Caracterización de línea celular de paratiroides humana (RCPTH) y evaluación de tumorigenicidad en ratones NOD/SCID / Characterization of human parathyroid cell line (RCPTH) and tumorigenicity evaluation in NOD/SCID

Background: Cell therapy could be an alternative for the treatment of hypoparathyroidism. Therefore efforts have been made to establish a cell line of parathyroid cells. Aim: To establish a continuous functional and non-tumorigenic human parathyroid cell line. Material and Methods: Nineteen tissue samples from 15 patients subjected to parathyroidectomy due to primary or secondary hyperparathyroidism were obtained. Functional, morphological and tumorigenic properties of the obtained cells were analyzed. Results: After two months of culture in conditions of immortalization, cells had an exponential growth without experiencing senescence. Therefore, more than 200 sub cultures have been performed. The cell line was denominated RCPTH. Morphological characterization showed monolayer growth with contact inhibition and a duplication time of 30 hours. On light microscopy, pleomorphism and low number of mitoses were observed. Cells accumulated glycogen, expressed calcium sensing receptor and had positive PTH cytoplasmic clusters. The line secreted PTH initially but subsequently, PTH production became undetectable. The cell line did not have tumor or metastatic growth. Conclusions: A parathyroid cell line has been established. The lack of PTH production is a problem that will require the search for mechanisms to activate it.

Complicaciones de la pancreatoduodenectomía, diagnóstico y manejo / Diagnosis and management of pancreatoduodenectomy complications

Pancreatoduodenectomy continues to have a high rate of complications. The most common and severe complications are intra or postoperative bleeding, pancreatic fistulae and derangements of gastric emptying. Each of these requires a great deal of clinical suspicion and an multidisciplinary management. This is a review of these complications, their clinical manifestations and their management.

A pesar de la disminución observada en las cifras de mortalidad de la pancreatoduodenectomía, continúa siendo una intervención asociada a una alta tasa de complicaciones. Las más comunes y asociadas a una mayor morbimortalidad son: el sangrado intra y post operatorio, la fístula pancreática y trastornos asociados al vaciamiento gástrico. Cada una de los eventos anteriores, requiere de un alto grado de sospecha clínica y de un manejo de tipo multidisciplinario. En este reporte se analizan las complicaciones anteriormente descritas, sus manifestaciones clínicas y los principios de su manejo.

Gastrectomía vertical posterior a retiro de banda gástrica / Sleeve gastrectomy performed simultaneously to extraction of a gastric band: experience in 10 patients

Background: Sleeve gastrectomy is replacing gastric banding in the management of morbid obesity. Aim: To report the results of sleeve gastrectomy performed simultaneously with the extraction of a gastric band. Material and Methods: We report ten patients aged 34 to 53 years (nine women) operated between 2008 and 2009. Results: The main indication for sleeve gastrectomy was the failure of the gastric band. No complications were recorded and patients were discharged 72 hours after the procedure. Conclusions: Sleeve gastrectomy can be carried out simultaneously with the extraction of a gastric band, without increasing operative complications.

Introducción: La Gastrectomía Vertical ha reemplazado a la banda gástrica en el manejo de un importante número de pacientes portadores de obesidad. El objetivo de este trabajo es mostrar los resultados de una serie de pacientes, en los que se realizó una Gastrectomía Vertical posterior a la extracción de una banda gástrica en un mismo tiempo operatorio. Método: La serie incluye a 10 pacientes operados entre Mayo de 2008 y Noviembre de 2009. La principal indicación de la Gastrectomía Vertical fue el fracaso de la banda como tratamiento de la obesidad. Resultados: En los 10 pacientes estudiados, la gastrectomía se pudo efectuar sin mayores dificultades ni diferencias con respecto al procedimiento habitual. No existieron complicaciones post operatorias, siendo la totalidad de los pacientes dados de alta dentro de las 72 horas. Conclusión: La Gastrectomía Vertical representa una alternativa de manejo en pacientes portadores de una banda gástrica con indicación de extracción de esta, ya sea por fracaso o por síntomas asociados a su presencia. El procedimiento puede efectuarse de manera segura en el mismo acto operatorio y sus resultados son comparables a los observados cuando la técnica se efectúa en pacientes que no han sido intervenidos previamente.

SPECT/CT preoperatorio, una nueva herramienta diagnóstica para localizar adenomas paratiroideos: presentación de 2 casos clínicos / Localization of functioning parathyroid adenomas by SPECT/CT: report of two cases

Single photon emission computed tomography and computed tomography (SPECT/CT), integrates a gamma camera and a CT scan and is effective for the location of parathyroid adenomas. We report a 55 years old male and a 80 years old female with primary hyperparathyroidism. In both cases the 99mTc-Sestamibi parathyroid scintigraphy detected a functioning nodule whose presence was confirmed with SPECT/CT.

El SPECT/CT integra una gamacámara y un escáner radiológico en un solo equipo híbrido que fusiona la imagen de la cintigrafía SPECT (tomografía computada de fotón único) con la imagen morfológica obtenida con un escáner de baja intensidad, sin movilizar al paciente, en una perfecta correspondencia anátomo-funcional, permitiendo identificar con exactitud la localización de un adenoma paratiroideo. Se describen dos pacientes con hiperparatiroidismo primario, con ecotomografía convencional negativa, donde el SPECT/CT demostró la localización exacta de adenomas de ubicación no habitual.

Pancreatitis autoinmune: experiencia clínica y revisión de la literatura / Autoimmune pancreatitis: report of 10 cases

Background: Autoimmune pancreatitis is a special form of chronic pancreatitis, more common in men and usually presenting as obstructive jaundice or abdominal pain. It may be associated with other immunological disorders and sometimes it is possible to find positive serological markers. Typical images show pancreatic enlargement with focal or diffuse stenosis of the pancreatic duct but sometimes it presents as a focal pancreatic mass that is difficult to differentiate from pancreatic carcinoma. Aim: To report ten cases of autoimmune pancreatitis. Material and Methods: Retrospective review of clinical records of 10 patients aged 26 to 56 years (six males) with autoimmune pancreatitis. Results: The clinical presentation was obstructive jaundice in six cases, acute pancreatitis in two, persistent increase in serum amylase and Upase in one, and permanent abdominal pain and weight loss in one. On imaging studies, a circumscribed mass was founded in six patients. An endoscopic retrograde colangiopancreatography was performed in four patients showing an abnormal pancreatic duct in all. Six patients were operated and tissue for pathological study was obtained in five, showing inflammatory infiltration. Vive patients were treated with steroids with a good clinical response. Conclusions: Autoimmune pancreatitis must be borne in mind in the differential diagnosis of pancreatic lesions.

Tumor cervical por enfermedad de Kikuchi: Una entidad clínica a la que no estamos habituados. Caso clínico / Histiocytic necrotizing lymphadenitis: Report of three cases

Histiocytic necrotizing lymphadenitis (HNL), also known as Kikuchi 5 disease is a rare condition of unknown etiology. Patients present with cervical lymph node enlargement, fever and malaise. The diagnosis is made by excision biopsy. However, this entity must be distinguished from both reactive processes and malignant tumors such as lymphoma. The clinical course is self limited with spontaneous resolution within a few months. We report three patients with the disease. A 37 year-old woman with a 4 months history of a painless submaxillary mass of 2.5 cm diameter, attached to the deep tissues of the neck. The mass was excised and the biopsy report was HNL. After 26 months of follow up, the patient is asymptomatic. A 30 year-old woman with a history of 2 months of a painless lateral cervical mass and aspiration biopsy was reported as suspicious for lymphoma. An excision biopsy was performed, that was reported as HNL. In both patients, lymphoma was ruled out by immunohistochemistry. A 33 year-old woman with a 3 weeks history of an asymptomatic lateral cervical mass. Biopsy was reported as HNL. This condition must be included in the differential diagnosis of cervical asymptomatic masses. The clinician must be aware of it to avoid long-term, costly treatments.

Incidencia de hipocalcemia pos tiroidectomía total / Incidence of hypocalcemia after total thyroidectomy

Background: Postoperative hypocalcemia is one of the most common complications of thyroid surgery. It is related to the type of disease (malignant or benign), the number of identified parathyroid glands during the surgical procedure, and the surgeon's experience. Total thyroidectomy is the procedure of choice in our hospital for benign and malignant thyroid disease, but it can increase the incidence of complications. Aim: To evaluate the incidence of postoperative hypocalcemia in patients subjected to a total thyroidectomy. Material and methods: Two studies were performed. A retrospective review of medical records of 448 patients subjected to total thyroidectomy, looking for serum calcium levels of less than 8 mg/dl and clinical signs of hypocalcemia. In a second study, 45 patients were followed with measurements of preoperative and postoperative serum calcium levels. Results: In the retrospective study, only 136 records had reliable information. Clinical signs of hypocalcemia were registered in 14 percent of patients and a low serum calcium level was detected in 50 percent. In the prospective study, 42 percent of patients had a postoperative low serum calcium level and seven patients (15 percent) had symptoms. Patients were handled with oral calcium and calcitriol in some cases. Ninety nine percent of patients had normal serum calcium levels two moths after surgery. Conclusions: In this series, the rate of postoperative hypocalcemia after total thyroidectomy is similar to internaitonal reports.

Cultivo primario e inmortalización de células de paratiroides para trasplante celular, en hipoparatiroidismo quirúrgico / Primary culture and immortalization of parathyroid cells for cell transplantation, in surgical hypoparathyroidism

El hipoparatiroidismo permanente ocurre después de tireidectomía (0,2-4 por ciento) o de cirugía paratiroidea. Lamentablemente el autotransplante no es 100 por ciento efectivo para prevención, y los pacientes deben recibir suplementación de vitamina D y calcio de por vida, con un costoso y a veces difícil manejo médico. Poca experiencia hay a nivel mundial de alotrasplantes paratiroideos en humanos. Un grupo de investigadores logró un período de sobrevida del injerto de 1 año en 8 pacientes, pero sin consignar los requerimientos de calcio y vitamina D. La dificultad de esta terapia es el rechazo por aloinmunización, y el establecimiento de cultivos primarios duraderos que permita conseguir una masa de células suficiente para el trasplante. Se ha logrado mantener cultivos, y función endocrina de ellos, por 60 días máximo. Nuestro objetivo es modificar y optimizar los cultivos primarios de paratiroides humana para: a)Obtener una línea continua de células paratiroideas, b)caracterizar la línea en cuanto a función endocrina, y c)disminuir la antigenicidad, como fuente futura de trasplante celular. La serie presentada incluye 5 pacientes intervenidas quirúrgicamente por hiperparatiroidismo primario, con diagnóstico definitivo de adenoma paratiroideo. Las muestras fueron sometidas a digestión enzimática y disgregación mecánica, cultivándose finalmente en placas de Petri a 37 °C. Resultados: Todos los cultivos primario fueron efectivos, con morfología típica a la microscopia. El primer cultivo creció y produjo PTH, pero no sobrevivió a contaminación del medio de cultivo. Los otros 4 están aún en período de expansión (crecimiento y multiplicación) con 150,60,40 y 35 días de cultivo. La función endocrina de las células en cultivo fue estudiada midiendo PTH en el medio de cultivo. Se obtuvo una producción promedio de 521,6 pg/ml en 24 horas (224-730 pg/ml). Todos los cultivos fueron positivos para esta medición.

Antibacterial resistance of community-acquired respiratory tract pathogens recovered from patients in Latin America: results from the PROTEKT surveillance study (1999-2000)

PROTEKT (Prospective Resistant Organism Tracking and Epidemiology for the Ketolide Telithromycin) is a global surveillance study established in 1999 to monitor antibacterial resistance of respiratory tract organisms. Thirteen centers from Argentina, Brazil and Mexico participat ed during 1999-2000; they collected 1,806 isolates (Streptococcus pneumoniae 518, Haemophilus influenzae 520, Moraxella catarrhalis 140, Staphylococcus aureus 351, S. pyogenes 277). Overall, 218 (42.1 percent) of the S. pneumoniae isolates had reduced susceptibility to penicillin, 79 (15.3 percent) were penicillin-resistant and 79 (15.3 percent) were erythromycin-resistant. Mexico had the highest prevalence of penicillin (76.5 percent) and erythromycin (31.2 percent) resistance. Of 77 erythromycin-resistant S. pneumoniae tested for resistance genotype, 43 possessed mef(A), 33 possessed erm(B) and 1 possessed both erm(B) and mef(A) mechanism. All S. pneumoniae isolates were fully susceptible to telithromycin, linezolid, teicoplanin and vancomycin. Among H. influenzae isolates, 88 (16.9 percent) produced b-lactamase, ranging from 11 percent (Brazil) to 24.5 percent (Mexico). Among M. catarrhalis isolates, 138 (98.6 percent) produced b-lactamase. Twenty-four (8.7 percent) of the S. pyogenes isolates were erythromycin-resistant; resistance being attributable to mefA (n=18), ermTR (n=5) and ermB (n=1). All H. influenzae, M. catarrhalis and S. pyogenes were fully susceptible to telithromycin. Methicillin resistance was found in 26.5 percent of the S. aureus isolates (Argentina 15 percent; Mexico 20 percent; Brazil 31.3 percent). Telithromycin was effective against 97.7 percent of methicillin-susceptible isolates. PROTEKT confirms that antibacterial resistance is an emerging problem in Latin America. The previously reported high levels of pneumococcal resistance to the b-lactam and macrolides were exceeded. New agents that do not induce resistance or that exert low selective pressure, e.g. telithromycin, are essential to safeguard future antibacterial efficacy

Susceptibility of S. pneumoniae to various antibiotics aong strains isolated from patients and healthy carriers in different regions of Brazil(1999-2000)

Resistance of microbes to commonly used antibiotics became a major concern at the end of the last century. Because Streptococcus pneumoniae is the most common pathogen in respiratory infections, we conducted microbiological assessment of drug susceptibility patterns among strains collected from two different population groups: 1) adult and pediatric patients (375 isolates) with different infections, and 2) healthy children in day care centers (<5 years old; 350 isolates). High level resistance to penicillin was not identified in either group. Intermediate resistance levels were similar in both groups (adults: 9.9; children: 9.2). The Central West region of Brazil tended to have lower susceptibility of S. Pneumoniae from infected adults and children to penicillin (81 vs. 93 in the South and 90 in the Southeast), tetracycline (64 vs. 80 and 76), and trimethoprim/sulfamethoxazole (14 vs. 34). Susceptibility was similar among strains from nasal cultures of healthy children tested in each of 4 regions of Brazil. All isolates were susceptible to cefaclor, cefotaxime and amoxacillin/clavulanate. This study, in two distinct populations, allowed characterization of local microbiological resistance patterns. This data is expected to be of use in guiding empiric therapy in the different regions of Brazil.

Ceramide glycanase from rat mammary tissues: inhibition by PPMP(D-/L-) and its probable role in signal transduction.

A ceramide glycanase (CGase activity has been characterized from lactating rat mammary tissue which cleaves the glycosidic bond between sphingosine and the glucose chain of a glycosphingolipid (GSL) thus liberating the intact oligosaccharide chain from a GSL. The majority (65%) of the hydrolase activity was detected in the supernatant fraction when the rat mammary tissue homogenate was centrifuged at 100,000 x g. Attempts to purify the enzyme indicated that the CGase protein is of hydrophobic nature as it binds to hydrophobic columns. The enzyme has been partially purified using hydrophobic columns in tandem. The partially purified protein was found to be immunoreactive to the antibody raised against the purified clam CGase. The immunostained band corresponded to a 64 kDa protein as also found with the clam enzyme. This immuno cross-reactivity indicated probable structural similarities between CGase proteins isolated from widely separated species in the evolutionary tree. The rat CGase was found to have a specific detergent requirement for optimal activity, and the pH optimum was found to be between 5 and 6. The enzyme activity is partially heat stable. It is not a divalent cation requiring enzyme; however, the activity is totally inhibited in the presence of mercury, indicative of a sulfhydryl group in the active site of the enzyme. The rat mammary CGase activity is inhibited in the presence of both D- and L-PPMP (1-phenyl-2-hexadecanoylamino-3-morpholino-1-propanol. HCl), homologs of PDMP (1-phenyl-2-decanoylamino-3-morpholino-1-propanol. HCl), a well-known inhibitor of GlcT-1 (Ceramide: UDP-Glc Glucosyltransferase), an enzyme in the glycolipid synthetic pathway. The inhibition seems to be of a competitive nature and the same type of inhibition is also observed with clam CGase. The CGase activity was found to be highest in lactating tissue compared to the activity found in either pregnant or post-lactating rat mammary tissues. Tissue survey indicated the presence of high levels of CGase in lactating rat liver, uterus, and ovary; moderate activity was detected in kidney and spleen. Both virgin and male rat mammary tissue also indicated a basic level of CGase activity. However, newborn spleen and mammary tissue showed a comparable level of activity to that found in lactating rat tissues. This report is mainly concerned with the characterization of CGase activity from a mammalian source and its importance in cellular processes.

Manejo de la patología tiroídea: utilidad y limitaciones de la biopsia percutánea con aguja fina y de la biopsia rápida / Management of thyroid pathology: usefulness and limitations of percutaneous biopsy with fine needle and quick biopsy

Fine needle aspiration biopsy of the thyroid (FNAB) has become an accepted procedure for evaluation of the thyroid nodule, with 899 performed at the Lahey Clinic from 1981 to 1990. We examined them by medical record, pathology and cytology review, with follow up by chart or personal communication. Three hundred forty five came to surgery, of which 188 (34 percent) were malignant; the specificity of the aspirate was 97 percent, sensitivity 92 percent, with false negative of 8 percnt and false positive rate of 5 percent. In combination with frozen section, the fine needle aspirate result improved the accuracy of the intraoperative estimate of malignancy (p=0.03). When the aspiration was benign but the lesion was clinically suspicious, a cancer was found at surgery in 13 percent of cases. Of the patients observed for a minimum of 5 years, 1,3 percent developed a carcinoma. Both cases had a non diagnostic FNAB. None of the patients with a clinical and cytological benign lesion developed cancer. The complication rate of FNAB was 1.3 percent. FNAB is a helpful and low risk diagnostic procedure but it needs to be done and read appropriately and its result used within the clinical context. Each medical team needs to monitor their results (continued quality control)

Neoplasias hepáticas en enfermos con glucogenosis: problemas diagnósticos y terapéuticos / Hepatic neoplasm in patients with glycogenosis: diagnostic and therapeutical problems

In a family composed by 8 brothers, 5 had a type I glycogen storage disease and tnhree presented with liver tumors complicated with hemorrhage or malignant transformation, during the followup. The periodic yltrasonographic control allowed the early diagnosis of these neoplasms. We described the clinical picture and treatment of 2 patients. Metabolic alterations were corrected during the preoperative period with parenteral nutrition. Resection was succesful in both cases. It is concluded that a close follow up and early treatment of these lesions is effective and avoids complications. In patients with multiple lesions and severe metabolic alterations, liver transplantation is the treatment of choice

El imperativo de la participación médica en la implementación de sistemas de control de calidad / The imperative of medical participation in the implementation of quality control systems

Changes in health care delivery in Chile over the lact years include rising costs and the relative increase of prepaid private insurance programs. It is expected that there will be increasing pressures on helath providers to disease cost while maintaining or improving quality. A series of common clinical problems are reviewed (herni repair, appendicitis, gallstone disease, trauma, preoperative evaluation) to demonstrate that using a scientific method-continuous quality improvement and considering tha local socioeconomic reality, this challenge can be met. Emphasis is made on the need for physicians to participate in such a process and on the teaching of these concepts. Medical societies and schools should consider these health care developments and adapt to this changes

Orientación actual en el tratamiento quirúrgico de la sinovitis hemofilica con la sinovectomía / Recent surgical treatment of the synovitis haemophilic with the synovectomy

Han sido revisadas 350 sinovectomías (hombro, codo, cadera, rodilla, tobillo) con un seguimiento de 8 meses a 15 años. Del examen minucioso, se pudo observar que la sinovectomía da los mejores resultados cuando la artropatia presenta las siguientes características: HISTORIA DE HEMARTROSIS repetidas sin intervalos de completa remisión; signos de inicial flogosis articular; signos radiológicos de leve sufrimiento osteo-condoral. Se demostró no resolutiva cuando la actividad destructora de la sinovial ha llegado al ápice se ha extinguido, cuando los daños articulares son con deformación de los extremos óseos y desviaciones axiales y el síntoma más importante es el dolor a la carga (cadera, rodilla, tobillo). Los autores se refieren a una larga experiencia con la sinovectomía, recogida en 10 años, en el tratamiento de la artropatia hemofílica. Los resultados de una revisión a distancia de la casuística operatoria presentados en el Congreso de Dousseldorf (1985) fueron satisfactorios en la evolución de la artropatía y respecto al dolor y a la función articular

La osteotomía correctora de miembros inferiores en la artropatía hemofílica / The osteotomy corrector of lower extremite in the hemophilic arthropaty

En los pacientes afectados de Artropatía Hemofílica, es frecuente observar, especialmente en los miembros inferiores, la presencia de posiciones viciosas y de desviaciones axiales. Las alteraciones osteoarticulares prevalentes en los estados avanzados de la artropatía son las responsables del desequilibrio mecánico, de las recidivas de la hemartrosis y del dolor. Para el tratamiento de la artropatía con deformidad articular hemos recurrido alguna vez a intervenir realizando una osteotomía correctora asociada a sinovectomía o a "Rebaja Articular", y otras veces a intervenir realizando osteotomía solamente. Han estado seguidas 23 osteotomías (5 inter-trocantéricas para cadera; 6 supracondíleas y 12 osteotomías altas de tibia, para la rodilla) Tabla 1. Osteotomías 23, Cadera , Supracondilea fémur 6, Proximales de Tibia 12, Pacientes 20. Los controles a larga data (de 1 a 6 años), han constatado en la mayoría de los pacientes operados, además de la estabilidad de la corrección obtenida, el reinicio de una marcha más correcta y de la capacidad para el trabajo, la desaparición del dolor y de las recidivas de hemartrosis. Resultados que hemos obtenido también en aquellos pacientes en los cuales se les realizó osteotomía solamente. El juicio del paciente fue casi siempre muy satisfactorio e igualmente, si el cuadro radiológico de la articulación no ha mostrado variaciones relevantes, la mejor distribución de carga ha producido una función articular más correcta y con mejoramiento de la sintomatología