Lesiones osteoarticulares en cirujanos ortopédicos. ¿Cómo lo afrontamos? / Osteoarthicular injuries in orthopedic surgeons. How do we deal with it?

Resumen: Introducción: La toma de decisiones terapéuticas es un proceso complejo en la cual deben considerarse múltiples variables. Existe una tendencia cada vez mayor hacia la indicación quirúrgica, aunque no siempre la evidencia científica sea contundente. Entender cómo los cirujanos toman decisiones puede mejorar nuestra comprensión de la variabilidad de los tratamientos. Objetivos: exponer la situación demográfica de las lesiones osteoarticulares en los cirujanos ortopédicos de Uruguay y cómo afrontan su propia lesión e identificar aquellas variables que influyen en la toma de decisiones terapéuticas en el ortopedista. Material y métodos: Utilizando la base de datos de la Sociedad de Ortopedia y Traumatología del Uruguay se identificaron residentes y cirujanos que presentaron al menos una lesión osteoarticular. Se entrevistó telefónicamente a cada uno de los seleccionados, obteniendo las variables de interés. Resultados: En un total de 274 residentes y traumatólogos, incluimos 56 profesionales y 69 lesiones osteoarticulares. Destacamos la existencia de múltiples lesiones de tratamiento controvertido, según la evidencia científica actual. El cirujano no siempre indicó el mismo tratamiento a sí mismo respecto al que indicaría a un paciente con la misma lesión. Miedo a las complicaciones, rápida reintegración laboral, opinión de un colega experto, entre otras, fueron algunas de las variables halladas en la decisión terapéutica. Conclusiones: Cuando la lesión asienta en el propio cirujano, se observó un accionar distinto con respecto a un paciente con igual lesión.

Abstract: Introduction: Therapeutic decision-making is a complex process in which multiple variables must be considered. There is a growing trend towards surgical indication, although scientific evidence is not always blunt. Understanding how surgeons make decisions can improve our understanding of treatment variability; Objectives: To expose the demographic situation of osteoarticular injuries in orthopedic surgeons in Uruguay and how they deal with their own injury and identify those variables that influence therapeutic decision-making in the orthopedist. Material and methods: Using the Uruguayan Society of Orthopedics and Traumatology database, residents and surgeons who had at least one osteoarticular injury were identified. Each of the selected ones was interviewed by telephone, obtaining the variables of interest. Results: In a total of 274 residents and Orthopedic surgeons, we include 56 professionals and 69 osteoarticular injuries. We highlight the existence of multiple injuries of controversial treatment, according to current scientific evidence. The surgeon did not always indicate the same treatment to himself, in respect of the one that would indicate a patient with the same injury. Fear of complications, rapid job reimbursement, opinion of an expert colleague, among others were some of the variables found in the therapeutic decision. Conclusions: When the lesion settles on the surgeon itself, a different action was observed with respect to a patient with equal injury.

Avaliação da progênie de ovelhas Merino Australiano cruzadas com carneiro Dorper ou Southdown / Evaluation of the progeny of Australian Merino ewes crossed with Dorper or Southdown ram

O presente estudo objetivou avaliar o efeito do genótipo do carneiro (Dorper ou Southdown), do sexo e do tipo de parto sobre características de crescimento de 268 cordeiros filhos de ovelhas Merino Australiano. Até o desmame, todos os animais permaneceram sobre pastagem de trevo-vermelho (Trifolium pratense ), chicória (Cychorium intibus ), trevo-branco (Trifolium repens ), festuca (Festuca arundinacea ) e azevém (Lolium multiflorum ), com carga animal de 10 ovelhas com seus cordeiros/ha. A partir do desmame (29,95±4,94kg de peso vivo e 109,45±7,41 dias de idade), os cordeiros permaneceram sobre a mesma pastagem utilizada durante a lactação, sendo terminados posteriormente sobre um cultivo de soja (Glycine max) , com carga animal de 30 cordeiros/ha. Não foi verificado efeito do genótipo do carneiro (P>0,05) sobre nenhuma das variáveis analisadas. Por outro lado, do nascimento ao desmame e do desmame até o embarque dos cordeiros para abate, os machos (criptorquidas) apresentaram ganhos de peso diário superiores (241 e 212g/dia; 121 e 94g/dia, para machos e fêmeas, respectivamente; P≤0,001), o que proporcionou um peso vivo ao embarque 14,9% superior em relação às fêmeas (40,89 e 35,59kg, para machos e fêmeas, respectivamente; P≤0,001). Os cordeiros de parto simples apresentaram maiores (P≤0,001) pesos vivos e medidas corporais ao nascimento, bem como maior velocidade de crescimento até o desmame (239 e 214g/dia, parto simples e duplo, respectivamente; P≤0,001). Porém, após o desmame, os cordeiros de parto duplo apresentaram maior ganho de peso (98 e 117g/dia) (P≤0,05) e uma superioridade (P≤0,001) em quilogramas de cordeiros desmamados (26,80 e 49,61kg) ou embarcados (33,91 e 64,69kg) por ovelha parida. Independentemente do sexo e do tipo de parto, todos os cordeiros superaram as exigências de peso e condição corporal mínima requerida para comercialização de cordeiros pesados no Uruguai, na metade do tempo que em média ocorre com os genótipos tradicionais.

This study aimed to evaluate the effect of ram genotype (Dorper or Southdown), sex and birth type on the growth characteristics of 268 lambs from Australian Merino ewes. Until weaning all animals were kept on red clover pasture (Trifolium pretense), chicory (Cychorium intibus), white clover (Trifolium repens), fescue (Festuca arundinacea) and ryegrass (Lolium multiflorum), with a stocking rate of 10 sheep and their lambs/ha. From weaning (29.95±4.94kg of body weight and 109.45±7.41 day-old), the lambs remained on the same pasture which was used during lactation, being subsequently finished on a soybean culture (Glycine max), with a stocking rate of 30 lambs/ha. No effect of ram genotype (P>0.05) was verified on any of the variables. On the other hand, the males (criptorquidas) presented superior weight gain from birth to weaning and from weaning until shipment of lambs for slaughter, (241 and 212g/day; 121 and 94g/day, for males and females, respectively; P≤0.001), which provided a body weight at shipment 14.9% higher than the female (40.89 and 35.59kg, for males and females, respectively; P≤0.001). Lambs originated from simple delivery presented higher (P≤0.001) body weight and body measures at birth, and a higher growth rate until weaning (239 and 214g/day, simple and double delivery, respectively; P≤0.001). Therefore, after weaning, the lambs originated from double delivery presented higher weight gain (98 and 117g/day) (P≤0.05) and were superior (P≤0.001) in kilograms of weaned lambs (26.80 and 49.61kg) or shipped (33.91 and 64.69kg) per parity ewes. Regardless of the sex and birth type, all lambs overcame the weight and body conditions required for commercialization of heavy lambs in Uruguai in half the average time of traditional genotypes.

Matrizes ovinas cruzadas são sempre mais eficientes do que as matrizes puras? / Are sheep crosses always more efficient than pure sheep?

Foi estudado o desempenho reprodutivo de 482 ovelhas multíparas (3/4 Texel x 1/4 Corriedale: TXC, 1/2 Romney Marsh x 1/2 Corriedale: RMC, 3/4 Poll Dorset x 1/4 Corriedale: PDC, 1/2 Finnish Landrace x 1/2 Merino Australiano: FLMA e Merino Australiano puras: MA), as características do crescimento de 585 cordeiros provenientes de carneiros Dorper e ovelhas: TXC (n = 68); RMC (n = 64); PDC (n = 68); FLMA (n = 183) e MA (n = 202) e os quilogramas de carne de cordeiros produzidos/kg de ovelha colocadas em cobertura (como indicador de eficiência), pastoreando campo natural e pastagens cultivadas. As ovelhas FLMA e TXC apresentaram as maiores taxas de parição (167,89 e 174,36%, respectivamente) em relação às demais cruzas, as quais não diferiram entre si (121,43 e 125,49%, PDC e RMC, respectivamente; P>0,05), porém foram superiores as MA (88,99%), sendo esse resultado uma consequência da maior quantidade de cordeiros nascidos/ovelha parida, que influenciou mais do que sua maior taxa de fertilidade. O genótipo da ovelha também afetou (P<0,0001) o crescimento dos cordeiros até o momento da sua venda com 41,6 ±6,7kg aos 206±7,25 dias de idade. Os cordeiros filhos das ovelhas TXC, PDC e RMC apresentaram maiores ganhos de peso diário que os filhos de FLMA, e esses maiores do que os MA. No entanto, de todas as cruzas avaliadas, somente a FLMA foi mais eficiente que a MA.

The reproductive performance of 482 multiparous ewes, with growth characteristics of 585 lambs from Dorper rams and ewes: 3/4 Texel x 1/4 Corriedale (TXC, n = 68); 1/2 Romney Marsh x 1/2 Corriedale (RMC, n = 64); 3/4 Poll Dorset x 1/4 Corriedale (PDC, n = 68); 1/2 Finnish Landrace x Australian Merino (FLAM, n = 183) and Australian Merino pure ewes (AM, n = 202) and kg of lamb produced/kg of sheep used in the service (as an indicator of efficiency), grazing natural and sown pastures, were studied. The TXC and FLAM sheep had the highest lambing percentage (167.89 and 174.36%, respectively) compared to the rest of the other crosses, and did not differ from each other (121.43 and 125.49%, PDC and RMC respectively, P>0.05), but were higher than AM (88.99%), due to the greater number of lambs born / ewe calving rather than their higher fertility. The type of ewe also affected (P<0.0001) lamb growth until its sale at 41.6±6.7 kg to 206±7.25 days of age, showing mothers of TXC lambs, PDC and RMC had higher daily gains than the FLAM and these more than those of MA. However, in all crosses tested, only FLAM was more efficient than MA.

El papel de la radioterapia en el tratamiento del cáncer de ovario: revisión de la literatura / The role of radiotherapy in ovarian cancer: literature review

Múltiples revisiones han estudiado el potencial coadyuvante en la radioterapia (RT) y quimioterapia (QT) en el tratamiento del cáncer de ovario, pero no se ha comparado adecuadamente la efectividad de la RT abdominal total (RTAT) versus nuevas drogas de QT. Tanto la cirugía como la QT previas a la RT aumentan la sobreviva total y libre de enfermedad, ya que radiosensibilizan al tumor favoreciendo su destrucción. Las distintas técnicas de RTAT no han demostrado diferencias significativas en la sobrevida ni en el control de la enfermedad, pero la RTAT de campos abierto si arrojó menor toxicidad tardía. En la actualidad nuevas técnicas como la IMRT (radioterapia de intensidad modulada) han comenzado a utilizarse con excelentes resultados. A pesar de los avances, muchos de estos pacientes desarrollan recurrencia intraabdominal, quedando fuera del rango terapéutico para QT y en dicho momento la RT puede ser utilizada también en forma paliativa con dosis grandes y únicas, cuidando la aparición de posibles complicaciones. Es probable que en el futuro se reintegre la RTAT en el tratamiento del cáncer de ovario de acuerdo a los hallazgos en el acto operatorio. Finalmente la RT/QT concomitantes, han demostrado su efecto sensibilizador sinergista y es esperable que con el tiempo se sigan integrando nuevas drogas con distintas interacciones como los taxanos y moléculas target. El tratamiento del cáncer de ovario sigue siendo esencialmente quirúrgico y con quimioterapia adyuvante, sin embargo también la radioterapia con quimioterapia han demostrado su efecto adyuvante. A pesar de ser una alternativa poco explorada en la actualidad es necesario estudiar prospectivamente el promisorio resultado de las nuevas técnicas de radioterapia en este tipo de pacientes.

Several studies have reviewed the potential coadjuvant of Radiotherapy (RT) and chemotherapy in the treatment of ovary cancer. However the effectiveness of total abdomen RT (RTAT) versus new QT drugs have not been adequately compared. Both surgery and QT prior to RT increase total and freedom from the disease since tumors become radiosensitive, thus favoring destruction. Diverse techniques such as IMRT (Intensity modulated radiation therapy) are being used with excellent results. Despite these advances, many of the patients develop intrabdominal recurrence leaving them out of the therapeutic scope/range for QT. RT may then be used as a palliative in big unique cases watching possible complications. RTAT may eventually be restarted in the treatment of ovary cancer depending on the findings during surgery. Finally, RT/QT concomitants have shown their effect in sensitivity and synergy and it is expected that new drugs with different interactions such as taxan and target molecules are added. Treatment of ovarian cancer remains essentially surgical and with chemotherapy, but both radio and chemotherapy has demonstrated their adjuvant effect. Despite being an unexplored alternative is necessary to study prospectively the promising results of new techniques of radiation therapy in these patients.

Braquiterapia endobronquial de alta tasa de dosis en pacientes con obstrucción de la vía aérea central: experiencia en el Instituto Nacional del Cáncer y revisión de la literatura / High dose rate endobronchial brachytherapy in patients with central airway obstruction

Introduction: The main indication of modern high dose rate end bronchial brachyherapy (HDR EBBT) is the palliation of symptoms related to the growth of the endobronchial lung cancer. Methods: EBBT was performed to 27 patients who suffered symptomatic tumoral endobronchial or tracheal pathology, due to primary bronchial disease or secondary metastasis cancer, evaluating the rate of clinical benefit. The tumors were located at tracheal, carinal or proximal bronchial level. Fibrobronchoscopy was performed to all the patients to measure the degree of airway obstruction and to install brachytherapy endobronchial catheters. Between 1 to 4 fractions of 7 to 7.5 Gy were administered. Dyspnea, cough and hemoptysis were subjectively registered before and after treatment, according to an international validated scale. Results: After treatment, all symptoms considerably decreased, disappearing all of the severe categories. Hemoptysis and dyspnea resolved in a 100 percent and 40 percent of patients, respectively; and cough disappeared or was reduced to a minimum grade in 90 percent of cases.

Introducción: La indicación principal de la braquiterapia endobronquial moderna (BTEB) de alta tasa de dosis (HDR), es la paliación de síntomas por crecimiento endobronquial de cánceres pulmonares. Métodos: Se realizó BTEB HDR a 27 pacientes sintomáticos de patología tumoral endobronquial o traqueal, debido a patologías primarias bronquiales o secundarias metastásicas. Los tumores se ubicaban en tráquea, carina o a nivel bronquialproximal. Para observar mejorías en la sintomatología clínica, a todos se les realizó una fibrobroncoscopía (FBC) para medir el grado de obstrucción bronquial e instalar catéteres endobronquiales de braquiterapia. Se administraron entre 1 y 4 fracciones de 7 a 7,5 Gy. Se registró subjetivamente la disnea, tos y hemoptisis antes y después del tratamiento, de acuerdo a una escala internacionalmente validada. Resultados: Tras el tratamiento todos los síntomas disminuyeron considerablemente, desapareciendo toda sintomatología severa. La hemoptisis y disnea desaparecieron en el 100 por ciento y 40 por ciento de los pacientes respectivamente, y la tos desapareció o disminuyó a grado leve en el 90 por ciento de los pacientes.

Radioterapia lumboaórtica en pacientes con cáncer de cuello uterino: experiencia del Instituto Nacional del Cáncer / Paraortic radiotherapy in patients with uterine cervical carcinoma: Instituto Nacional del Cáncer experience

Antecedentes: El cáncer de cérvicouterino continúa siendo una enfermedad prevalente en Chile. Es frecuente recibir pacientes en etapas IIB y IIIB donde el riesgo de compromiso ganglionar pelviano y lumbo-aórtico es elevado y el tratamiento es radioquimioterapia. Objetivo: Análisis retrospectivo de pacientes con cáncer cérvicouterino que recibieron radioterapia que incluía los territorios lumboaórticos. Método: Revisión de pacientes con cáncer cérvicouterino tratadas entre 1995 y 2007 en el Instituto Nacional del Cáncer, Santiago, Chile. En 39 pacientes el tratamiento incluyó las cadenas lumboaórticas. Se analizó toxicidad y evolución. Se utilizaron dos técnicas de radioterapia: la primera durante la década del 90, donde se empleaban dos campos paralelos y opuestos (anterior y posterior) y una segunda actual, donde se irradian en conjunto la pelvis y los lumboaórticos a través de 4 campos (laterales y AP-PA). Resultados: El análisis dosimétrico de las dos técnicas confirma un mayor volumen irradiado de tejidos normales con la técnica de dos campos, fundamentalmente intestino delgado. La toxicidad fue significativamente diferente, siendo la que utilizamos hoy menos tóxica y con bajas complicaciones gastrointestinales, a pesar de recibir un tratamiento de radio-quimioterapia concomitante (55 por ciento vs 0 por ciento). Conclusión: La radioterapia lumboaórtica es un tratamiento con una tolerancia aceptable incluso con quimioterapia concomitante. Esta revisión nos obliga a elaborar un nuevo trabajo para evaluar si la radioterapia lumboaórtica reduce el riesgo de recidiva y aumenta la sobrevida.

Background: Uterine cancer is still a prevalent disease in Chile. Is common to treat patients with tumors in stages IIB and IIIB where the risk of pelvic and paraortic limph node involvement is very high. Its treatment is radio-chemotherapy. Objective: To present a retrospective analysis of patients that suffered cervix-uterine cancer who were treated with radiotherapy including the aortic-lumbar area. Methods: From the revision of patients who were treated of cervix-uterine cancer between the years 1995 and 2007, 39 were treated including aortic-lumbar chains. Evolution and toxicity were analyzed. Two radiotherapy techniques were used. The first one, during the nineties, included two parallel previous and later and opposed fields, and a second technique, currently used, where pelvis and paraortic are radiated at the same time through four lateral (AP-PA) fields. Results: The dosimeter analysis of both techniques shows that there is a higher volume of radiated normal tissue with the two fields techniques, mainly in the small bowel. On the other hand, the toxicity was significantly different being today's technique less toxic and showing low gastrointestinal side effects, despite receiving a simultaneous radio-chemotherapy (55 percent vs 0 percent). Conclusion: The paraortic radiotherapy treatment has an acceptable level of tolerance even under simultaneous radio-chemotherapy. Given the results of this study, we see the need for undergoing a new research project in order to evaluate if the aortic-lumbar radiotherapy may reduce the risk of relapse and increase in survival rate.

Irradiación lumboaórtica en el cáncer cérvico uterino: análisis de la literatura / Radiotherapy of aortic-lumbar lymph nodes in the cervical cancer: literature review

Antecedentes: El cáncer de cuello uterino es una enfermedad prevalente en Chile y es una de las localizaciones tumorales más frecuentes tratadas en el Instituto Nacional del Cáncer. Es habitual recibir pacientes jóvenes con tumores avanzados, en etapas IIB y IIIB, con riesgo elevado de compromiso ganglionar, tanto pelviano como lumboaórtico y donde el tratamiento estándar es la radio-quimioterapia. Objetivos: Determinar si la irradiación lumboaórtica reduce el riesgo de recidiva y/o mejora la sobrevida en pacientes con compromiso ganglionar evidente y en aquellos con alto riesgo de compromiso a dicho nivel. Método: Revisión exhaustiva de la literatura publicada sobre la indicación de radioterapia lumboaórtica en el cáncer cérvico uterino, en pacientes con enfermedad evidente en los ganglios lumboaórticos y en aquellas en que la indicación es en casos de alto riesgo de compromiso en dicho nivel. Resultados: En pacientes con tumores cervicales de pequeño tamaño y con ganglios pelvianos positivos, sería beneficioso el tratamiento ganglionar lumboaórtico. Sin embargo, en aquellas pacientes con enfermedad pelviana masiva (IIIB)o en aquellas en que existe evidencia de enfermedad lumboaórtica, dicho beneficio no sería tan importante. Conclusión: Son las pacientes con enfermedad pelviana controlable y con elevado riesgo de tener compromiso ganglionar lumboaórtico (etapa IA-B, IIA-B con ganglios positivos en la pelvis), las que más se benefician de la radioterapia lumboaórtica.

Background: Uterine cancer is a prevalent disease in Chile and it is one of the most frequent cancer locations treated in the National Chilean Cancer Institute. It is also common to receive young patients that have advanced tumors in stages IIB and IIIB with high risks of compromises of lymphatic nodes of pelvis and aortic-lumbar zones. The treatment for these kinds of cancers is radio-chemotherapy. Aims: Determinate if the radiotherapy of aortic-lumbar lymph nodes lowers the chance of relapsing or increase the survival rate in patients with evident compromise of aortic-lumbar lymph nodes and in those with high risk of compromise in that level. Method: Exhaustive analysis of the literature about the indication of radiotherapy of aortic-lumbar lymph nodes in cervix cancer which is classified in those where the radiotherapy treatment is done in patients with evident compromise of aortic-lumbar lymph-nodes, and those where de radiotherapy is done in patients with high risk of compromise in that level. Results: In patients with small cervix tumors and positive lymphoid nodes the LA lymphatic nodes treatment would be beneficial. However, patients that suffer massive pelvic disease (IIIB) or that have evidence of the disease, the benefit would not be so important. Conclusion: Patients with controllable pelvic disease and with high risk of having aortic-lumbar lymph nodes compromise are the most benefit of radiotherapy in aortic-lumbar lymph nodes (stages IA-B, IIA-B with positive lymph nodes).

Mioblastoma de mama / Neoplasms muscle tissue of breast

Se presenta una especies portadora de un mioblastoma (tumor de células granulares) de la la mama, tumor poco frecuente y de importante diagnóstico diferencial con el cáncer de mama, debido a su gran semejanza clínica e imagenológica. Se trata de una paciente de 66 años de edad con nódulo de 3 centímetros de diámetro en mama derecha, de 6 meses de evolución, de consistencia pétrea, bien definido, no doloroso y con cambios en la piel subyacente, con estudio mamográfico: BI-rads 4. Se realiza biopsia incisional que reporto: Mioblastoma (Tumor de células granulares). En conclusión el mioblastoma representa un reto diagnóstico para el cirujano general debido debido a su semejanza con patología neoplásica. Se debe tener en cuenta al momento de la evaluación de pacientes con nódulos mamarios, en cuyo caso es de suma importancia el estudio anatomopatológico