidos a tiroidectomía total por cáncer / Postoperative thyroid bed granuloma incidence using ultrasonic knife in total thyroidectomy in cancer patients

Background: The postoperative thyroid bed granuloma incidence is high and it is an adittional difficulty for the ultrasound differential diagnosis of eventual local cancer recurrence. The ultrasonic knife utilization eventually can reduce the incidence of these granuloma when is compare with other traditional ligatures methods. Objective: to evaluate the postoperative thyroid bed granuloma incidence with the ultrasonic knife utilization, detected by ultrasound. Methods: retrospective study of 57 evaluable thyroidectomy performed for cancer between March and September 2010. In 46 patients were used traditional ligatures (silk or linen) and in 11, ultrasonic knife. Results: of the 57 patient included, 47 were females. The age average was 44 years old. Postoperative thyroid bed granuloma incidence was 36.3 percent (CI95 percent, 7.9 percent-64.7 percent) in the group where ultrasonic knife was used and 36.9 percent (IC95 percent, 23.0 percent-50.9 percent) in which traditional ligatures were used. No statistical difference was found (p = 0.974). Conclusions: The ultrasonic knife utilization had not reduced the postoperative thyroid bed granuloma incidence, when was compared with conventional ligatures. In this sense, this device is probably unable to add benefits for the differential diagnosis of thyroid cancer local recurrence.

Introducción: La incidencia de granulomas postoperatorios en el lecho tiroideo es alta y dificulta el diagnóstico diferencial ecográfico de posibles recidivas locales en cáncer. La utilización de bisturí ultrasónico disminuiría la incidencia de estos granulomas en comparación con métodos de sutura y hemostasia tradicionales con ligaduras. Objetivo: Evaluar si el uso de bisturí ultrasónico disminuye la incidencia de granulomas postoperatorios en el lecho tiroideo, que se detectan ecográficamente. Métodos: Retrospectivamente se revisaron los hallazgos ecográficos postoperatorios de 57 pacientes evaluables con cáncer de tiroides operados entre marzo y septiembre de 2010. En 46 pacientes se utilizó ligaduras (lino o seda) y en 11, bisturí ultrasónico. Resultados: De los 57 pacientes, 47 fueron mujeres. La edad promedio fue 44 años. La incidencia de granulomas fue 36,3 por ciento (IC95 por ciento de 7,9 por ciento-64,7 por ciento) en los pacientes en que se utilizó bisturí ultrasónico y 36,9 por ciento (IC95 por ciento de 23,0 por ciento-50,9 por ciento) en los pacientes en que se utilizó ligadura convencional. No hubo diferencia estadística (p = 0,974). Conclusiones: El uso de bisturí ultrasónico no disminuyó la incidencia de granulomas del lecho tiroideo, comparado con suturas convencionales. De esta forma, este recurso no aportaría beneficio en la diferenciación ecográfica de nódulos en el lecho tiroideo que pueden corresponder a recidivas tumorales o granulomas cicatriciales.

Medición volumétrica de grasa visceral abdominal con RM y su relación con elastografía hepática en una población diabética / Volumetric measurement of abdominal visceral fat by MRI and its relation to transient elastography in a diabetic population

Background. Increase in visceral fat is associated to the development of fatty liver and liver fibrosis. Hepatic elastography is a novel noninvasive method for assessing liver fibrosis. Objective. To evaluate the relationship between visceral adipose tissue volume (VAT), subcutaneous adipose tissue volume (SAT) as measured by Magnetic Resonance Imaging (MRI) and transient elastography (TrE) values using ARFI (Acoustic Radiation Force Impulse) in type 2 Diabetic Mellitus patients (DM2). Methods. We included 20 DM2 patients (mean age: 62 years, range: 55-75, mean weight: 77.8 kg, range: 61.5-97). Patients underwent an MRI study in a Philips Intera 1.5T scanner. MR imaging protocol included a spectral excitation sequence centered on the fat peak. The sequence included 32 cross sections, 7mm thick, from the diaphragmatic cupula to the inferior border of the kidney. VAT was measured by using the semiautomatic Image J software. Each patient underwent a hepatic elastograpy (HE); 10 ARFI measurements were performed in the right hepatic lobe. Finally, a statistical analysis was performed by applying Pearson correlation between abdominal fat volumes and ARFI scores Results. Mean VAT was 2472 +/- 861 cc, (1173-4020 cc), whilst the mean ARFI was 1.62 ± 0.8 m/s, (0.8-3.4 m/s). Correlations obtained were r=0.08 between VAT and ARFI (p=0.72); 0.13 between SAT and ARFI (p=0.57), and -0.06 between (VAT+SAT) and ARFI (p=0.77). By subdividing the sample universe, we observed that the group with ARFI scores greater than 1.6 m/s (7 patients) had a correlation of 0.63 between VAT and ARFI (p=0.12); of 0.66 between SAT and ARFI (p=0.10), and of 0.94 between VAT+SAT and ARFI (p=0.001). In the subgroup with ARFI values inferior to 1.6 m/s (13 patients), the correlation was of 0.11 between VAT and ARFI (p=0.71); of 0.26 between SAT and ARFI (p=0.38), and of 0.32 between ( VAT+SAT) and ARFI (p=0.28). When adjusted for gender, ARFI scores greater than.

Introducción. La acumulación de grasa visceral se asocia al desarrollo de enfermedad hepática. La elastografía hepática es un método novedoso no invasivo para evaluar fibrosis hepática. Objetivo. Evaluar la relación entre el volumen de tejido adiposo visceral (VAT), volumen de tejido adiposo subcutáneo (SAT) medido por resonancia magnética (RM), con índices de elastografía hepática (EH) utilizando ARFI (fuerza de impulso de radiación acústica) en pacientes con Diabetes Mellitus tipo 2 (DM2). Métodos. Fueron incluidos 20 pacientes (edad promedio: 62 años, rango: 55-75 años, peso promedio: 77,8 kg, rango: 61,5-97 kg) con DM2. Los pacientes se sometieron a un examen de RM en un resonador Philips Intera 1.5T. Al protocolo de RM se agregó una secuencia de excitación espectral centrada en el peak de grasa. La secuencia incluyó 32 cortes transversales, grosor 7mm, desde la cúpula diafragmática hasta el borde inferior renal. En las imágenes se midió VAT utilizando el software Image J (freeware). En cada paciente se realizó una EH, utilizando ARFI con 10 medidas en lóbulo hepático derecho. Finalmente, se realizó un análisis estadístico a través de la correlación de Pearson entre los volúmenes de grasa abdominal y ARFI. Resultados. El promedio de VAT fue 2472 +/- 861 cc, (1173-4020 cc), el promedio de ARFI fue 1,62 ± 0,8 m/s, (0,8-3,4 m/s). Se obtuvieron correlaciones de r=-0,08 entre VAT y ARFI (p=0,72), de 0,13 entre SAT y ARFI (p=0,57), y de -0,06 entre (VAT+SAT) con ARFI (p=0,77). Subdividiendo el universo muestral, se encontró que el grupo con ARFI mayor que 1,6 m/s (7 pacientes) obtuvo una correlación de 0,63 entre VAT y ARFI (p=0,12), de 0,66 entre SAT y ARFI (p=0,10), y de 0,94 entre (VAT+SAT) con ARFI (p=0,001). En el subgrupo con ARFI inferior a 1,6 m/s (13 pacientes) la correlación fue 0,11 entre VAT y ARFI (p=0,71), de 0,26 entre SAT y ARFI (p=0,38), y de 0,32 entre (VAT+SAT) y ARFI (p=0,28).

Utilidad y complicaciones de la biopsia percutánea esplénica con aguja tru-cut guiada por imágenes / Ultrasound guided needle biopsy of the spleen: review of 13 procedures

Background: Needle biopsies of the spleen were avoided due to the fear of bleeding in a highly vascularized organ. However their safety, even using 18 gauge needles, has been demonstrated. Aim: To report the experience with ultrasound guided needle biopsies of the spleen. Material and Methods: Retrospective review of records of ultrasound guided biopsies of the spleen using Tru-cutTM needles, performed between 2005 and 2009. Results: Thirteen procedures performed in 12 patients were identified. A specific diagnosis was achieved in nine (69 percent) procedures (lymphoma in four, melanoma in 2, sarcoma in 1, extremedullary erythropoiesis in one and splenic cryptococcosis in one. Two patients with negative results were subjected to a new biopsy, which yielded the diagnosis of lymphoma. A third patient was studied elsewhere, finding a malignant tumor. Two patients had complications, one had a vagal reaction and other had a perisplenic hematoma without clinical repercussion. Conclusions: Ultrasound guided needle biopsy of the spleen is a safe and useful procedure.

Objetivo: Reportar la experiencia de biopsias percutáneas esplénicas con aguja tru-cut guiadas por imágenes. Materiales y Métodos: Revisión retrospectiva de biopsias esplénicas con aguja tru-cut guiadas por ultrasonido (US) y tomografía computada (TC) realizadas en nuestro hospital desde Enero de 2005 a Abril de 2009. Resultados: Se identificaron un total de 13 procedimientos. La biopsia percutánea logró un diagnóstico específico en 9 (69 por ciento) de las 13 intervenciones. Los diagnósticos fueron linfoma (n = 4), melanoma (n = 2), sarcoma (n = 1), hematopoyesis extramedular (n = 1) y criptococosis esplénica (n = 1). De las biopsias no diagnósticas 3 casos correspondieron a patología neoplásica y uno a patología benigna. Se reportaron 2 complicaciones (15 por ciento). Discusión: La biopsia esplénica percutánea guiada por imágenes con aguja tru-cut es un procedimiento útil y seguro, capaz de determinar el diagnóstico definitivo en la mayoría de los pacientes y evitar la mayoría de las esplenectomías diagnósticas.

Classification and hearing evolution of patients with sudden sensorineural hearing loss

The aim of this study was to analyze clinical aspects, hearing evolution and efficacy of clinical treatment of patients with sudden sensorineural hearing loss (SSNHL). This was a prospective clinical study of 136 consecutive patients with SSNHL divided into three groups after diagnostic evaluation: patients with defined etiology (DE, N = 13, 10%), concurrent diseases (CD, N = 63, 46.04%) and idiopathic sudden sensorineural hearing loss (ISSHL, N = 60, 43.9%). Initial treatment consisted of prednisone and pentoxifylline. Clinical aspects and hearing evolution for up to 6 months were evaluated. Group CD comprised 73% of patients with metabolic decompensation in the initial evaluation and was significantly older (53.80 years) than groups DE (41.93 years) and ISSHL (39.13 years). Comparison of the mean initial and final hearing loss of the three groups revealed a significant hearing improvement for group CD (P = 0.001) and group ISSHL (P = 0.001). Group DE did not present a significant difference inthresholds. The clinical classification for SSNHL allows the identification of significant differences regarding age, initial and final hearing impairment and likelihood of response to therapy. Elevated age and presence of coexisting disease were associated with a greater initial hearing impact and poorer hearing recovery after 6 months. Patients with defined etiology presented a much more limited response to therapy. The occurrence of decompensated metabolic and cardiovascular diseases and the possibility of first manifestation of auto-immune disease and cerebello-pontine angle tumors justify an adequate protocol for investigation of SSNHL.

Intoxicación neonatal por sulfato de magnesio: caso clínico / Magnesium neonatal intoxication: a case review

Magnesium Sulfate is currently the treatment of choice for severe preeclampsia and eclampsia. Since it crosses the placenta, magnesium can reach high levels in fetal plasma, occasionally reaching levels higher than maternal plasma. Objective: To analyze a 35 weeks gestational age newborn, who presented hypermagnesemia due to maternal treatment with magnesium sulfate (in routine dosage) indicated for severe preeclampsia. Clinical Case: The mother was infused with MgS04 for 17 hours until pregnancy was interrupted because of fetal monitoring. The baby weighed 2,620 grams, was depressed, hypotonic, cyanotic and without respiratory effort and only partially responded to initial resuscitation with positive pressure ventilation. The infant was admitted to the Neonatal Intensive Care Unit for monitoring, support and management. High levels of plasma MgS04 were found (4.7 mg/dl), compatible with the diagnosis of hypermagnesemia. Symptoms and signs slowly disappeared, and the child was discharged after 10 days of hospitalization. Conclusion: We present the clinical case of a newborn with a history of maternal use of magnesium sulfate, who presented hypermagnesemia characterized by neonatal depression, hypotonia, central apnea with oxygen requirement and who progressively normalized in a 10 day period.

El Sulfato de Magnesio es actualmente el medicamento de elección para el tratamiento de la embarazada con preeclampsia severa y eclampsia. Dado que atraviesa la placenta, alcanza elevados niveles en el plasma fetal, pudiendo en ocasiones superar la concentración plasmática materna. Objetivo: Analizar la evolución de un neonato de 36 semanas de edad gestacional que cursó con cuadro de hipermagnesemia secundario a tratamiento materno con sulfato de magnesio en dosis habituales, indicado como terapia de una preeclampsia severa. Caso clínico: Madre recibe infusión de MgS04 por un total de 17 hrs antes de decidirse la interrupción del embarazo por vía alta debido a un registro sospechoso. Se obtuvo recién nacido de 2 620 gramos, deprimido, sin esfuerzo respiratorio, hipotónico y cianótico, que respondió parcialmente a la reanimación inicial con ventilación a presión positiva. Se decidió ingreso a Cuidados Intensivos de la Unidad de Neonatología para monitorización, soporte y manejo. Se detectaron niveles plasmáticos elevados de MgS04 de 4,7 mg/dL compatibles con el diagnóstico de Hipermagnesemia. La signología fue disminuyendo progresivamente, decidiéndose el alta luego de 10 días de hospitalización. Conclusión: Se presenta caso clínico de un recién nacido, con antecedente de sulfato de magnesio administrado a la madre y que evoluciona con un cuadro de hipermagnesemia caracterizado por depresión neonatal, apneas centrales, requerimientos de oxígeno e hipotonía, los cuales van normalizándose progresivamente en el curso de 10 días.

Pielonefritis aguda en el embarazo y susceptibilidad antimicrobiana de uropatógenos: comparación de dos décadas / Acute pyelonephritis in pregnancy and antimicrobial susceptibility of uropathogens: comparison of two decades

ANTECEDENTES: La infección de tracto urinario (ITU) es la patología infecciosa bacteriana más frecuente del embarazo. Los esfuerzos por lograr una detección precoz y tratamiento adecuado se basan en la toma sistemática de urocultivo al inicio del embarazo, estudiando los agentes causales y la sensibilidad de éstos a los antibióticos recomendados durante la gestación. OBJETIVO: Describir los cuadros clínicos y microbio-lógicos de los casos de ITU registrados en embarazadas atendidas en nuestra institución durante el año 2007 y compararlos con los reportes de 1988 y 2001. MÉTODOS: Se revisaron las historias clínicas de 112 embarazadas que cursaron ITU durante 2007, determinando la frecuencia de pielonefritis aguda (PNA), agente infeccioso y susceptibilidad a los antimicrobianos. Se compararon estos datos con los registrados en 2001 y 1988 mediante el cálculo de Odds Ratios. RESULTADOS: La proporción de PNA mostró una tendencia decreciente entre 1988, 2001 y 2007 (p<0,001). Escherichia coli fue el agente infeccioso más frecuente, sin embargo, su frecuencia disminuyó entre 2001 y 2007 (OR 0,32; IC95% 0,17-0,58). Se observó un aumento de ITU por Streptococcus agalactiae (SGB) (OR 3,98; 1,85-8,67) durante igual período. La sensibilidad antimicrobiana a ampicilina, gentamicina, nitrofurantoina y cotrimoxazol no presentó diferencias significativas entre 2001-2007. CONCLUSIÓN: Se documentó un cambio en el perfil clínico y microbiológico de las ITU en embarazadas, reduciéndose la proporción de PNA e ITU por Escherichia coli.

BACKGROUND: Urinary tract infection (UTI) is the most frequent bacterial infectious pathology during pregnancy. Efforts to accomplish an early detection and treatment are based on universal urine culture during pregnancy, study of etiologic agents and their susceptibility to antimicrobials prescripted during pregnancy. OBJECTIVE: To describe the clinical and microbiological characteristics of cases of UTI in pregnant women attended in our institution during 2007 and compare them with the reports of 1988 and 2001. METHODS: Clinical records of 112 pregnant women who presented UTI were reviewed, establishing the frequency of acute pyelonephritis (APN), infectious agent and antimicrobial susceptibility. Data were compared statistically with the records of 2001 and 1988 by calculating odds ratios. RESULTS: The proportion of APN showed a decreasing trend between 1988, 2001 and 2007 (p<0.001). Escherichia coli was the most frequent infectious agent, although its frequency reduced between 2001 and 2007 (OR 0.32; IC95% 0.17-0.58). On the other hand, the frequency of UTI caused by Streptococcus agalactiae (GBS) increased during the same period of time (OR 3.98; 1.85-8.67). Antimicrobial susceptibility to ampicillin, gentamicin, nitrofurantoin y cotrimoxazole did not present significant differences between 2001-2007. CONCLUSION: A change in the clinical and microbiological characteristics of UTI in pregnant women was documented. The proportion of APN and UTI caused by Escherichia coli were reduced.

Hiperparatiroidismo normocalcémico asociado a hipovitaminosis D, hipercalciuria renal y nódulo paratiroideo: caso clínico / Normocalcemic hyperparathyroidism secondary to vitamin D deficiency and renal hypercalciuria: report of one case

We report a 77 years old woman with osteoporosis in whom a hyperparathyroidism secondary vitaminD deficiency and renal hypercalciuria was diagnosed. Serum calcium was normal. During the diagnostic work up, a parathyroid nodule was discovered and subjected to a fine needle aspiration biopsy, that showed normal parathyroid cells. The patient was treated with calcitriol, cholecalciferol, hydrochlorothiazide and intravenous zolendronic acid. There was a reduction in urinary calcium and serum PTH levels and improvement of serum 25 hydroxy vitamin D levels.

Sepsis neonatal por Streptococcus Grupo B / Group B Streptococcus neonatal sepsis: up-to-date

Group B Streptococcus is one of the leading bacterias causing early onset neonatal sepsis. It constitutes an important factor of neonatal morbidity and mortality and high costs in health. Many strategies have been formulated to avoid vertical transmission from the colonized mother to the newborn, in an attempt to prevent infection of the infant. The most used nowadays is antibiotic prophylaxis given to the mother during labor, depending on the results of recto-vaginal culture taken during 35 to 37 weeks of gestation. This strategy has importantly diminished the prevalence of early onset neonatal sepsis by this agent, although there is still concern about the potential generation of antibiotic resistance and drug-induced adverse reactions in the mother. New techniques for prevention are being developed, such as vaccines against Streptococcus. In the newborn, infection caused by Streptococcus has a broad spectrum of clinical manifestations, like sepsis and meningitis which are the most frequent and lethal. Neurological sequelae are common among the survivors, so an early suspicion of disease must lead to a prompt antibiotic treatment.

El Streptococcus grupo B (SGB) es uno de los principales agentes causales de sepsis neonatal precoz, siendo un importante factor de morbimortalidad neonatal y de costos en salud pública. Se han implementado múltiples estrategias para evitar la transmisión vertical desde la madre colonizada a su recién nacido, de modo de prevenir la infección de éste último. La más usada en la actualidad es la profilaxis antibiótica administrada a la madre en el momento del parto dependiendo del resultado de un cultivo perineal realizado entre las semanas 35 y 37 de gestación. Mediante esta estrategia se ha logrado disminuir de manera importante la incidencia de la sepsis neonatal por este agente, pero existen aprehensiones acerca de la posible generación de resistencia antibiótica o reacciones adversas a fármacos por parte de la madre. Por esto último, nuevas técnicas de prevención se encuentran en estudio, como las vacunas contra el SGB. En los recién nacidos la infección por Streptococcus agalactiae puede manifestarse de diversas maneras, siendo la sepsis y la meningitis las más frecuentes y mortales. El porcentaje de secuelas entre los sobrevivientes es elevado, por lo que ante la sospecha precoz de infección debe iniciarse tratamiento antibiótico a la brevedad.

Profilaxis de sepsis neonatal por Streptococcus Agalactiae (grupo B) basada en vacunas: revisión de la literatura / Prophylaxis of early neonatal sepsis Streptococcus Agalactiae (group B) based on vaccines: literature review

El Streptococcus agalactiae o grupo B (SGB), es el principal agente de sepsis neonatal precoz. A pesar de los intentos de prevención de esta infección, aún no se logra la efectividad esperada. Es por esto que se ha intentado desarrollar una vacuna que pueda prevenir la mayoría de las patologías que esta bacteria produce, incluyendo la sepsis neonatal precoz y tardía. De esta manera se evitarían las limitaciones actuales de la profilaxis antibiótica. Los intentos de crear una vacuna han incluido la utilización de polisacáridos del SGB tanto puros como asociados a proteínas como el toxoide tetánico. También, se han usado proteínas específicas de la cápsula que tienen potencial efectividad como factores inmunogénicos. Las vacunas conjugadas son las más estudiadas en la actualidad, habiendo completado estudios clínicos en fase II, tanto en adultos sanos como en embarazadas. Al ser la sepsis neonatal una complicación grave aún no controlada óptimamente, la creación de una vacuna contra este patógeno sería de gran impacto en salud pública. Se presentan los diferentes tipos de vacunas desarrolladas y el estado de avance en el que se encuentran.

Streptococcus agalactiae or group B, is the mayor causing agent of early onset neonatal sepsis. Although mayor prevention strategies have been made, the expected effectiveness hasn't been achieved. That's why efforts have been made to develop a vaccine that can prevent most of the diseases these bacteria can produce, including early and late onset neonatal sepsis. These way, actual antibiotic prophylaxis limitations can be avoided. Attempts include the utilization of Streptococcus group B polysaccharides in their pure state or combined with proteins as tetanic toxoid. Specific capsule proteins have been used also because of their potential effectiveness as inmunogenic factors. Overall vaccines conjugated ones are the most studied, having completed phase II clinical trials in healthy adults and pregnant women. Neonatal sepsis is a severe complication that has not been controlled yet, so the creation of a vaccine against this pathogen would be of great impact in public health. We introduce now the different developed vaccines and their state of progress.

Tiroglobulina y sus limitaciones en el seguimiento del carcinoma diferenciado del tiroides: Report of two cases / Recurrence of differentiated thyroid carcinoma without concomitant elevation of serum thyroglobulin

Thyroid carcinoma is the most prevalent endocrine tumor, and the papillary carcinoma (PC) is the most common histological type. In the follow-up, after thyroidectomy serum thyroglobulin (s-Tg) is used as a marker to evaluate recurrence of thyroid carcinoma. In most cases, this parameter allows an adequate diagnosis, but occasionally s-Tg may miss the detection of a recurrence. We report a 57 year-old female and a 36 year-old male sujected to a total thyroidectomy for a papillary thyroid carcinoma with intermediate and high-risk of recurrence. Both had a cervical recurrence without a concomitant increase in s-Tg levels. In both, Tg staining was positive in the tumor cells. These cases confirm that in these patients, the follow-up must be done with measurement of s-Tg and complementary diagnostic tests.

Conocimiento sobre polifarmacia en un grupo de personas de 65 años o más residentes en una egida del área metropolitana en Puerto Rico / Knowledge on polypharmacy in a group of 65-year-old people or older living in a sector of the metropolitan area of Puerto Rico

Addressing the high utilization of medications among the elderly, this study explored the degree of knowledge of polypharmacy and its consequences, as well as the pattern of utilization by a group of elders 65 years of age and over in the San Juan metropolitan area of Puerto Rico. A dual technique was utilized: focus groups and a survey. Two focus groups were performed in order to explore issues pertaining the following domains: quality of life, doctor-patient and pharmacist-patient relationships, degree of knowledge of polypharmacy, and need of information. A questionnaire was administered to obtain information regarding their pattern of drug utilization. Results of focus groups indicated that the elderly have learned how to cope with their chronic conditions and be able to continue with quality of life. Additionally, results suggested a need form the elderly to develop more assertiveness and closeness with their health care providers, both doctor and pharmacist; as well as a lack of sufficient knowledge of the serious implications that polypharmacy brings. Results from the survey revealed and confirmed their inappropriate utilization of medications, and suggest that this segment consults multiple physicians, all of which may bring potential problems of adverse drug interactions. Further investigation is needed to examine fully the issue of polypharmacy, as well as the need of education that results in empowerment of patients, families and communities.

Características de presentación del microcarcinoma papilar del tiroides. Experiencia retrospectiva de los últimos 12 años / Pathological characteristics of thyroid microcarcinoma. A review of 402 biopsies

Background: Thyroid microcarcinoma is a tumor of 10 mm or less, that should have a low risk of mortality. However, a subgroup of these carcinomas is as aggressive as bigger tumors. Aim: To describe the pathological presentation of these tumors, and compare them with larger tumors. Material and methods: All pathological samples of thyroid carcinoma that were obtained between 1992 and 2003, were studied. In all biopsies, the pathological type, tumor size, the focal or multifocal character, the presence of lymph node involvement and the presence of lymphocytic thyroiditis or thyroid hyperplasia, were recorded. Results: One hundred eighteen microcarcinomas and 284 larger tumors were studied. The mean age of patients with microcarcinoma and larger tumors was 42.7±14 and 49.3±16 years respectively (p <0,001) and 83% were female, without gender differences between tumor types. Mean size of microcarcinomas was 8.6 mm and 116 (98%) were papillary carcinomas. Of these, 109 (94%) were well differentiated and seven (6%) were moderately differentiated. Thirty six (31%) were multifocal and in 10 (8,6%), there was lymph node involvement. The mean size of larger tumors was 23.8 mm and 241 (85%) were papillary carcinomas. Of these, 200 (83%) were well differentiated, and 41 (17%) were moderately differentiated. Eighty five (35%) were multifocal and in 44 (18%) there was lymph node involvement. The prevalence of thyroiditis and hyperplasia was significantly higher among microcarcinomas than in larger tumors (15 and 2.5%, respectively, p <0.001, for the former; 32.4 and 1.7%, respectively, p <0.001, for the latter). Conclusions: In this series, one third of microcarcinomas were multifocal and 10% had lymph node involvement. Therefore, the aggressiveness of these tumors is higher than what is reported in the literature and they should be treated with total thyroidectomy.

Tuberculosis ganglionar retroperitoneal y mesenterica: caso clinico / Retro-peritoneal and mesenteric ganglionary tuberculosis: clinical case

Se describen las características del compromiso ganglionar por Mycobacterium tuberculosis en un paciente con SIDA en quien se demuestra alteraciones de linfonódulos retroperitoneales y mesentéricos en tomografía computada. Se discute las diferencias con el compromiso secundario a infección por Mycobacterium avium intracellulare y además el diagnóstico diferencial con otras formas de compromiso ganglionar.

Enfermedad vesicular inaparente o microlitiasis en pacientes con pancreatitis aguda: una situación clínica frecuente / Occult gallbladder disease or microlithiasis in patients with acute pancreatitis: a frequent clinical situation

Patients admitted with the diagnosis of AP to a clinical hospital were included in the study. According to an abdominal ultrasound study, patients were classified as having or not cholelithiasis. A duodenal biliary drainage was performed in 15 patientes with AP and without gallbladder stones. Results: Patients without cholelithiasis had recurrent AP more often than patients with biliary AP (53 and 3.3 percent respectively). Excessive alcohol ingestion did not rule out the possibility of biliary etiology. In 6 patients, the analysis of duodenal bile showed cholesterol crystals, and cholecystectomy confirmed the existence of gallbladder disease in 54. All of them remained asymptomatic during a follow-up period of four years. One patient refused surgery, with subsequent development of galls tones and recurrent episodes of AP. In other 4 patients, gallbladder disease was confirmed by percutaneous gallbladder puncture or during cholecystectomy. No recurrence of AP were observed during the follow-up. Conclusions: Microlithiasis or "occult" gallbladder disease accounts for at least 67 percent of the original "non-biliary" AP. Duodenal bile analysis is a useful and necessary technique for the evaluation of patients with "non-biliary" actue pancreatitis. Careful clinical and echographic follow-up of this subgroup of patients with AP is mandatory