Certificación y recertificación de especialistas en reumatología: una mirada desde CONACEM / Certification and recertification of specialists in rheumatology: a look from CONACEM

Desde 1984 la Corporación Nacional Autónoma de Certificación de Especialidades Médicas (CONACEM) ha certificado a 12.665 especialistas médicos en Chile. La disciplina de Reumatología inició su certificación en 1985, habiendo certificado hasta diciembre de 2013 a 106 especialistas. Para la certificación existen tres vías posibles: a) Haber aprobado un Programa de Formación Universitario Acreditado, lo que hizo el 37 por ciento de los postulantes; b) Cumplir los requisitos de Adiestramiento en Práctica durante cinco años, como sucedió con el 58 por ciento de los postulantes, y c) Haber sido formado en el extranjero de acuerdo a programas convalidados (5 por ciento). Existen dos programas universitarios acreditados, de dos años de duración, con un cupo total anual de ocho alumnos; ambos se desarrollan en Santiago. Salvo los médicos aprobados en los Programas Universitarios acreditados, el resto de los postulantes requirió aprobar un examen práctico, y desde 2002, además, un examen escrito, como requisito para dar el práctico, y que ha resultado con 0 por ciento de reprobación en el período de 12 años. Las certificaciones dadas hoy tienen una duración de 10 años al inicio y serán de siete años en la recertificación. La caducidad de las certificaciones está aparejada al proceso de recertificación, de lo cual se discuten las razones que lo avalan; se presentan los requisitos y una tabla de créditos a cumplir, elaborada por CONACEM. La legislación vigente, y en proceso, requiere la actuación de al menos una entidad certificadora, condición que ha sido otorgada legalmente en forma única por el Ministerio de Salud a CONACEM a partir del 11/02/2014...

Since 1984, 12.665 different medical specialists have been certified in Chile by the Corporación Autónoma de Certificación de Especialidades Médicas (CONACEM). The certification in Rheumatology specialty was initiated in 1985 reaching 106 candidates approved until December 2013. Three ways are available to achieve certification: a) to be approved by a reputable university program in the specialization; this way has been used by 37 percent of postulants. b) to fulfill the requirements of a 5 years practical training program, as 58 percent of postulants did; c) to have passed a training program abroad, similar to those in force in Chile (5 percent). There are 2 two-year-long reputable university programs with a total annual capacity of 8 students; both programs are developed in Santiago. With the exception of doctors completing reputable university programs, others postulants are require to pass a five days practical examination. Since 2002 a written test has been added, which must be taken and approved as a condition of the practical examination. Written examinations have demonstrated 100 percent approval in 12 years. Extended certifications currently have a 10 years duration for the first time and 7 years for subsequent recertification. Revocation of certification involves installing a recertification mechanism. The reasons that support the recertification are analyzed, and also present the requirements to obtaining it. Current legislation requires that certification and recertification are done by accrediting entities. CONACEM has been legally recognized by de Ministery of Health since February 2014 as the unique entity to perform that labor...

Anticuerpos anti-tiroglobulina en el seguimiento de pacientes con cáncer diferenciado de tiroides: ¿marcadores de enfermedad residual o recidivante? / Anti thyroglobulin antibodies in the follow up of patients with differentiated thyroid cancer

Background: Anti thyroglobulin antibodies are present in 25 percent of patients treated for a differentiated thyroid cancer, invalidating thyroglobulin determination. Those patients subjected to total thyroidectomy and free of disease, should reduce the production of these antibodies, due to the lack of antigenic stimulus. Therefore, anti thyroglobulin antibodies could be useful to detect early relapses. Aim: To assess the relationship between anti thyroglobulin antibodies and the evolution of the disease in patients treated for thyroid cancer. Material and methods: Retrospective analysis of 26 patients treated for thyroid cancer with positive anti thyroglobulin antibodies, followed for three years. These were divided in those with or without lymphocytic thyroiditis (19 and 7 respectively). Results: At the first year of follow up, anti thyroglobulin antibody concentration was 401ñ94.9 UI/ml (xñsem) in patients with thyroiditis and 38.9ñ8.9 UI/ml in those without thyroiditis (p < 0.005). During the three years of follow up, no differences in anti thyroglobulin antibodies were observed between patients with or without tumor relapse. Conclusions: Concentration of anti thyroglobulin antibodies was higher in patients with thyroiditis and did not differentiate patients with tumor relapse

Hamartoma hipotalámico, una causa de pubertad precoz: caso clínico / Hypothalamic hamartoma causing precocious puberty: report of 1 case

Hypothalamic hamartomas are non neoplastic lesions that may cause precocious puberty with or without complex seizures, personality disorders and mental retardation. We report a 14 years old male that had a precocious puberty at the age of 11 and a prolonged episode of altered sensorium with automatism, that was diagnosed as a complex seizure. Physical examination showed a sexual development classified as Tanner stage III-IV, a height of 168 cm and a weight of 61 kg. Neurological examination was normal. A CAT scan showed a 13x13x9 mm mass in the suprasellar cistern, between the infundibulum and the brain stem, without exerting a mass effect over adjacent structures. It was diagnosed as an hypothalamic hamartoma

Efecto de dosis bajas de calcitonina sobre la remodelación ósea en mujeres postmenopáusicas con alto recambio / Effects of low calcitonin doses on bone remodeling in postmenopausal women with high bone turnover rate

Background: Calcitonin is specially indicated for the treatment of osteoporosis in women that cannot receive estrogen replacement therapy or that have a high bone turnover rate. Aim: To study the effects of low intranasal calcitonin doses on bone remodeling in postmenopausal women with a high bone turnover. Patients and methods: Forty one healthy women aged 56 ñ 6 years old, with a mean lapse after menopause of 7.6 ñ 6.5 years and with a high bone turnover rate, evidenced by an urinary hydroxyproline (mg/dl)/creatinine (g/dl) ratio of 52.4 ñ 7.2, were studied. They were randomly assigned to receive 100 or 50 U/calcitonin thrice a week during 3 months or to a control group that received placebo. All received 500 mg/day calcium carbonate. Urinary hydroxyproline/creatinine ratio was measured a 0, 15, 30, 60 and 90 days. Plasma bone fraction of alkanine phosphatases was measured at 0, 30 and 90 days. Results: Initial urinary hydroxyproline/creatinine ratio and plasma bone fraction of alkanine phosphatases were similar in all study groups and there was no change in these parameters during the study period. Conclusions: Intranasal calcitonin in doses of 100 U thrice a week or less, does not modify accelerated bone turnover in postmenopausal women

Recambio óseo en nodrizas adolescentes: evaluación al término de la gestación, lactancia y postdestete / Bone turnover in lactating teenagers: assessment at the end of pregnancy during and after the breast feeding period

Background: There is paucity of information about bone metabolism during pregnancy or breast feeding in teenagers. Aim: To study bone turnover at the end of pregnancy and during breast feeding in teenagers and correlate it with environmental, hormonal or nutritional variables. Subjects and methods: Thirty teenagers during their breast feeding period after a first pregnancy and 30 nulliparous girls matched for age, age of menarche and body mass index were assessed three weeks after delivery (period 1), at six months of breast feeding (period 2) and one year after the lactating period (period 3). Calcium intake and plasma calcium, phosphorus, alkaline phosphatases, parathormone, estradiol and prolactin were measured. Calcium, creatinine and hydroxyproline were also measured in a morning urine sample. Results: Lactating and control girls were aged 16.3ñ0.8 and 16.1ñ0.7 years old respectively. Calcium intake in lactating and control girls was 798ñ421 and 640ñ346 g/day respectively in period 1, 612ñ352 and 592ñ309 mg/day in period 2 and 495ñ180 and 456ñ157 g/day in period 3. During periods 1 and 2, lactating girls had higher alkaline phosphatases (161ñ37 compared to 119ñ28 U/l and 149ñ37 compared to 106ñ23 U/l), parathormone (4.3ñ2.6 compared to 2.8ñ0.8 ng/dl and 3.6ñ1.6 compared to 3.0ñ0.9 ng/dl) and urinary hydroxyproline (95ñ16 compared to 63ñ15 mg/g creatinine and 84ñ19 compared to 59ñ15 mg/g creatinine). No differences were observed in period 3. No correlation between bone turnover variables, body mass index or hormonal parameters, was observed. Conclusions: In teenagers, there is an increase in bone turnover at the end of pregnancy, that persists during the lactating period. These changes are not related to nutritional or hormonal variables

Autoanticuerpos anti-tiroglobulina: detección y posible interferencia en la medición de tiroglobulina en suero / Thyroglobulin autoantibodies: detection and possible interference in serum thyroglobulin measurement

Background: Thyroglobulin measurement is useful for the follow up of patients subjected to total thyroidectomy for differentiated thyroid carcinoma. Thyroglobulin autoantibodies may interfere with its determination. Aim: To measure thyroglobulin autoantibodies and their interference with thyroglobulin determination. Material and methods: The presence of thyroglobulin autoantibodies was investigated in 801 serum samples sent to the laboratory for measurement of thyroglobulin levels. A serum was considered positive for these autoantibodies when radioactivity corresponding to 125I-thyroglobulin bound to thyroglobulin autoantibodies, precipitated with human gamma globulin, exceeded in 1.4 times that of a negative sera pool. In positive sera, thyroglobulin autoantibody concentration was measured and its interference with thyroglobulin radioimmunoassay was assessed through a recuperation test using exogenous thyroglobulin. Results: Thyroglobulin autoantibodies were detected in 149 sera (18.6 percent). Of these, 65 had a recuperation that fluctuated between 1 and 80 percent. Thyroglobulin autoantibody concentration was negatively correlated with recuperation percentages (r= -0.64; p <0.001) but not with thyroglobulin concentrations (r= 0.08). Thyroglobulin was higher in positive sera with a recuperation over 80 percent than in sera with a recuperation of less than 80 percent (12.7 ñ 1.7 and 5.9 ñ 0.6 ng/ml, respectively; p <0.001). Conclusions: Thyroglobulin autoantibodies interfere with thyroglobulin measurement by radioimmunoassay, sequestering variable amounts of thyroglobulin. The presence of these autoantibodies must be investigated prior to thyroglobulin determination

Hipertiroxinemia con eutiroidismo clínico: análisis a propósito de un caso / Hyperthyroxinemia and clinical euthyroidism: report of one case

The association of hyperthyroxinemia and euthyroidism is frequent and characterized by high plasma thyroxin concentrations, normal TSH values and absence of clinical signs of hyperthyroidism. We report an asymptomatic 28 years old male presenting with a serum total plasma thyroxin of 18.5 µg/dl (N 6.1-12.5), a free thyroxin of 2.9 ng/dl (N 0.8-1.4), a TSH of 3.4 µIU/ml (N 0.5-5), and a triiodothyronine of 128 ng/dl (N 80-180). Laboratory assessment did not find high thyroxin binding globulin, albumin or prealbumin concentrations or antithyroxin antibodies. The thyroxin binding capacity of albumin was elevated to 58.2 µg/dl (N 11.5-34.1). TSH responded normally to TRH stimulus and was suppressed with exogenous triiodothyronine, which caused an hyperthyroid syndrome. We concluded that this patient had a familial dysalbuminemia

Carcinoma papilar esclerosante difuso del tiroides: comunicación de dos casos / Diffuse sclerosing papillary thyroid carcinoma: report of two cases

Unlike classical papillary carcinoma, diffuse sclerosing papillary thyroid carcinoma presents as a diffuse goiter with a discretely irregular surface, associated to hypo or hyperthyroidism, specially in young women. We report two women aged 41 and 23 years old with this disease, one with normal thyroid function and the other with hyperthyroidism. It is concluded that diffuse sclerosing papillary thyroid carcinoma must be suspected in patients with rapidly growing goiter with irregular surface or diffuse minute calcifications, specially in the presence of hypo or hyperthyroidism. Fine needle aspiration is a good diagnostic procedure

Poliadenopatías cervicales por enfermedad de Kikuchi y Fujimoto / Cervical polyadenopathies by Kikuchi's and Fujimoto's diseases

Kikuchi and Fujimoto disease is a benign subacute necrotizing lymphadenitis, probably associated to a viral infection, that affects mostly young Asian women. We report a 19 years old woman, with a vast familiar history of thyroid disease (3 uncles with papillary thyroid carcinoma and one with Hashimoto thyroiditis). After an upper respiratory infection, she presented with painless cervical adenopathies. Cervical ultrasound examination detected an 8 mm thyroidal nodule. She was operated with the diagnosis of thyroidal cancer. The pathological examination confirmed that the nodule was papillary thyroidal cancer, but the study of the resected lymph nodes, revealed a Kikuchi and Fujimoto disease

Macrotumor suprarrenal diagnosticado por tomografía axial computarizada: experiencia clínica en 33 casos / Adrenal macrotumor diagnosed by computarized tomography: clinical experience in 33 cases

Thirty three patients aged 9 to 86 years old, 15 female, with an adrenal macrotumor diagnosed by CAT scan, were analized. Thirty percent of tumors were functioning (70 percent secreted cathecolamines and 30 percent cortisol). Eighty two percent had an adrenal localization and 18 percent were para-adrenal. Thirty four percent were malignant. These tumors were mostly non functioning, 70 percent occured in men and 67 percent were metastatic. Most adrenal macrotumors in this series were non functioning and 36 percent were malignant

Modificación de la reabsorción ósea con terapia hormonal de reemplazo en la postmenopausia / Modification of bone resorption with replacement hormonal therapy in postmenopause

Eighty three postmenopausal women without replacement hormonal therapy, 54 postmenopausal women receiving replacement hormonal therapy and 16 premenopausal women (considered as control group) were studied. Hydroxyproline was measured in an early morning urine sample, after one day of diet without meat or gelatin. Urinary hydroxyproline in premenopausal women was 33.7ñ7.9 mg/g creatinine. The figure for postmenopausal women with hormonal replacement therapy was 33.5ñ7.9 mg/g creatinine. Postmenopausal women without replacement therapy had an urinary hydroxyproline of 47.4ñ8.5 mg/g creatinine, significantly higher than that of premenopausal and supplemented women. In 21 postmenopausal women, hydroxyproline was measured before and after 3 months of replacement therapy; values decreased 35.5ñ11 percent in this period and there was a direct correlation between initial values and the degree of reduction (r=0.69, p<0.001). Postmenopausal women receiving hormone replacement therapy have a urinary hydroxyproline excretion similar to that of premenopausal women