Inestabilidad anterior de hombro con defecto óseo no crítico: ¿Bankart-Remplissage o Latarjet? / Anterior shoulder instability with non critical bone loss: Bankart-Remplissage or Latarjet?

Resumen: Introducción: Los defectos óseos se asocian a inestabilidad de hombro recidivante. Bankart-Remplissage (B+R) y Latarjet (L) son alternativas de tratamiento. Pocos estudios comparan ambas técnicas. Objetivo: Comparar evolución funcional, complicaciones y tasa de recidiva, entre B+R y L en pacientes con inestabilidad glenohumeral anterior con defecto óseo no crítico. Material y métodos: Estudio retrospectivo de cohortes, en pacientes operados entre 2010 y 2018. Ciento siete pacientes fueron reclutados, de éstos, se obtuvo información desde su ficha clínica. Se midió tamaño de Hill-Sachs (HS) y defecto glenoideo en tomografía axial computarizada (TAC). Se envió encuesta remota evaluando funcionalidad con SSV, WOSI, EVA y qDASH. Cuarenta y ocho pacientes completaron el seguimiento remoto (26 B+R y 22 L). Media de seguimiento de 3.8 años. Resultados: Al comparar ambos grupos no hubo diferencias significativas en WOSI, EVA, qDASH ni SSV. No hubo diferencia en el número de complicaciones (B+R: 13 [18.8%], L: 5 [13.2%], p = 0.16), reoperaciones (B+R: 4 [5.7%], L: 1 [2.6%], p = 0.41) ni reluxación (B+R: 4 [5.7%], L: 1 [2.6%], p = 0.41). En pacientes que realizan deporte de contacto o colisión, L tuvo mejor SSV (92.5 vs 72.5 p = 0.048) y WOSI total (98.3 vs 67.3 p = 0.043). B+R en extremidad dominante presentó mayor tasa de complicaciones (50 vs 9.1% p = 0.038). No se encontró asociación para complicaciones y reluxación según defecto glenoideo o número de luxaciones previo a cirugía. Conclusión: Bankart-Remplissage y Latarjet tienen similar resultado funcional y tasa de reluxación en nuestros grupos estudiados. Latarjet muestra mejor resultado funcional subjetivo en deportistas de contacto y menores complicaciones en extremidad dominante.

Abstract: Introduction: Significant Hill-Sachs lesions are associated with recurrent shoulder instability. Bankart-Remplissage (B+R) and Latarjet (L) are valid treatments for these injuries. Few studies compare both techniques. Objective: To compare functional outcome, complications and recurrent instability rate between B+R and L in patients operated for anterior shoulder instability (ASI) with significant Hill-Sachs (HS) lesions and non critical glenoid bone loss (NC-GBL). Material and methods: Retrospective cohort study with patients operated between 2010 and 2018 for ASI. 107 met inclusion criteria. Demographic data, complications, recurrence rate and subsequent procedures were obtained from their medical records. CT scan imaging was used to assess humeral and glenoid bone loss. Online questionnaires were sent for assesing functional outcomes with SSV, WOSI, VAS and qDASH. 48 patients completed the online assessment (26 B+R, 22 L). The mean follow-up was 3.8 years. Results: Comparing both groups, there were no differences in WOSI, SSV, EVA and qDASH. There was no difference in complication rate (B+R: 13 [18.8%], L: 5 [13.2%], p = 0.16), revisions (B+R: 4 [5.7%], L: 1 [2.6%], p = 0.41) and recurrent instability (B+R: 4 [5.7%], L: 1 [2.6%], p = 0.41). L in subgroup who practiced collision sports had better SSV (92.5 vs 72.5 p = 0.048) and WOSI (98.3 vs 67.3 p = 0.043). B+R in dominant extremity had worst complication rate (50 vs 9.1% p = 0.038). Association was not found between complications and recurrent instabillity according to glenoid bone defect or previous dislocation episodes. Conclusion: Significant Hill-Sachs lesions with NC-GBL, both Bankart-Remplissage and Latarjet achieve satisfactory results, with similar recurrent instability and functional outcomes. Latarjet has better subjetive funtional results in collision sports and less complication in dominant extremity compared to Bankart-Remplissage.

Melanoma maligno gastrointestinal de origen primario desconocido: reporte de caso / A case report of malignant gastrointestinal melanoma of unknown primary origin

Resumen Una de las características inusuales del melanoma cutáneo es la capacidad de metastatizar en el intestino delgado. A menudo se diagnostica durante la autopsia, en la cual se ha encontrado depósitos metastásicos en el 50%-60% de los casos, pero menos del 2% al 4% de los pacientes con diagnóstico de melanoma tiene metástasis gastrointestinal (GI) durante el curso de la enfermedad y entre el 4%-9% de casos de melanoma GI tiene un primario desconocido. La rápida identificación y resección del melanoma en el tracto digestivo podría mejorar la tasa de supervivencia en aquellos pacientes en los que se presentan complicaciones, como obstrucción intestinal. Se presenta un caso clínico de melanoma gastrointestinal de origen primario desconocido. El porcentaje de este tipo de casos es poco frecuente. La paciente presentó cuadro clínico de náuseas, hiporexia, epigastralgia, fatiga, parestesias en región dorsal derecha y disminución de 9 kilogramos en 3 semanas. Le realizaron tomografía computarizada (TAC) de abdomen contrastado, que reportó 3 lesiones en hígado de predominio isodenso en el parénquima, con algunas áreas de menor densidad al interior, localizadas en los segmentos 2, 5, 7 y 8 del hígado al que se le realizó la biopsia. Se llevó a cabo endoscopia de vías digestivas altas con biopsia de 2 lesiones hiperpigmentadas en la segunda porción de duodeno. El examen histopatológico de las biopsias evidenció melanoma maligno. Se excluyeron todas las localizaciones típicas de melanoma primario durante el procedimiento diagnóstico.

Abstract One of the unusual characteristics of cutaneous melanoma is its ability to metastasize in the small intestine. It is often diagnosed during autopsies of cutaneous melanoma patients. Metastatic deposits have been found in 50% to 60% of these autopsies, but less than 2% to 4% of patients diagnosed with melanoma have gastrointestinal metastasis during the course of the disease. Between 4% and 9% of gastrointestinal melanoma cases have unknown primary tumors. Rapid identification and resection of melanoma in the digestive tract could improve the patient survival rate and prevent complications such as intestinal obstructions from occurring. We present a rare clinical case of gastrointestinal melanoma of unknown primary origin. The patient had a clinical picture of nausea, hyporexia, epigastralgia, fatigue, paresthesias in the right dorsal region and had lost nine kilograms in three weeks. An abdominal CT scan showed three predominantly isodense liver lesions in the parenchyma, with some areas of lower density located in segments 2,5,7 and 8 of the liver. These were biopsied. Upper digestive tract endoscopy took biopsy samples of two hyperpigmented lesions in the second portion of the duodenum. Histopathological examination showed malignant melanoma. All typical locations of primary melanoma were excluded during the diagnostic procedure.

Infección por adenovirus en el Hospital de niños Roberto del Río 2016 / Adenovirus infection at the Roberto del Río children's Hospital 2016

En los meses de invierno, las enfermedades respiratorias representan la primera causa de hospitalización en hospitales pediátricos. La mayoría de estas enfermedades son causadas por virus, dentro de los cuales se encuentra el adenovirus (AdV), el cual puede generar infecciones diseminadas graves, secuelantes e incluso letales y se caracteriza por tener una rápida transmisión entre pacientes, generando brotes intrahospitalarios. Se identificó a 54 pacientes hospitalizados con infección por adenovirus en el periodo de marzo-julio del 2016 con una edad promedio de 18,3 meses, de los cuales 23 casos fueron infecciones asociadas a la atención de salud (IIAS) y 2 tuvieron desenlace fatal. Los casos de IIAS, se asociaron a una mayor tasa de hospitalización prolongada (p= <0.01), ingreso a UPC (p= <0.01) y uso de ventilación mecánica (p= <0.01). No se encontró asociación entre la presencia de antecedentes mórbidos con el desarrollo de IIAS. Las IIAS por adenovirus se asocia a una hospitalización prolongada, ingreso de unidades de alta complejidad y necesidad de uso de ventilación mecánica. Dado que el adenovirus se transmite a través de contactos directo, aerosoles y fómites, las medidas básicas de precaución de contacto y de aislamiento permiten reducir los contagios nosocomiales, recayendo la responsabilidad en todo el equipo de salud a cargo.

Respiratorio deseases are frequent in winter times. being the main cause of hospital admissions. Viral infecciones are the main etiology, and adenovirus infección clould lead to severe disease, with cross infections. We identified 54 patients admitted to the Roberto del Río Childrens hospital in 2016, with a mean age of 18,3 months old; 23 cases where nosocomial infection, and 2 were fatal. Hospital acquired adenovirus infection were associated to long hospital stay (p= <0.01), intensive care admission (p= <0.01) and ventilatory support (p= <0.01). We did not find previous illness conditions. Adenovirus hospital acquired infection is associated with longer hospital stay and dead. Adenovirus is transmitted with direct contact, aerosols and fomites, therefore basic contact precautions are important.

Componentes ocupacionales a evaluar en el proceso de tratamiento y rehabilitación del consumo problemático de drogas / Assessment of occupational components in the treatment and rehabilitation process of problematic drug abuse

La recolección de datos se llevó a cabo a través de la revisión de la literatura existente sobre el tema y una entrevista semiestructurada a siete Terapeutas Ocupacionales, con experiencia en el área de estudio. La entrevista se centró en los siguientes temas: Componentes Ocupacionales evaluados por terapeutasocupacionales durante el proceso de Tratamiento y Rehabilitación, modelos y evaluaciones utilizadas por terapeutas ocupacionales y Componentes Ocupacionales que muestran mayor déficit. Los resultados de esta investigación revelaron que la mayoría de los terapeutas ocupacionales evalúan los componentes ocupacionales de rutina/hábitos, roles, volición, tiempo libre e historia laboral en la etapa de ingreso a Centros de Tratamiento y Rehabilitación. Los resultados también revelaron una carencia de modelos y evaluaciones adecuadas y específicas desde la Terapia Ocupacional en el tema de estudio. Este estudio concluye en que existe una carencia de homogeneidad en el lenguaje, instrumentos de evaluación y los modelos utilizados entre Terapeutas Ocupacionales en los distintos Centros de Tratamiento y Rehabilitación.

This research topic is framed within the field of occupational therapy and problematic drug abuse. The purpose of this qualitative study is to explore what occupational components occupational therapists assess in the process of treatment and rehabilitation of problematic drug abuse. The study also explores the models and assessments used during this process. The participants were selected out of the list of Treatment and Rehabilitation Centers, that provides Occupational Therapy intervention in an Intensive Outpatient Program. This list was obtained from thedatabase of the National Council for Narcotics Control (CONACE). Data was collected through literature review on the topic and semi-structured interviews with seven Occupational Therapists with experience in the field of Drug Addiction Treatment and Rehabilitation. Theinterviews focused on the following topics: occupational components that are assessed for occupational therapists during the process of Treatment and Rehabilitation, models or theoretical frameworks and assessments used during this process and occupational components most affected. The results revealed that the majority of occupational therapists evaluate the occupational components of routine / habits, roles, volition, leisure and work history at the stage of admission to Treatment and Rehabilitation Centers. In addition, the results reveal a lack of appropriate and specific models andassessments from the occupational therapy perspective within the field of drug abuse. This study concludes that there is a lack of homogeneity in language, assessment tools and models used between the Occupational Therapists working in the Treatment and Rehabilitation Centers.

Uso de tests diagnósticos en la práctica clínica (Parte 2): Aplicación clínica y utilidad de un test diagnóstico / Clinical use of diagnostic tests (Part 2): Clinical application and usefulness of a diagnostic test

La utilidad clínica de un test diagnóstico se califica de acuerdo a la magnitud en la que éste contribuye a modificar la probabilidad pre test de ocurrencia de un determinado diagnóstico. Para tales efectos, el cálculo y aplicación de razones de verosimilitud (likelihood ratios, LR) constituye una herramienta de gran utilidad. Cada resultado posible de un test posee un LR, a partir del cual es posible estimar cuánto aumenta o disminuye la probabilidad pre test, permitiendo al clínico descartar un diagnóstico, confirmarlo o bien continuar su investigación mediante la solicitud de nuevos exámenes. En la primera parte del presente artículo se analizaron las propiedades de un test diagnóstico (validez, reproducibilidad y seguridad). En esta segunda parte se ilustra el sustrato teórico subyacente al concepto de LR, se explica su metodología de cálculo y se describe su aplicación clínica.

The clinical usefulness of a diagnostic test is determined by the extent to which it helps to modify the pretest probability of occurrence of a certain diagnosis. For this purpose, the calculation and application of likelihood ratios (LR) is a very useful tool. Every possible result of a test has a LR, which allows for an estimation of the magnitude by which the pretest probability increases or decreases, thereby helping the physician rule out, confirm, or continue investigating a diagnosis with new tests. In the first part of this article the properties of a diagnostic test (validity, reproducibility and safety) were analyzed. This second part illustrates the theoretical background underlying the concept of LR, explains the methodology for calculating them and describes their clinical application.

Uso de tests diagnósticos en la práctica clínica (Parte 1): análisis de las propiedades de un test diagnóstico / Clinical use of diagnostic tests (Part 1): analysis of the properties of a diagnostic test

Diagnostic tests are widely used in clinical practice. Qualitative analysis of diagnostic test properties (validity, reproducibility and safety) has been systematized using clinical epidemiology tools that have introduced a series of concepts such as sensitivity, specificity and predictive values. Based on data reported by a clinical investigation, the present article illustrates the theoretical background underlying these concepts, explains the methodology for their calculation, and analyzes their main strengths and limitations. A second article (Part 2: Clinical application and usefulness of a diagnostic test), describes the manner in which information provided by a test should be applied in order to correctly resolve a clinical dilemma.

Los tests diagnósticos constituyen herramientas complementarias ampliamente utilizadas en la práctica clínica. La Epidemiología Clínica ha sistematizado el análisis cualitativo de sus propiedades (validez, repro-ducibilidady seguridad) mediante la introducción de una serie de conceptos tales como sensibilidad, especificidad y valores predictores. En base a los datos aportados por una investigación clínica, el presente artículo ilustra el sustrato teórico subyacente a los conceptos anteriormente mencionados, detalla su forma de cálculo y analiza sus principales fortalezas y limitaciones. En un segundo artículo (Parte 2: Aplicación clínica y utilidad de un test diagnóstico) se describe la forma en que la información aportada por una prueba debe ser aplicada correctamente en la resolución de un dilema clínico.

Comparison between open and laparoscopic appendectomy in non-complicated appendicitis

BACKGROUND/OBJECTIVE: An extensive web search failed to provide studies from Puerto Rico regarding whether open (OA) or laparoscopic appendectomy (LA) should be performed for non-complicated appendicitis. Our goal is to compare these techniques in terms of time at operating room (OR), length of surgery, hospital stay, pain medication requirements, in-hospital complications and readmissions. METHODS: 126 patients (64 OA; 62 LA) with non-complicated appendicitis were studied retrospectively. Data obtained: demographics, CT-Scan use, surgery and operating room time, days in hospital, complications, diet commencement, pain medications doses, pathology and readmission. RESULTS: Difference was found in total time at OR (80.1+/-29 minutes OA; 105.7+/-22.6 LA) and in surgery length (41+/-28 OA; 48+/-16 LA), but not in hospital stay (2.1 days OA; 2.2 LA) nor in in-hospital complication rate. Negative appendectomy rate was 24% LA vs. 3% OA. Readmission rate was higher in OA with 5% wound infection rate. CONCLUSION: Techniques are similar in mean hospital stay, in-hospital complications, and pain medication requirements. LA had a higher negative appendectomy rate but of these patients five had surgical diagnosis of acute appendicitis and after appendectomy, signs and symptoms resolved; and two patients had interval appendectomies. As these patients were cured, the real negative appendectomy rate is 13%, similar to the historically accepted 16%. The other eight patients had an adequate diagnosis. We are concerned OA negative appendectomy rate is only 3%; we wonder if surgeons are waiting too long to operate patients. Readmission was higher in OA (wound infection rate of 5%). Although it takes more time in the OR, LA is as safe as OA, has a low rate of complications and lower readmission rate.

Prevalencia de marcadores serológicos ANCA y ASCA en una población con colitis ulcerosa / Presence of antineutrophil cytoplasmic antibodies (ANCA) and anti Saccharomyces cerevisiae antibodies (ASCA) among patients with ulcerative colitis

Background: The diagnosis of inflammatory bowel disease is supported by clinical findings and complementary tests. The presence of specific serological markers could be helpful in the characterization of this condition. Aim: To assess the prevalence of ANCA and ASCA in a group of patients with ulcerative colitis (UC) and its association with clinical features. Material and Methods: Sixty four patients with UC in remission (age range 16-72 years, 33 males) were studied. In a venous blood sample ANCA were measured by indirect immunofluorescence and ASCA by enzyme immune assays for IgG and IgA. Results: Forty four percent of patients were positive for ANCA, 9 percent for ASCA and 6 percent for both markers. There was a significant correlation between the presence of ANCA and duration of the UC (<5 years 50 percent, 5-10 years 42.9 percent, 15 years 30 percent) and the number of crises (one crises 31 percent, 2-5 crises 51.9 percent and >5 crises 87.5). The proportion of colectomized patients with positive ANCA was higher (57.1 percent). Conclusions: The prevalence of ANCA in the studied population is similar to the published data. The presence of ANCA was significantly higher in UC patients with shorter evolution, higher number of crises and in those with a history of colectomy. There was a low prevalence of ASCA positive patients.

Faringitis aguda, ¿estreptocóccica? Empleo del estudio etiológico y de antimicrobianos en dos centros pediátricos universitarios / Sore throat, ¿streptococcal etiology? Use of etiological screening and antimicrobial prescription in two university pediatric centers

Se describen aspectos clínicos, del diagnóstico y tratamiento de faringitis en pacientes pediátricos, 421 en un centro ambulatorio y 289 en la unidad de emergencia de un hospital universitario, que consultaron en un periodo de 14 meses. En los centros respectivos hubo 65 y 76 por ciento de pacientes en que se realizaron exámenes para documentar la etiología estreptocóccica. Se demostró la existencia de Streptococcus pyogenes en 37 por ciento de los explorados, siendo similar en ambos centros, con una incidencia máxima de 50 por ciento en el grupo etario de 6 a 10 años. En 217 pacientes no se realizó estudio etiológico, de éstos 162 (75 por ciento) recibieron tratamiento antimicrobiano. Se enfatiza la importancia de los exámenes de confirmación bacteriológica para la correcta indicación de antimicrobianos en esta patología.

The effect of salinity on the growth and carotenogenesis in two Chilean strains of Dunaliella salina Teodoresco

We studied the effect of salt concentration on the growth and carotenogenesis in two Chilean strains of Dunaliella salina, CONC-006 and CONC-007, cultivated in two media of different chemical composition J/l and PES, under controlled laboratory conditions. Growth rates, k (div day-1), intrinsic production rates of total carotenoids per unit time rcar (day-1), maximum levels of total carotenoids, K (mg l-1), and maximum production of total carotenoids per unit time, rK/4 (micrograms l-1 day-1) were estimated from growth and carotenogenesis data. The highest maximum productivity of total carotenoids was 978 micrograms l-1 day-1 obtained in CONC-007 at 25 percent NaCl, and the lowest 15 micrograms l-1 day-1, in CONC-006 at 30 percent NaCl, both growing in PES medium. CONC-007 showed the highest growth rates, 0.76 and 0.65 div day-1, at the lowest salt concentration (5 percent) in PES and J/1, respectively. On the contrary, the strain CONC-006 exhibited a different growth pattern in both media. Its maximum growth rate in J/1 was 0.37 div day-1 at 20 percent NaCl, and in PES, 0.53 div day-1 at 5 percent NaCl. According to these results, the best integration of growth and carotenogenesis in CONC-007 was obtained at 15 percent NaCl in J/1 from 10 to 25 percent NaCl in PES and in CONC-006, from 5 to 20 percent NaCl in J/1 and from 5 to 10 percent NaCl in PES