Dolor lumbar: revisión y evidencia de tratamiento / Low back pain: review and evidence of treatment

El dolor lumbar corresponde a uno de los síntomas más prevalentes en la humanidad, siendo la segunda causa más frecuente de atención médica a nivel mundial. Existen diversos enfoques de diagnóstico y tratamiento para dolor lumbar, entre ellos la temporalidad del síntoma, el trabajo de diagnóstico sindromático, los síntomas de alarma, también llamados "banderas rojas", que pueden hacer sospechar patologías de mayor gravedad o urgencia. El estudio etiológico puede ser necesario en casos agudos con estas banderas rojas y en casos crónicos. Este estudio se realiza principalmente con imágenes (radiografías, tomografía computada, resonancia magnética, SPECT/CT) y ocasionalmente con exámenes de laboratorio. La mayor parte de los tratamientos están enfocados en el manejo conservador, principalmente el ejercicio físico guiado y asociado a fármacos analgésicos. Existen terapias alternativas tales como la acupuntura, el tai-chi, entre otros, algunas de ellas han mostrado ser un buen complemento al manejo del dolor lumbar. El enfoque multidisciplinario es la tendencia más actual de manejo, esto incluye el trabajo e intervención de diversos profesionales abordando el problema de forma integral, incluyendo el manejo psicoterapéutico. Intervenciones como las infiltraciones de columna han demostrado reducir el dolor por tiempos cortos, siendo útiles como puente para realizar un tratamiento apropiado. La cirugía solo se reserva para casos refractarios, siendo controversiales los resultados existentes en la literatura.

Low back pain is one of the most prevalent symptoms in humanity, being the second most common cause of medical attention worldwide. There are various approaches to diagnosis and treatment for low back pain, including the temporality of the symptom, the work of syndromatic diagnosis, the alarm symptoms, also called "red flags", that can make suspect pathologies of greater severity or emergency. The etiological study may be necessary in acute cases with these "red flags" and in chronic cases. This study is mainly done with images (X-rays, CT scan, MRI, SPECT/CT) and occasionally with laboratory tests. Most of the treatments are focused on conservative management, mainly guided physical exercise associated with analgesic drugs. There are alternative therapies such as acupuncture, tai-chi, among others, some of them have proven to be a good complement to the management of low back pain. The multidisciplinary approach is the most current management trend, this includes the work and intervention of various professionals addressing the problem in an integral way, including psychotherapeutic management. Interventions such as spinal infiltrations have been shown to reduce pain for short times, being useful as a bridge for proper treatment. Surgery is only reserved for refractory cases, the results existing in the literature being controversial.

The role of left atrial enlargement and age in the prediction of recurrence in embolic strokes of undetermined source / El papel del crecimiento auricular izquierdo y la edad como predictores de recurrencia en infarto cerebral embólicos de origen indeterminado

Abstract Objectives: Left atrial disease is an independent risk factor for ischemic stroke and can be used to predict atrial fibrillation (AF). We examine whether left atrial enlargement (LAE) could predict stroke recurrence in patients with embolic stroke of undetermined source (ESUS). Materials and methods: Sixty-four patients with a confirmed diagnosis of ESUS were followed for a median of 22 months. Clinical data and echocardiogram findings were recorded. The echocardiogram interpretation was performed centrally and blindly. The Brown ESUS – AF score was used to categorize patients into high (human resource planning [HRP]: score > 2) and low-risk patients (non-HRP score 0-1). Stroke recurrence was the primary outcome. Results: The median age was 62 years (range: 22-85 years); and 33 (51.6%) were men. The median initial NIHSS score was three points (range: 0-27). Twelve (18.8%) patients were categorized as HRP. We found a significant tendency toward recurrence among HRP versus non-HRP patients. Three (25%) HRP versus 2 (3.8%) non-HRP experienced recurrence (OR: 8.3 95% CI 1.2-57; p=0.042); this association was related to severe atrial dilatation (OR: 14.5 95% CI 0.78-277, p = 0.02) and age > 75 years (OR: 12.7 95% CI 1.7-92.2, p = 0.03). We found no differences in recurrence in a univariate analysis. Conclusions: Patients with severe LAE who are 75 years old or older have a significant tendency to experience stroke recurrence.

Resumen Objetivos: La patología atrial izquierda es factor de riesgo independiente para infarto cerebral y puede utilizarse para predecir fibrilación auricular. Examinamos si el crecimiento aurícular izquierdo puede predecir recurrencia en pacientes con infarto embolico de origen indeterminado (ESUS). Materiales y métodos: Sesenta y cuatro pacientes con diagnóstico confirmado de ESUS fueron seguidos por una mediana de seguimiento de 22 meses. Registramos los datos clínicos y ecocardiográficos. La interpretación ecocardiográfica fue centralizada y cegada. La escala de Brown ESUS – AF fue utilizada para categorizar a los pacientes en riesgo alto (HRP puntaje > 2) y bajo riesgo (no-HRP: puntaje 0-1). El descenlace primario fue recurrencia de infarto cerebral. Resultados: Mediana de edad fue de 62 años (rango: 22-85 años); 33 (51.6%) fueron hombres. La mediana inicial de la escala de NIHSS fue de 3 putnos (rango de 0 a 27). 12 (18.8%) pacientes fueron de alto riesgo (HRP) y 52 (81.3%) de bajo riesgo (non- HRP). El grupo HRP mostró tendencia significatica hacia mayor recurrencia. Tres (25%) HRP versus 2 (3.8%) no-HRP experimentaron recurrencia (OR: 8.3 IC 95% 1.2-57; p = 0.042); esta asociación se relacionó con dilatación auricular severa (OR: 14.5 IC 95% 0.78-277, p = 0.02) y edad > 75 años (OR: 12.7 IC 95% 1.7-92.2, p = 0.03). En el análisis multivarioado, no encontramos significativas. Conclusiones: El crecimiento auricular izquierdo severo y la edad mayor de 75 años mostraron tendencia significativa a recurrencia de infarto cerebral.

Differences in knee sensorimotor control by physical activity level and sex / Diferenças no controle sensorimotor do joelho por nível atividade física e sexo

ABSTRACT Objective: The aim of this study was to compare the differences in knee sensorimotor control between healthy men and women by measuring the joint position sense (JPS), sensation of muscle tension (steadiness), and onset of muscle activation (OMA). Methods: Twenty-four healthy women and 27 healthy men were tested. Knee sensorimotor control was assessed using the JPS test with electrogoniometers in 3 different ranges of motion, sensation of muscle tension using the isometric steadiness technique, and OMA against a mechanical perturbation. Each assessment was compared by sex, physical activity level, and right or left lower limb. Results: The men obtained better values in the JPS test between 90º and 60º and between 30º and 0º than the women. The subjects with higher levels of physical activity also showed better values, between 90º and 60º and between 30º and 0º. The best results for steadiness were found in the women and the subjects with higher levels of physical activity. In the OMA test, no significant differences were found in the studied variables. Conclusion: The results suggest that higher levels of physical activity may determine better sensorimotor control. Men have better articular sensation, and women have better muscle strength control. Level of evidence III, Cross sectional study.

RESUMO Objetivo: O objetivo desse estudo foi comparar as diferenças no controle sensório-motor de joelho entre mulheres e homens saudáveis medindo o sensação da posição articular (SPA), Coeficiente de variações da força (Steadiness) e inicio ou ativação muscular (IAM) Métodos: Foi avaliado 24 mulheres saudáveis e 27 homens saudáveis, realizando avaliações de SPA, o Sensação de tensão muscular (Steadiness) e o IAM, comparadas segundo sexo, nível de atividade física e extremidades inferiores direita ou esquerda. Resultados: SPA: Os homens obtiveram melhores valores nessa prova entre 90-60° (p=0,0127) e em 30-0° (p=0,0017) ao comparado com as mulheres. as pessoas com maior nível de atividade física também se encontram melhores resultados entre 90-60° (p=0,0328) e 30-0° (p=0,0173). STEADINESS: Os melhores resultados foram para as mulheres em ambas extremidades (direita p=0,0002 e esquerda p=0,0009) e pessoas com maior nível de atividade física (direita p=0,0065 e esquerda p=0,0173). Para IAM não foi encontrado diferenças significativas nas variáveis estudadas. Conclusão: Os resultados sugerem que tanto maior nível de atividade física puderam determinar maior resultado no controle sensório-motor. Os homens tiveram maior sensação articular e as mulheres maior controle steadiness. Nível de evidência III, Estudo transversal.

¿Es importante la experiencia del cirujano en el porcentaje de márgenes positivos en la prostatectomía radical? / Correlation between the surgeons experience and the rate of positive surgical margins in radical prostatectomy

Los márgenes positivos son un factor de riesgo de recurrencia después de una prostatectomía radical. La experiencia del cirujano sería fundamental para prevenirlos. Estudiamos el impacto de los márgenes positivos en la recurrencia y la experiencia del cirujano como factores predictores de márgenes positivos. Material y método: Revisión de pacientes de bajo a intermedio riesgo (estadio T2 o menos, APE 10 o menos y Gleason 7 o menos) sometidos a prostatectomía radical entre enero de 1999 y diciembre de 2008 (n= 498). Edad promedio 61+/-7 años, 83 por ciento estadio clínico T1c, 17 por ciento T2. APE promedio de6,2+/-1,9 ng/ml. Promedio de seguimiento de 30+/-20 meses. Se evaluó la sobrevida libre de recurrencia bioquímica (APE >0,2), con un modelo de Cox de riesgos proporcionales. Como cofactores estudiamos, la edad, el estadio clínico, el APE, el score de Gleason, el volumen tumoral, compromiso de vesículas seminales, y margen positivo. Se realizó un análisis de regresión múltiple para evaluar el impacto de estos factores en los márgenes positivos, considerando también la experiencia del cirujano (se calculó una mediana de cirugías promedio por año y se dividió el grupo de cirujanos en de alto volumen (mayor a la mediana) o bajo volumen y cirugías realizadas primariamente por residentes. Resultados: El porcentaje de márgenes positivos bajó significativamente durante el periodo 39 por ciento vs 28 por ciento (p<0,05 primeros vs segundos 5 años). El porcentaje de márgenes positivos por cirujano varió entre 4 por ciento y 47 por ciento. Los márgenes positivos (p <0,0003 IC 1,7-6,8) y el compromiso de vesículas seminales (p <0,001 IC2-20,1) predijeron una mayor recurrencia. El volumen del tumoral y la edad se correlacionaron con mayores márgenes positivos no así la experiencia del cirujano o que la cirugía fuera realizada por un residente. Conclusión: El margen positivo es un factor de riesgo significativo para recidiva bioquímica en pacientes...

Positive surgical margins (SM) are a risk factor for recurrence following radical prostatectomy (RP).The surgeon’s experience seems to be fundamental to avoid positive SM. We studied the surgeon’s experience as a predictor for finding positive SM and the impact of positive SM in recurrence rates. Material and method: We reviewed patients with low to intermediate risk (stage < T2, < PSA level of 10 and Gleason < 7) submitted to radical prostatectomy between January 1999 and December 2008 (n =498).Average age was 61 years, 83 percent were stage T1c and 17percent was stage T2. Average PSA level was 6.2 ng/ml. Average follow up was 30 months. The COX model for proportional risks was used to evaluate biochemical recurrence free survival (PSA >0.2). As cofactors, we studied age, clinical stage, PSA level, Gleason score, tumor volume, involvement of seminal vesicles and positive SM. We used multiple regression analysis to evaluate the impact of these factors on positive SM, adding the surgeon’s experience. We calculated a median of average surgeries per year and divided the surgeons into high volume or low volume. Surgeries performed by residents were recorded separately. Results: The percentage of positive SM decreased significantly during the study period: 39 percent vs 28 percent (p <0.05). Percentage of positive SM per surgeon ranged from 4 percent to 47 percent. Positive SM (p <0.0003 CI1.7-6.8) and seminal vesicles involvement (p <0.001 CI 2-20.1) predicted a higher recurrence rate. Tumor volume and age correlated with higher rates of positive SM. However there was no correlation between recurrence rate and the surgeon’s experience. Conclusion: Positive SM is a risk factor for biochemical recurrence in low to intermediate risk patients. This fact does not appear to be related to the surgeon’s experience or to tumor volume.