El tratamiento paciente específico del hipertiroidismo con radioyodo: una oportunidad a la mejora / Radioiodine treatment of hyperthyroidism with patient-specific techniques: an improvement opportunity

Introducción: La aplicación de actividades fijas en el tratamiento del hipertiroidismo con I131 (yoduro de sodio, conocido también como radioyodo), es el método más usado en nuestro país, a pesar de la individualidad morfo-funcional que caracteriza esta afección. Sin embargo, no existe aún, un consenso internacional sobre la dosis más conveniente para cada caso, y por ende, los resultados no siempre son los deseados. Objetivo: Evaluar la aplicabilidad de varios métodos de cálculo de dosis paciente-específica para el tratamiento de hipertiroidismo con yoduro de sodio. Métodos: Se realizó un análisis de los resultados de varios métodos de cálculo de dosis recomendados internacionalmente a partir de la actividad fija prescrita en 10 pacientes, con el empleo de tecnologías y herramientas ya desarrolladas y disponibles en el país. Se evaluó la variabilidad inter-especialista y su impacto en la dosis planificada para el tratamiento. Resultados: El uso de la información incompleta de la biodistribución y farmacocinética del paciente produjo diferencias entre -42 por ciento y 37 por ciento de las dosis para el mismo paciente. El resultado de la comparación del método de cálculo recomendado por la Sociedad Europea de Medicina Nuclear, manejando la masa por gammagrafía-2D / 3D y por ultrasonido, arrojó diferencias no significativas entre sí. La variabilidad inter-especialista de las actividades prescrita mostró diferencias significativas, que arrojan sobre el mismo paciente, discrepancias entre 44Gy y 243Gy de las dosis terapéuticas a recibir, situación que puede comprometer el éxito del tratamiento y producir efectos secundarios no deseados. Conclusiones: Las técnicas dosimétricas paciente-específicas se pueden implementar satisfactoriamente en nuestro país. Las diferencias numéricas encontradas, especialmente la variabilidad inter-especialista, demuestran la no estandarización terapéutica, lo que apoya el uso de la farmacocinética paciente-específica pre terapéutica y la masa por gammagrafía-3D para planificar el tratamiento siempre que sean posible(AU)

Introduction: Despite of its typical morpho-functional individuality, fixed activities remain as the most used method in Cuba for hyperthyroidism treatment with I (sodium iodide, also known as radioiodine). However, there is not yet an international consensus on the most convenient doses for each case, so, the results are not always the desired ones. Objective: To evaluate the applicability of various patient-specific dose calculation methods for the treatment of hyperthyroidism with sodium iodide. Methods: It was carried out an analysis in 10 patients of the results of some methods for dose calculation from the prescribed fixed activity recommended internationally, with the use of technologies and tools already developed and available in the country. The inter-specialist variability and its impact in the planned dose for the treatment were assessed. Results: The use of uncompleted biodistribution and pharmacokinetics information of the patient showed differences between -42 percent and 37 percent in the doses for the same patient. The outcome of the comparison of the calculation method recommended by the European Society of Nuclear Medicine managing the mass by 3D/2D gammagraphy and ultrasound, presented no significant discrepancies among them. The inter-specialist variability of prescribed activity was statistically significant, and it can produce in the same patient differences between 44Gy and 243Gy of the therapeutic doses, which could affect the treatment success and lead to unnecessary side effects. Conclusions: The patient´s personalized calculation methods can be satisfactorily applied in Cuba. The numeric differences found, especially inter-specialist variability, show the lack of therapeutic standardization, which supports the use of pre-therapeutic patient-specific pharmacokinetics and the mass by 3D-gammagraphy to plan the treatment when possible(AU)

Experimental dry socket: microscopic and molecular evaluation of two treatment modalities / Alveolite experimental: análise microscópica e molecular de duas modalidades de tratamento

PURPOSE: To evaluate two treatment modalities of dry socket in rats and to discuss the first findings of the molecular analysis in this experimental model. METHODS: 84 rats underwent a tooth extraction were divided in 4 groups: I-uninfected socket (control), II-infected socket without any treatment, III-infected socket treated with irrigation of 2 percent sodium iodide and 3 percent hydrogen peroxide solution, IV-infected socket submitted to curettage, irrigation with physiological saline solution and fulfilled with metronidazole paste as base. The groups were subdivided in postoperative sacrifice periods: 6/15/28 days. A quantitative and a qualitative microscopic analysis was performed. Also, a quantitative analysis was performed using a RealTimePCR to evaluate the genes expression in the wound healing: Collagen Type I/COL-I, vascular endothelial growth factor/VEGF, osteocalcin/OCN, alkaline phosphatase/ALP, runt-related transcription factor 2/RUNX2 and tumor necrosis factor alpha/TNF-α. RESULTS: The group I showed higher bone formation, followed by groups IV, III, II respectively. The group II presented higher inflammatory infiltrate and the wound healing was delayed compared with other groups. It was obtained a significant positive correlation between bone neoformation and the expression of OCN and RUNX2, inflammatory infiltrate with TNF-α and a negative correlation between bone neoformation and TNF-α. CONCLUSION: No significant difference was found between the treatments.

OBJETIVO: Avaliar duas modalidades de tratamento da alveolite em ratos e discutir os primeiros achados de uma análise molecular neste modelo experimental. MÉTODOS: 84 ratos foram submetidos a uma extração dentária e foram divididos em quatro grupos: I- alvéolo não infectado (controle), II- alvéolo infectado sem tratamento, III- alvéolo infectado tratado com irrigação de iodeto de sódio a 2 por cento e solução de peróxido de hidrogênio a 3 por cento, IV- alvéolo infectado submetido à curetagem, irrigação com solução salina fisiológica e preenchimento com pasta a base de metronidazol. Os grupos foram subdivididos em períodos de sacrifício pós-operatório: 6/15/28 dias. Uma análise quantitativa e qualitativa microscópica foi realizada. Além disso, uma análise quantitativa foi realizada utilizando RealTimePCR para avaliar a expressão de genes no reparo alveolar: o colágeno tipo I / COL-I, o fator de crescimento endotelial vascular / VEGF, osteocalcina / OCN, fosfatase alcalina / ALP, fator de transcrição runt relacionados 2 / RUNX2 e fator de necrose tumoral alfa / TNF-α. RESULTADOS: O grupo I mostrou maior formação óssea, seguido pelos grupos IV, III, II, respectivamente. O grupo II apresentou maior infiltrado inflamatório e a cicatrização foi atrasada em comparação com outros grupos. Foi obtida uma correlação positiva entre a neoformação óssea e a expressão de OCN e RUNX2, infiltrado inflamatório com TNF-α e uma correlação negativa entre a neoformação óssea e TNF-α. CONCLUSÃO: Nenhuma diferença significativa foi encontrada entre os tratamentos.

Mudanças evolutivas no tratamento da doença de Graves com iodo radioativo: 12 anos de experiência em um hospital universitário / Changing trends in the treatment of Graves' disease with radioiodine: a 12-year experience in a university hospital

OBJETIVO: Avaliar a mudança no perfil e abordagem dos pacientes com doença de Graves submetidos a dose terapêutica de radioiodo. MATERIAIS E MÉTODOS: Avaliamos, retrospectivamente, 226 pacientesportadores de doença de Graves submetidos a dose terapêutica de radioiodo entre janeiro de 1990 e dezembro de 2001. O período de 12 anos foi dividido em três períodos de 4 anos para fins de análise estatística,sendo comparadas variáveis clínicas e laboratoriais nos períodos descritos. RESULTADOS: Constatamos que o número de pacientes encaminhados para a dose terapêutica, assim como o percentual de pacientes do sexo feminino (de 62% para 86%; p = 0,005), tiveram incremento significativo. Houve aumento significativo no percentual de pacientes em uso de metimazol previamente à dose terapêutica (de 9,1% para 35,6%;p = 0,03). A dose média de iodo administrada também teve incremento significativo (de 7,6 mCi para 12,7mCi; p = 0,000003), com reflexo direto em um maior percentual de pacientes curados (de 55,6% para 83,7%; p = 0,004) um ano pós-dose terapêutica. CONCLUSÃO: A dose terapêutica de radioiodo tem sido um método cada vez mais aceito nos pacientes com doença de Graves e a dose administrada tem sido cada vez maior, no intuito de cura permanente e diminuição das chances de recidiva.

OBJECTIVE: To evaluate the changes in clinical parameters and in the approach to patients submitted to radioiodine therapy for Graves' disease. MATERIALS AND METHODS: Dossiers of 226 patients submitted to radioiodine therapy for Graves' disease in the period between January 1990 and December 2001 were retrospectively evaluated. For the purposes of statistical analysis, the 12-year period was subdivided into three periods of 4 years, with a comparison of clinical and laboratory variables in these periods. RESULTS: The authors have observed that the total number of patients referred for radioiodine therapy as well as the percentage of female patients presented a significant increase (from 62% to 86%; p = 0.005). The percentage of patients pretreated with methimazole before radioiodine therapy increased significantly (from 9.1% to35.6%; p = 0.03). The mean radioiodine dose delivered has also presented a significant increase (from 7.6 mCi to 12.7 mCi; p = 0.000003) with a direct reflection on a higher percentage of patients cured one year after the radioiodine therapy (from 55.6% to 83.7%; p = 0.004). CONCLUSION: Radioiodine therapy has increasingly been accepted for treatment of patients with Graves' disease and the doses delivered have increased to achieve a permanent cure as well as a reduction of the chances of recurrence.

Influence of preventive dental treatment on mutans streptococci counts in patients undergoing head and neck radiotherapy

The aim of this study was to evaluate the influence of chlorhexidine gluconate, sodium fluoride and sodium iodine on mutans streptococci counts in saliva of irradiated patients. MATERIAL AND METHODS: Forty-five patients were separated into three experimental groups and received chlorhexidine (0.12 percent), sodium fluoride (0.5 percent) or sodium iodine (2 percent), which were used daily during radiotherapy and for 6 months after the conclusion of the treatment. In addition, a fourth group, composed by 15 additional oncologic patients, who did not receive the mouthwash or initial dental treatment, constituted the control group. Clinical evaluations were performed in the first visit to dental clinic, after initial dental treatment, immediately before radiotherapy, after radiotherapy and 30, 60, 90 days and 6 months after the conclusion of radiotherapy. After clinical examinations, samples of saliva were inoculated on SB20 selective agar and incubated under anaerobiosis, at 37ºC for 48 h. Total mutans streptococci counts were also evaluated by using real-time PCR, through TaqMan system, with specific primers and probes for S. mutans and S. sobrinus. RESULTS: All preventive protocols were able to reduce significantly mutans streptococci counts, but chlorhexidine gluconate was the most effective, and induced a significant amelioration of radiotherapy side effects, such as mucositis and candidosis. CONCLUSION: These results highlights the importance of the initial dental treatment for patients who will be subjected to radiotherapy for head and neck cancer treatment.

Virtual elimination of iodine deficiency disorders in Bolivia / Eliminación casi total de los trastornos por deficiencia de yodo en Bolivia

El Gobierno de Bolivia ha tenido desde 1983 un programa nacional para combatir los trastornos por deficiencia de yodo (TDY), que a principios de la década de 1980 afectaban a más de la mitad de la población del país. La principal estrategia empleada de forma sostenida en la lucha contra los TDY es la yodación de toda la sal destinada para consumo humano. En 1996, el Gobierno de Bolivia invitó a un grupo de expertos a revisar, en colaboración con los integrantes del programa dentro del país, cuánto se había avanzado hacia la eliminación de los TDY de todo el territorio nacional. El equipo revisor examinó los datos recolectados mediante las encuestas más recientes sobre la disponibilidad y el uso de la sal yodada y las concentraciones de yodo excretadas por la orina. Sobre la base de criterios internacionales establecidos para estos indicadores, el equipo llegó a la conclusión de que Bolivia había eliminado los TDY como problema de salud pública de alcance nacional, pese a pruebas de que algunas comunidades aisladas de los Andes todavía carecían de una ingesta adecuada de yodo. El equipo hizo recomendaciones para mejorar el programa y garantizar su sostenibilidad. Asimismo, examinó los métodos de producción y el control de la calidad del proceso de yodación y recomendó medidas para reducir la variabilidad del contenido de yodo en la sal

Bolivia has long been known to have a severe national problem with iodine deficiency, characterized by the ubiquitous and obvious signs of goiter and cretinism. Large-scale surveys of children in primary schools, conducted in 1981 and 1983, found a national goiter prevalence of over 60% and demonstrated that the entire country was affected by iodine deficiency to a similar degree. In 1983 the Government of Bolivia established the National Program for the Fight Against Goiter (PRONALCOBO), led and overseen by the Ministry of Social Services and Public Health. Establishment of the Program was assisted by funds from the Government of Italy provided through the WHO/ UNICEF Joint Nutrition Support Program. Since 1991 the Program has benefited from continued technical and financial support from the UNICEF Subregional Andean Iodine Deficiency Disorders Control Program, and since 1994 it has also been supported by funds made available to UNICEF by Kiwanis International. Drawing on prior experience from salt iodization projects in Tarija and Potosí departments, the Program adopted the iodization of all salt for human consumption as the main longterm strategy. In addition, iodized oil was made available up to 1994 in areas of known high endemicity. The major strategy, presently known as Universal Salt Iodization, is being implemented by the small-scale salt processing enterprises in the country, which have recently organized themselves into the Association of Salt Processors of Bolivia. The Program has taken full advantage of the long Bolivian cultural tradition of communitybased participation.