Síndrome de Klinefelter, testosterona y sueño: a propósito de un caso clínico / Klinefelter's syndrome, testosterone and sleep: a clinical case

Se presenta un caso clínico de Síndrome de Klinefelter y se revisan que los aspectos en relación al sueño en estos pacientes, siendo relevante a ser abordado y estudiado debido a la relación causal entre el metabolismo de esteroides sexuales afectados. En especial la testosterona y cómo esto influye en la microarquitectura del sueño y la probabilidad de presentar síndrome de apnea obstructiva del sueño, con las repercusiones cognitivas que pueden sumarse a las ya descritas por el síndrome en si. De allí la importancia de un seguimiento y abordaje dirigido en este aspecto, al momento del diagnóstico y en el seguimiento a largo plazo. Palabras Clave: Testosterona, sueño, vitamina D, S. de Klinefelter, esteroides.

A clinical case of Klinefelter's Syndrome is presented and the aspects related to sleep in these patients are reviewed, being relevant to be addressed and studied due to the causal relationship between the metabolism of affected sex steroids, especially testosterone and how this influences the microarchitecture of sleep and the probability of presenting obstructive sleep apnea syndrome with the cognitive repercussions that can be added to those already described by the syndrome itself. Hence the importance of a targeted follow-up and approach in this aspect, at the time of diagnosis and in long-term follow-up. Keywords: Testosterone, sleep, Klinefelter, vitamin D, steroids.

Circulating sex hormones in women with severe anxiety during pregnancy / Hormonas sexuales circulantes en mujeres con ansiedad severa durante el embarazo

Abstract Introduction Anxiety, mood- and stress-related behaviors are regulated by sex hormones in pregnant and non-pregnant women. Very scarce information exists about the role of sex steroids in pregnant women displaying high levels of anxiety. Objective To determine sex hormones serum levels in pregnant women exhibiting high levels of anxiety symptoms. Method The Hamilton Anxiety Rating Scale (HARS/ HAM-A) was used to assess the intensity of anxiety symptoms in third-trimester pregnant women. Two groups were included in the study, pregnant women exhibiting severe anxiety (ANX; HARS scores ≥ 25; n = 101) and healthy control subjects (CTRL; n = 40) displaying lower scores for anxiety (HARS scores ≤ 7). Estradiol (E2), progesterone (P4), and testosterone (T) serum levels were measured using a standard chemiluminescent immunoassay. Bivariate and partial correlations were performed to detect significant associations between groups, clinical measures, biochemical data, and HARS scores. Results The anxiety group (ANX) showed an increase in E2 and T serum levels (p < .001) compared to CTRL. Conversely, significantly lower P4 levels were found in the symptomatic group (p < .001) as compared to the CTRL hormone values. The P4:E2 index was significantly reduced in pregnant women with high levels of anxiety (p < .001). Negative correlations between anxiety (HARS) scores, P4 serum levels (p = .02), and P4:E2 ratio (p = .04) were found in the symptomatic group. Conversely, T serum levels displayed a positive association (p = .001) with high levels of anxiety symptoms in the same group, after adjusting our data by clinical confounders. Discussion and conclusion Serum levels of sex-steroid hormones are altered in pregnant women exhibiting severe anxiety.

Resumen Introducción La ansiedad, el estado de ánimo y el estrés están regulados por diversos esteroides sexuales. Existe poca información sobre el papel que juegan estos esteroides en mujeres embarazadas con niveles elevados de ansiedad. Objetivo Determinar los niveles séricos de hormonas sexuales en mujeres embarazadas con altos índices de síntomas de ansiedad con respecto a mujeres gestantes sanas. Método Determinación de la intensidad de síntomas ansiosos empleando la escala de Hamilton de Ansiedad (HAM-A) en 141 mujeres embarazadas en el tercer trimestre de gestación. Cuantificación de los niveles séricos de estradiol (E2), progesterona (P4) y testosterona (T) por inmunoensayo estándar. Aplicación de las correlaciones de Pearson para detectar asociaciones entre parámetros clínicos y valores hormonales entre los grupos de estudio. Resultados Las mujeres con ansiedad severa (ANX; n = 101; HAM-A ≥ 25) mostraron niveles séricos más altos de E2 y T (p < .001), así como niveles más bajos de P4 (p < .001) en relación con el grupo control (CTRL, n = 40, HAM-A < 7). Se detectó una disminución significativa en el índice P4:E2 en el grupo de ANX (p < .001) y se observaron correlaciones negativas y positivas entre los puntajes elevados de ansiedad con los niveles circulantes de P4 (p = .02), en la taza P4:E2 (p = .04) y en los niveles séricos de T (p = .001) respectivamente, al ajustar nuestros datos con variables confusoras. Discusión y conclusión Los niveles circulantes de los esteroides sexuales se encontraron alterados en mujeres con ansiedad severa.

Caracterización clínica y epidemiológica de la enfermedad pulmonar obstructiva crónica / Clinical and epidemiological characterization of chronic obstructive pulmonary disease

Objetivo: caracterizar clínica y epidemiológicamente a los pacientes con enfermedad pulmonar obstructiva crónica. Métodos: estudio descriptivo retrospectivo trasversal, que incluyó pacientes adultos con diagnóstico de enfermedad pulmonar obstructiva crónica en un hospital universitario de Medellín. Material y métodos: la fuente de información fue secundaria a través de historias clínicas, el análisis se realizó en el programa Jamovi, empleando un análisis univariado. Resultados y discusión: se incluyeron 552 pacientes, la edad mediana fue 76 años con predominio del sexo femenino (56.7%). Respecto a la exposición a sustancias tóxicas respiratorias importantes en el desarrollo de la enfermedad, 24.1% consumían cigarrillo y 23% exposición a biomasa. Al momento del ingreso hospitalario 17.9% fueron clasificados con disnea grado IV; 74.1% recibió beta-agonistas de corta acción y antimuscarínicos de corta acción 60%; 11.6% requirió ingreso a las unidades de cuidados intensivos o especiales y 7.8% fallecieron durante la hospitalización. Conclusiones: se evidencia subdiagnóstico espirométrico de la enfermedad que puede estar relacionado con las limitaciones económicas, tecnológicas y de recurso humano capacitado, lo cual afecta el adecuado diagnóstico y manejo de la enfermedad, así como impacta la calidad de vida de los pacientes.

Objective: clinical and epidemiological characterization of patients with chronic obstructive pulmonary disease (COPD). Methods: a retrospective, cross-sectional, descriptive study, which included adult patients with a diagnosis of COPD in a university hospital in Medellín. Data sources were secondary, based on medical records. The Jamovi program was used to perform a univariate analysis. Results and discussion: 552 patients were included. Median age was 76 years with a female predominance (56.7%). Regarding exposure to major respiratory toxic substances implicated in the development of the disease, 24.1% were tobacco smokers and 23% were exposed to biomass smoke. At the time of hospital admission,17.9% were classified as having grade 4 dyspnea; 74.1% received short acting beta-agonists and 60% short-acting antimuscarinics,11.6% required intensive care unit or special care unit admission, and 7.8% died in hospital. Conclusions: under-diagnosis of COPD by spirometry may be related to economic, technological, and trained human resource limitations, which affect adequate diagnosis and management of the disease, as well as patient ́s quality of life.

Long-term outcomes of intraoperative triamcinolone injection versus postoperative oral prednisolone in congenital cataract surgery / Resultados de longo prazo do uso intraoperatório de triancinolona versus oral pós-operatório de prednisolona na cirurgia de catarata congênita

ABSTRACT Purpose: To compare the long-term ocular findings of children that were operated of congenital cataract before the age of two and that received an intraoperative intracameral triamcinolone injection or used postoperative oral prednisolone to modulate ocular inflammation. Methods: All patients who had previously participated in a clinical trial that analyzed the 1-year surgical outcomes of congenital cataract surgery utilizing intracameral triamcinolone (study group) or oral prednisolone (control group) were eligible to participate in this prospective cohort research. Patients' medical records were reviewed, and the children underwent a complete ophthalmologic exam on final follow-up. Biomicroscopic findings, intraocular pressure, central corneal thickness, the need for additional surgical interventions, and findings compatible with glaucoma were the primary end measures. Results: Twenty-six eyes (26 patients) were included (study group = 11 eyes; control group = 15 eyes). The mean follow--up was 8.2 ± 1.2 years and 8.1 ± 1.7 years in the study and control groups, respectively (p=0.82). All eyes presented a centered intraocular lens. There was no statistically significant difference between the groups with regards to the presence of posterior synechia (p=0.56), intraocular pressure (p=0.49), or central corneal thickness (p=0.21). None of the eyes fulfilled the glaucoma diagnostic criteria, presented secondary visual axis obscuration, or were reoperated. Conclusion: The long--term ocular findings of children that underwent congenital cataract surgery and received an intraoperative intracameral triamcinolone injection were similar to those that used postoperative oral prednisolone to modulate ocular inflammation. This suggests that intracameral triamcinolone may substitute oral prednisolone in congenital cataract surgery, facilitating the postoperative treatment regimen and compliance.

RESUMO Objetivo: Comparar os achados oculares em longo prazo de crianças que se submeteram à cirurgia de catarata congênita antes dos dois anos de idade e receberam uma injeção intracameral de triancinolona no intraoperatório ou usaram prednisolona oral no pós-operatório para modular a inflamação ocular. Métodos: Neste estudo prospectivo de coorte, todos os pacientes que participaram de um ensaio clínico anterior, que analisou os resultados cirúrgicos de 1 ano da cirurgia de catarata congênita usando triancinolona intracameral (Grupo de Estudo) ou prednisolona oral (Grupo Controle), eram elegíveis para participar. Os prontuários médicos dos pacientes foram revisados e as crianças foram submetidas a um exame oftalmológico completo no acompanhamento final. As principais medidas de desfecho foram: achados biomicroscópicos, pressão intraocular, espessura central da córnea, a necessidade de intervenções cirúrgicas adicionais e achados compatíveis com glaucoma. Resultados: Vinte e seis olhos (26 pacientes) foram incluídos (Grupo de Estudo = 11 olhos; Grupo de Controle = 15 olhos). O seguimento médio foi de 8,2 ± 1,2 anos e 8,1 ± 1,7 anos nos Grupos de Estudo e Controle, respectivamente (p=0,82). Todos os olhos apresentavam lente intraocular centrada. Não houve diferença estatisticamente significativa entre os grupos com relação à presença de sinéquia posterior (p=0,56), pressão intraocular (p=0,49) ou espessura central da córnea (p=0,21). Nenhum dos olhos preencheu os critérios diagnósticos para glaucoma, apresentou opacificação secundária do eixo visual ou foi reoperado. Conclusão: Os achados oculares em longo prazo de crianças que se submeteram à cirurgia de catarata congênita e receberam uma injeção intracameral de triancinolona no intraoperatório foram semelhantes aos que usaram prednisolona oral no pós-operatório para modular a inflamação ocular, sugerindo que a triancinolona intracameral pode substituir a prednisolona oral na cirurgia de catarata congênita, facilitando o tratamento pós-operatório e a adesão ao mesmo.

Bone effects of epidural and intra-articular glucocorticoids: a systematic literature review / Efectos óseos de los glucocorticoides epidurales e intraarticulares: revisión sistemática de la literatura

Osteoporosis and vertebral and non-vertebral fractures are common in glucocorticoids (GC) treated patients. Oral GC treatment leads to bone loss, particularly of trabecular bone. The benefits of GC used in rheumatological and traumatological disorders are known but they would have possible negative effects on bone. This systematic review aimed to evaluate the effects of epidural steroid injections (ESI), and intra-articular and intramuscular GC administration on bone mineral density (BMD) and fragility fractures. A systematic review of Medline/PubMed, Cochrane, and LILACS up to November 2020 was conducted. Meta-analyses, systematic reviews, randomized and non-randomized controlled trials, and prospective and retrospective studies comparing the effect of ESI, intra-articular or intramuscular GC used compared to a control group or baseline measurements were included. Results: A total of 8272 individuals were included among the 13 selected articles (10 about ESI and 3 about intra-articular GC; no article was found evaluating intramuscular GC). Only a few studies showed a negative effect of ESI on bone in the qualitative analysis considering osteopenia and osteoporosis in lumbar spine, femoral neck and total hip and BMD as surrogate outcomes. On the other hand, the qualitative analysis showed that most studies found an increased risk of fragility fracture. However, only two studies could be included in the quantitative analysis, in which there were no differences between patients exposed to ESI versus controls in all evaluated regions. In conclusion, there was insufficient evidence to suggest that ESI and intra-articular GC, unlike oral GC, negatively affect bone mass. Longitudinal studies are needed to obtain more knowledge regarding the effect of ESI or intra-articular GC on BMD and fragility fractures. (AU)

La osteoporosis y las fracturas vertebrales y no vertebrales son comunes en pacientes tratados con glucocorticoides (GC). El tratamiento oral con GC conduce a la pérdida ósea, particularmente del hueso trabecular. Los beneficios de los GC utilizados en patologías reumatológicas y traumatológicas son conocidos, pero tendrían posibles efectos negativos sobre el hueso. Esta revisión sistemática tuvo como objetivo evaluar los efectos de las inyecciones epidurales de esteroides (ESI), GC intraarticulares e intramusculares sobre la densidad mineral ósea (DMO) y las fracturas por fragilidad. Se realizó una revisión sistemática de Medline/PubMed, Cochrane y LILACS hasta noviembre de 2020. Se incluyeron metanálisis, revisiones sistemáticas, ensayos controlados aleatorizados y no aleatorizados, estudios prospectivos y retrospectivos que compararon el efecto de ESI, GC intraarticular o intramuscular utilizado en comparación con un grupo de control o mediciones iniciales. Resultados: Se incluyeron un total de 8272 individuos entre los 13 artículos seleccionados (10 sobre ESI y 3 sobre GC intraarticular; no se encontró ningún artículo que evaluara GC intramuscular). Solo unos pocos estudios mostraron un efecto negativo del ESI sobre el hueso en el análisis cualitativo considerando la osteopenia y la osteoporosis en la columna lumbar, el cuello femoral y la cadera total y la DMO como un resultado indirecto. Por otro lado, el análisis cualitativo mostró que la mayoría de los estudios encontraron un mayor riesgo de fractura por fragilidad. Sin embargo, solo dos estudios pudieron incluirse en el análisis cuantitativo, en los que no hubo diferencias entre los pacientes expuestos a ESI versus los controles en todas las regiones evaluadas. En conclusión, no hallamos datos suficientes para sugerir que la ESI y los GC intraarticulares, a diferencia de los GC orales, afectan negativamente a la pérdida ósea. Se necesitan estudios longitudinales para obtener más conocimiento sobre el efecto de ESI o GC intraarticular en la DMO y las fracturas por fragilidad. (AU)

Pelvic Ewing Sarcoma: The Great Mimicker / Sarcoma de Ewing pélvico: o grande imitador

Abstract Ewing sarcoma is the most common malignant bone tumor of the pelvis in children and young adults. Even with aggressive treatment, its survival rate is amongst the poorest. Classical presentation may not be the rule. It may simulate clinically, imagiologically and histopathologically other nonmalignant entities. Therefore, its suspicion should not be overlooked. We report two cases of pelvic Ewing sarcoma: the first mimicking eosinophilic granuloma, and the second mimicking osteomyelitis. In the latter, we also report an atypical finding of its natural history: an initial response to antibiotic and anti-inflammatory treatment. In both cases, we highlight the possibility of an inconclusive percutaneous bone biopsy and the importance of immunochemistry and cytogenetics for the definitive diagnosis.

Resumo O sarcoma de Ewing é o tumor ósseo maligno da pelve mais comum em crianças e adultos jovens. Mesmo com tratamento agressivo, sua taxa de sobrevivência está entre as piores. A apresentação clássica pode não ser a regra. Ele pode simular clinicamente, imaginologicamente e histopatologicamente outras entidades não malignas. Portanto, sua suspeita não deve ser negligenciada. Relatamos dois casos de sarcoma pélvico: o primeiro imitando granuloma eosinofílico e o segundo imitando osteomielite. Neste último, também relatamos um achado atípico de sua história natural: uma resposta inicial ao antibiótico e ao tratamento anti-inflamatório. Em ambos os casos, destacamos a possibilidade de uma biópsia óssea percutânea inconclusiva e a importância da imunoquímica e da citogenética para o diagnóstico definitivo.

Atrofodermia Idiopática de Pasini y Pierini, un abordaje inusual / Idiopathic atrophoderma of Pasini and Pierini, an unusual approach

La atrofodermia idiopática de Pasini y Pierini es una entidad poco frecuente y de etiología aún no esclarecida, se presenta con una frecuencia hasta seis veces mayor en mujeres que en hombres y una posible asociación con la esclerodermia localizada (morfea). Paciente femenina de 30 años, quien consultó por una lesión asintomática de dos años de evolución en el glúteo izquierdo. En el examen físico se evidenció una placa ovalada, deprimida y acrómica en su centro, que mide cinco por diez centímetros. La paciente había sido tratada previamente con múltiples terapias tópicas sin obtener mejoría clínica. Se realizó la biopsia de piel que demostraba cambios mínimos en epidermis, homogenización y adelgazamiento de colágeno sin afección de anexos. Se hizo correlación con los hallazgos clínicos y se decidió iniciar tratamiento con esteroides intralesionales de alta potencia (acetónido de triamcinolona). Posterior a la administración de dos aplicaciones del medicamento, con cuatro semanas de diferencia entre ellas, se evidenció la resolución completa de la dermatosis. Un mes después de la última dosis la paciente no mostró recidivas

diopathic atrophoderma of Pasini and Pierini is a rare entity of unclear etiology, occurring as much as six times more frequently in women than in men, with a possible association with localized scleroderma (morphea). It is about a 30 years old woman who consulted with an asymptomatic lesion of two years of evolution on the left gluteal region. Physical examination revealed an oval plaque, depressed and acromic in its center, measuring five by ten centimeters. A 30 years old female patient who consulted about an asymptomatic lesion of two years of evolution on the left gluteal region. Physical examination revealed an oval plaque, depressed and acromic in its center, measuring five by ten centimeters. The patient was previously treated with multiple topical therapies without clinical improvement.Skin biopsy showed minimal changes in the epidermis, homogenization, and thinning of the collagen without adnexal involvement. After a correlation was made with the clinical findings, starting treatment with high-potency intralesional steroids (triamcinolone acetonide) was recommended. After administering two applications of the drug, four weeks apart, the complete resolution of the dermatosis was evidenced. One month after the last dose, the patient showed no recurrence

Proteinuria y síndrome nefrótico / Proteinuria and Nephrotic Syndrome

Introducción: El síndrome nefrótico es una patología que afecta el complejo glomerular del riñón, se caracteriza por una proteinuria mayor 3500 mg/d. De acuerdo a la respuesta de los esteroides se puede clasificar en síndrome nefrótico en esteroide resistente o esteroide sensible. Objetivo: Determinar la relación que existe entre la proteinuria y las variantes del síndrome nefrótico en adultos. Métodos: Se realizó un estudio descriptivo, retrospectivo, tipo serie de casos, con una población de 28 pacientes. Se recolectaron y se procesaron los datos a través del software Epi-Info 7,2TM; la frecuencia simple, la media estadística, prueba t de Student, y el coeficiente de correlación de Pearson. Resultados: En el análisis combinatorio de los fármacos adyuvantes para síndrome nefrótico, el grupo que utilizó antiproteinúricos pero no estatinas, demostró una diferencia estadísticamente significativa entre la proteinuria postratamiento media del grupo de síndrome nefrótico esteroideo resistente (6202 mg/d) vs síndrome nefrótico esteroideo sensible (65,9 mg/d) (valor de p 0,418). Existe una correlación negativa entre los niveles proteinuria postratamiento y el nivel de albúmina sérica postratamiento (r = - 0,7 valor de p < 0,00001). Conclusiones: Se demostró la ausencia de asociación entre la proteinuria inicial y las variantes de síndrome nefrótico esteroide sensible y esteroide resistente (valor de p = 0,8)(AU)

Introduction: Nephrotic syndrome is a pathology that affects the glomerular complex of the kidney, characterized by proteinuria greater than 3500 mg/d. According to the response to steroids, nephrotic syndrome can be classified as steroid-resistant or steroid-sensitive. Objective: To determine the relationship between proteinuria and the variants of the nephrotic syndrome in adults. Methods: A descriptive, retrospective, case series type study was carried out with a population of 28 patients. The data was collected and processed through Epi-Info 7.2TM software; simple frequency, statistical mean, student's t-test, and Pearson's correlation coefficient. Results: The statistically significant difference was obtained in the antiproteinuric and non-statin group, between the mean post-treatment proteinuria of the steroid resistant nephrotic syndrome group (6202 mg/d) in comparison to steroid sensitive nephrotic syndrome (65.9 mg/d) (p value 0.0418). There is negative correlation between post-treatment proteinuria levels and post-treatment serum albumin level (r= -0.7 p value <0.00001). Conclusions: The absence of association between initial proteinuria and steroid-sensitive and steroid-resistant variants of nephrotic syndrome was demonstrated (p value=0.8)(AU)

Update of the Brazilian consensus recommendations on Duchenne muscular dystrophy / Atualização das recomendações do consenso brasileiro para distrofia muscular de Duchenne

Abstract In the last few decades, there have been considerable improvements in the diagnosis and care of Duchenne muscular dystrophy (DMD), the most common childhood muscular dystrophy. International guidelines have been published and recently reviewed. A group of Brazilian experts has developed a standard of care based on a literature review with evidence-based graded recommendations in a two-part publication. Implementing best practice management has helped change the natural history of this chronic progressive disorder, in which the life expectancy for children of the male sex in the past used to be very limited. Since the previous publication, diagnosis, steroid treatment, rehabilitation, and systemic care have gained more significant insights with new original work in certain fields. Furthermore, the development of new drugs is ongoing, and some interventions have been approved for use in certain countries. Therefore, we have identified the need to review the previous care recommendations for Brazilian patients with DMD. Our objective was to create an evidence-based document that is an update on our previous consensus on those topics.

Resumo Nas últimas décadas, houve progressos significativos no diagnóstico e no tratamento da distrofia muscular de Duchenne (DMD), considerada a distrofia muscular mais comum na infância. Diretrizes internacionais foram publicadas e revisadas recentemente. Um grupo de especialistas brasileiros desenvolveu um padrão de atendimento baseado em revisão de literatura, com recomendações graduadas pautadas em evidências compiladas em uma publicação dividida em duas partes. A implementação de melhores práticas de manejo ajudou a modificar a história natural desta doença crônica, progressiva, que, no passado, oferecia uma expectativa de vida muito limitada para crianças do sexo masculino. Desde a publicação desse consenso anterior, o diagnóstico, o tratamento com esteroides, a reabilitação e os cuidados sistêmicos ganharam novas possibilidades a partir da divulgação dos resultados de trabalhos originais em algumas dessas áreas. Além disso, as pesquisas e o desenvolvimento de novos fármacos estão em andamento, e algumas intervenções já foram aprovadas para uso em determinados países. Nesse contexto, identificamos a necessidade de rever as recomendações anteriores sobre o manejo dos pacientes brasileiros com DMD. Nosso objetivo principal foi elaborar uma atualização baseada em evidências sobre esses tópicos do consenso.

Consumo de ayudas ergogénicas nutricionales y farmacéuticas en personas que asisten a gimnasios del municipio de Cercado, Cochabamba

Dado el problema de salud pública que plantean los esteroides anabólicos, el consumo de ayudas ergogénicas está aumentando a nivel mundial, no es en Bolivia. Además, existe un consumo desmedido de suplementos nutricionales y farmacéuticos, así como efectos reversibles e irreversibles de los esteroides anabólicos. Objetivos: describir cómo se consumen las ayudas ergogénicas nutricionales y farmacéuticas y cómo los asistentes a gimnasios en el municipio Cercado de Cochabamba perciben sus efectos en su salud. Métodos: se realizó un estudio observacional transversal con 378 participantes mayores de 18 años, (estratificada) divididos en cuatro grupos; Amateur, Fitness, Deportista y en nueve gimnasios y dos grupos (NABBA-IFFB) y deportistas en general en el área metropolitana de Cercado Cochabamba. Resultados: se encontró que el 74,6% consume alguna sustancia que mejoran el rendimiento; el consumo de ayudas ergogénicas nutricionales fue del 57,1%(n=216) y farmacológicas el 17,4% (n=66). El tiempo dedicado a entrenamiento y dieta para el grupo amateur es estadísticamente significativo con un valor de (p<0,05). Los efectos percibidos y reportados por el consumo de ayudas ergogénicas farmacológicas (esteroides anabólicos androgénicos) son principalmente cambios de humor, alteración en la libido y acné. Entre los efectos secundarios irreversibles dos casos de hombres desarrollaron ginecomastia y dos mujeres desarrollaron clítoromegalia. Conclusiones: los usuarios de ejercicio en el gimnasio consumen grandes cantidades de sustancias nutricionales y/o farmacológica que mejoran el rendimiento.

Given the public health problem posed by anabolic steroids, the consumption of ergogenic aids is increasing worldwide, not indifferently in Bolivia. In addition, there is an excessive consumption of nutritional and pharmaceutical supplements, as well as reversible and irreversible effects of anabolic steroids. Objectives: to describe how nutritional and pharmaceutical ergogenic aids are consumed and how gym-goers in the Cercado municipality of Cochabamba perceive their effects on their health. Methods: a crosssectional observational study was conducted with 378 participants over 18 years of age, (stratified) divided into four groups; Amateur, Fitness, Athlete and in 9 gyms and 2 groups (NABBA-IFFB) and athletes in general in the metropolitan area of Cercado Cochabamba. Results: it was found that 74.6% consumed some performance-enhancing substance; the consumption of nutritional ergogenic aids was 57.1% (n=216) and pharmacological aids 17.4% (n=66). Time dedicated to training and diet for the amateur group is statistically significant with a value of (p<0.05). The perceived and reported effects of the consumption of pharmacological ergogenic aids (anabolic androgenic steroids) are mainly mood changes, libido alteration and acne. Among the irreversible side effects 2 cases of men developed gynecomastia and 2 women developed clitoromegaly. Conclusions: exercise users in the gym consume large amounts of nutritional and/or pharmacological performance enhancing substances.

Redução de danos entre praticantes de musculação que consomem esteroides / Harm reduction among strength training practitioners who consume steroids

Resumo Esta pesquisa analisa os processos críticos para a redução de danos entre consumidores de esteroides, no contexto de academias de ginástica da região Metropolitana de Goiânia, Goiás, e os sujeitos do estudo foram selecionados por meio da técnica de Bola de Neve. Foi realizada análise de conteúdo a partir da transcrição de quinze entrevistas, e a exploração do material produzido levou à construção de quatro categorias a posteriori. Foram observadas ações - como o gerenciamento individual de riscos, a exemplo da autoexperimentação para avaliar a qualidade do produto e da automedicação na forma de terapias pós-ciclo - e, ao mesmo tempo, processos que conferem proteção à saúde, especialmente relativos às redes de apoio e à posição socioeconômica favorável dos participantes deste estudo. Considera-se importante estruturar ações proativas, contínuas e integradas de redução de danos que respondam às necessidades de saúde de quem consome esteroides, assim como implementar estratégias que superem tanto a abordagem de guerra às drogas quanto a abordagem apenas pragmática e individual do gerenciamento de riscos.

Abstract This research analyzes the critical processes for harm reduction among steroid consumers, in the context of gyms in the metropolitan region of Goiânia, Goiás. The study subjects were selected using Snowball sampling. Content analysis was carried out from the transcription of fifteen interviews, and the exploration of the produced material led to the construction of four categories a posteriori. Actions-such as individual risk management, by self-experimentation to assess the product's quality and self-medication in the form of post-cycle therapies, for example-were observed and, at the same time, processes that afford health protection, especially regarding the support networks and favorable socioeconomic position of this study's participants. Structuring proactive, continuous, and integrated harm reduction actions that respond to steroid consumers' health needs is considered important, as well as implementing strategies that overcome both the war on drugs approach and the merely pragmatic and individual approach to risk management.

Anti-inflammatory treatment after selective laser trabeculoplasty: a systematic review of the literature and meta-analysis of randomized control trials / Tratamento anti-inflamatório após trabeculoplastia seletiva a laser: revisão sistemática da literatura e meta-análise de ensaios clínicos randomizados controlados

ABSTRACT We assessed the effects of anti-inflammatory treatment after selective laser trabeculoplasty through a systematic search of the MEDLINE, COCHRANE, and ClinicalTrials.gov. The outcome measures were intraocular pressure, anterior chamber inflammation, and discomfort. Evidence synthesis was performed using fixed effects or random-effects model according to the heterogeneity of the included studies. Heterogeneity was assessed using Q-statistic and I2. For an overall estimate of continuous outcomes, the mean differences and their 95% confidence intervals were applied, while odds ratios and their 95% confidence intervals were applied for dichotomous outcomes. Six studies were included in all. No significant difference was noted in the patients for intraocular pressure and discomfort when treated with anti-inflammatory drops. However, the patients showed benefit from reduced anterior chamber inflammation in the first postoperative week [FE OR=0.43, 95% CI=(0.19, 0.95), PQ=0.97, I2=0%], with no significant difference between the outcomes of non-steroidal anti-inflammatory drugs and steroids [FE OR=0.75, 95% CI=(0.20, 2.82), PQ=0.37, I2=0%]. Anti-inflammatory drops reduce anterior chamber inflammation after selective laser trabeculoplasty but showed no effect on the intraocular pressure.

RESUMO O objetivo deste estudo é avaliar os efeitos do tratamento anti-inflamatório após a trabeculoplastia seletiva a laser. Uma busca sistemática foi feita no MEDLINE, COCHRANE e ClinicalTrials.gov. As medidas de resultado foram pressão intraocular, inflamação da câmara anterior e desconforto. A síntese de evidência foi realizada utilizando-se modelo de efeitos fixos ou efeitos aleatórios, de acordo com a heterogeneidade dos estudos incluídos. A heterogeneidade foi avaliada utilizando-se Q-statistic e I². Para uma estimativa global dos resultados contínuos, foram usadas diferenças médias e seus intervalos de confiança de 95% enquanto para resultados dicótomos, usou-se odds ratios e seus intervalos de confiança de 95%. Seis estudos foram incluídos. Nenhuma diferença significativa foi encontrada em pacientes tratados com gotas anti-inflamatórias em termos de pressão intraocular e desconforto. No entanto, eles se beneficiaram da redução da inflamação da câmara anterior na primeira semana pós-operatória [FE OR=0,43, IC 95% = (0,19, 0,95), PQ=0,97, I2=0%], sem diferença significativa entre anti-inflamatórios não esteroidais e esteroidais [FE OR=0,75, IC 95% = (0,20, 2,82), PQ=0,37, I2=0%]. Gotas anti-inflamatórias reduzem a inflamação da câmara anterior após trabeculoplastia seletiva a laser, não afetando a pressão intraocular.

COVID-19 and mortality in patients with systemic lupus erythematosus

In december 2019, a new disease erupted in Wuhan, China, caused by coronavirus 2019 (CO-VID-19), which produces severe acute respiratory syndrome (SARS-CoV-2). Some cases associate COVID-19 with autoimmune disorders; the role of this virus in autoimmunity is poorly understood. Systemic lupus erythematosus (SLE) is an autoimmune disorder. Baricitinib is a Janus kinase inhibitor (JAK) approved for the treatment of autoimmune and inflam matory disorders, recently used for treating severe COVID-19 disease. We discuss four cases of SLE with COVID-19, two of whom were admitted to the intensive care unit and died, with a history of lupus nephritis; the following two cases survived. The risk fac tors which increase mortality in SLE are not yet known; however, lupus nephritis was associated with COVID-19 mortality. More studies are needed to understand the risk between autoimmune disorders and COVID-19. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2551).

Desde diciembre de 2019 estalló en Wuhan, China, una nueva enfermedad causada por corona-virus 2019 (COVID-19), causante del síndrome respiratorio agudo severo (SARS-CoV-2). Algunos casos asocian al COVID-19 a trastornos autoinmunes, el papel de este virus en la autoinmunidad está poco dilucidada. El lupus eritematoso sistémico (LES) es una enfermedad autoinmune. El baricitinib es una molécula inhibidora de quinasa de Janus (JAK) aprobada para el tratamiento de trastornos autoinmunitarios e inflamatorios, recientemente utilizado para el manejo de la enfermedad grave por COVID-19. Se trata de cuatro casos de LES con COVID-19, dos de las cuales ingresaron a la unidad de cuidados intensivos y fallecieron con antecedente de nefritis lúpica, los dos casos siguientes so brevivieron. Aún se desconocen los factores de riesgo que incrementan la mortalidad en LES; sin embargo, se asoció nefritis lúpica con mortalidad en COVID-19. Se requieren más estudios para comprender el riesgo entre las enfermedades autoinmunes y COVID-19. (Acta Med Colomb 2022; 47. DOI:https://doi.org/10.36104/amc.2022.2551).

Efectos antirresortivos y antimicrobianos de los antiinflamatorios no esteroideos en lesiones periapicales / Antiresorptive and antimicrobial effects of nonsteroidal anti-inflammatory drugs in periapical lesion

Los antiinflamatorios no esteroideos (AINE) son un grupo de fármacos que han sido comúnmente prescritos por sus propiedades antiinflamato- rias, antipiréticas y analgésicas, mismas que se deben a la inhibición de la formación de prostaglandinas. Este mecanismo ha sido ampliamente respaldado en la literatura; sin embargo, en la actualidad poco se co- noce sobre las propiedades adicionales de estos medicamentos como el efecto antirresortivo y antimicrobiano. La función antirresortiva se debe principalmente al bloqueo de la producción de prostaglandinas en específico la PGE2, que posee gran potencial osteoclastogénico, esencial para la aparición de lesiones periapicales; asimismo, la acción antimicrobiana de los AINE está relacionada con la afectación directa de la perpetuación de biopelícula, potencian la acción de los antibióticos, entre otros. Dichos efectos combinados podrían contribuir en la cura- ción de lesiones periapicales. El objetivo de este estudio es recopilar información actualizada sobre estas funciones agregadas de los AINE, con el fin de dar a conocer a los profesionales estos beneficios en la terapéutica de las lesiones periapicales (AU)

Non-steroidal anti-inflammatory (NSAIDs) are a group of drugs that have been commonly prescribed for their anti-inflammatory, antipyretic and analgesic properties, which are due to the inhibition of prostaglandin formation. This mechanism has been widely supported in the literature; however, currently little is known about the additional properties of these drugs such as the antiresorptive and antimicrobial effect. The antiresorptive function is mainly due to the blockage of prostaglandin production, specifically PGE2, which has great osteoclastogenic potential, and is essential for the appearance of periapical lesions; likewise, the antimicrobial action of NSAIDs is related to the fact that they directly affect the perpetuation of biofilms, enhance the action of antibiotics, among others. These combined effects could contribute to the healing of periapical lesions. The aim of this study is to gather updated information on these added functions of NSAIDs, in order to inform professionals about these benefits in the therapy of periapical lesion (AU)

La accidentada historia del descubrimiento de la vitamina D, en su primer centenario / The checkered history of the discovery of vitamin D, in its first centenary

El año 2022 marca el primer centenario del descubrimiento de la vitamina D, hallazgo que recompensó la prolongada búsqueda de la causa del raquitismo, su prevención y tratamiento. Al mismo tiempo puso en marcha importantes investigaciones relaciona-das con su biotransformación y el mecanismo de su acción antirraquítica, además de estudios sobre diversos efectos biológicos sin relación directa con su papel en la salud ósea. Esta breve revisión se limitará a delinear la prehistoria de la vitamina D y los diversos estudios, básicos y clínicos, que condujeron a su descubrimiento y caracterización química. (AU)

The year 2022 marks the centenary of the discovery of vitamin D, a breakthrough that rewarded the long search for the cause of rickets, its prevention and treatment. At the same time, it launched important investigations related to its biotransformation and the mechanism of its antirachitic action, as well as studies on various biological effects without direct relation to its role in bone health. This brief review will be limited to an outline of the prehistory of vitamin D and the various basic and clinical studies that led to its discovery and chemical characterization. (AU)

Caracterización de pacientes con dolor lumbar crónico tratados con bloqueo epidural transforaminal / Characterization of patients with chronic low back pain treated with transforaminal epidural block

Introducción: Mediante el presente estudio se realizará la caracterización clínica y demográfica de pacientes con lumbalgia crónica intervenidos con inyección epidural transforaminal de esteroides (bloqueo) en un hospital de cuarto nivel de complejidad. Materiales y métodos: Se realizó un estudio analítico retrospectivo de temporalidad longitudinal en el que se incluyeron 85 pacientes adultos con lumbalgia crónica intervenidos con bloqueo transforaminal desde el 1 de enero de 2020 al 31 de marzo de 2021. Resultados: 53 adultos (62,4%) eran mujeres y 32 (37,6) eran hombres. En promedio, la edad de estos individuos fue de 54+/- 14 an ̃os. En 37 casos (43,5%) se realizó de forma bilateral y 42 individuos (49,4%) requirieron este tipo de bloqueo en tres niveles lumbares. La media de síntomas relacionados fue de 24,37+/- 23,5 meses. Como etiología desencadenante, 33 individuos (38,8%) tenían enfermedad degenerativa del disco, 25 (29,4%) por espondiloartrosis, 16 (18,8%) por espondilolistesis. En relación al dolor lumbar subjetivo se registró una disminución de -4,1 ± 3,4 (CV = 82,1%) (p = 0,00). Discusión: La inyección epidural transforaminal de esteroides en pacientes con lumbalgia crónica es un procedimiento seguro y mínimamente invasivo, que durante el período de tiempo estudiado no presentó complicaciones ni hospitalización posterior. La mayoría de la población intervenida corresponde a mujeres entre 35 y 55 an ̃os. Se observó una disminución de la lumbalgia subjetiva después de un mes de realizar este procedimiento. Nivel de evidencia: Estudio analítico retrospectivo de temporalidad longitudinal. Nivel III

Introduction: Through this study, the clinical and demographic characterization of patients with chronic low back pain who underwent transforaminal epidural injection of steroids (block) will be carried out in a fourth level of complexity hospital. Materials and methods: A retrospective analytical study of longitudinal temporality was carried out in which 85 adult patients with chronic low back pain who underwent transforaminal block surgery were included from January 1, 2020 to March 31, 2021. Results: 53 adults (62.4%) were women and 32 (37.6) were men. On average, the age of these individuals was 54+/- 14 years. In 37 cases (43.5%) it was performed bilaterally and 42 individuals (49.4%) required this type of block at three lumbar levels. The mean number of related symptoms was 24.37+/- 23.5 months. As a triggering etiology, 33 individuals (38.8%) had degenerative disc disease, 25 (29.4%) due to spondyloarthrosis, 16 (18.8%) due to spondylolisthesis. In relation to subjective low back pain, a decrease of -4.1 ± 3.4 (CV = 82.1%) was recorded (p = 0.00). Discussion: Transforaminal epidural injection of steroids in patients with chronic low back pain is a safe and minimally invasive procedure, which during the period of time studied did not present complications or subsequent hospitalization. The majority of the operated population corresponds to women between 35 and 55 years old. A decrease in subjective low back pain was observed after one month of performing this procedure. Level of evidence: Retrospective analytical study of longitudinal temporality. Level III

Efeitos adversos relacionados ao uso de hormônio em pessoas transexuais: revisão integrativa / Adverse effects related to hormone use in transgender people: integrative review

As pessoas Transexuais são aquelas que apresentam identidade de gênero diferente do sexo biológico e gênero atribuído ao nascer. Há um sentimento de não relação entre o sexo e gênero e, assim, sentem a necessidade de adquirir certas características corporais do gênero com o qual se identificam. Por vezes, essa transição ocorre por meio da utilização de hormônios e/ou procedimentos estéticos. Durante o processo da hormonização, certos efeitos adversos ocorrem e podem apresentar vários riscos e problemas à saúde. Para tanto, indaga-se: Quais são as evidências científicas sobre efeitos adversos em pessoas transexuais que utilizam hormônio de sexo cruzado? Assim, o presente trabalho objetivou identificar e analisar os efeitos adversos descritos na literatura relacionados ao uso de hormônios em pessoas transexuais. Trata-se de uma revisão integrativa cuja busca dos artigos foi realizado em dezembro de 2021 até o mês de janeiro de 2022, nas seguintes bases de dados: Embase, PubMed, MEDLINE, Scopus e Lilacs. Foram incluídos 18 artigos para integrar o presente estudo. A análise de dados dos artigos incluídos partiu da ordenação e categorização do problema de pesquisa e com auxílio de estatística descritiva, com emprego da frequência e porcentagem. A partir da análise crítica dos artigos permitiu a identificação dos efeitos adversos. Foram identificados 75 efeitos adversos, os mais identificados foram a diminuição significativa de HDL e o aumento considerável de IMC ambos apresentaram o mesmo porcentual 6,7% (n = 5), seguidos do surgimento de acne com 5,3%(n=4), hiperuricemia e hiperprolactinemia ambos apresentam 4% (n = 3). Portanto, os resultados alcançados neste estudo, fornecem maior compreensão dos eventuais problemas que os efeitos adversos podem causar no organismo. Diante disso, constata-se a necessidade da realização de estudo direcionado especificamente aos efeitos adversos dos hormônios em pessoas transexuais que optam por usar hormônios para a realização de transição de gênero. Outro ponto importante a ser estudado é qual seria o hormônio ideal ou a combinação ideal de hormônio que produz resultados mais satisfatórios ou menos efeitos adversos. Também, há necessidade da realização do monitoramento desses indivíduos durante todo o processo.

Transgender people are those who have a gender identity different from the biological sex and gender assigned at birth. There is a feeling of unrelatedness between sex and gender, and thus they feel the need to acquire certain body characteristics of the gender with which they identify. Sometimes this transition occurs through the use of hormones and/or aesthetic procedures. During the process of hormonization, certain adverse effects occur and can present several risks and problems to health. Therefore, the following questions are posed: What is the scientific evidence on adverse effects in transsexual people who use cross-sex hormone? Thus, the present work aimed to identify and analyze the adverse effects described in the literature related to the use of hormones in transsexual people. This is an integrative review whose search for articles was carried out from December 2021 to January 2022, in the following databases: Embase, PubMed, MEDLINE, Scopus, and Lilacs. Eighteen articles were included in this study. The data analysis of the included articles started with the ordering and categorization of the research problem and with the help of descriptive statistics, using frequency and percentage. The critical analysis of the articles allowed the identification of adverse effects. Seventy-five adverse effects were identified, the most identified were a significant decrease in HDL and a considerable increase in BMI, both with the same percentage of 6.7% (n = 5), followed by the appearance of acne with 5.3% (n = 4), hyperuricemia and hyperprolactinemia, both with 4% (n = 3). Therefore, the results achieved in this study, provide greater understanding of the possible problems that adverse effects can cause in the body. In view of this, there is a need for a study directed specifically at the adverse effects of hormones on transsexuals who choose to use hormones for their gender transition. Another important point to be studied is what would be the ideal hormone or the ideal combination of hormones that produces more satisfactory results or fewer adverse effects. Also, there is a need for monitoring these individuals during the entire process.

Hiperglicemia y diabetes inducidas por esteroides / Hyperglycemia and steroid-induced diabetes

La hiperglicemia y/o diabetes inducida por esteroides, se define como la elevación de la glicemia, causada por la acción de los fármacos glucocorticoideos, sobre el metabolismo de los carbohidratos, y presenta una prevalencia entre un 20% al 50%, en pacientes sin diabetes previa, existiendo mayor riesgo para esta patología en pacientes con diabetes pre-existente, obesidad, uso crónico de esteroides o en dosis altas, entre otros. El diagnóstico se rige por los criterios para diabetes en la mayoría de los casos. No obstante, existen casos en donde la hiperglicemia por esteroides es sub-diagnosticada. Su manejo se basa en el tratamiento farmacológico (antidiabéticos orales, subcutáneos e insulina) y no farmacológico (dieta y ejercicio), tomando en cuenta, el patrón glicémico, peso, edad, co-morbilidades, dosis, tipo y tiempo de uso de los esteroides. La relevancia de conocer como diagnosticar y tratar dicha patología, se debe al riesgo de ingreso hospitalario, de infección, de mala cicatrización y de mortalidad en casos no tratados. En vista del aumento del uso de glucocorticoides en la actualidad, se hace una revisión del abordaje terapéutico de la hiperglicemia y diabetes inducida por esteroides.

Hyperglycemia and Steroid-induced Diabetes is defined as the elevation of glycemia caused by the action of glucocorticoid drugs on carbohydrate metabolism, with a prevalence between 20% and 50% in patients without Diabetes. Though, there is a greater risk of this pathology in patients with pre-existing Diabetes, Obesity, chronic use of steroids or in high doses, among others. In most cases, the diagnosis is governed by the criteria of Diabetes; however, there are cases where hyperglycemia Steroid-induced is under-diagnosed. Its management is based on pharmacological treatment (oral and subcutaneous hypoglycemic agents and insulin) and non-pharmacological treatment (diet and exercise), in accordance with the glycemic pattern, weight, age, co-morbidities, dose, type and the duration of the use of steroid. The relevance of knowing how to diagnose and treat this pathology is the risk of hospital admission, infection, poor healing and mortality in untreated cases. In view of the increased use of glucocorticoids nowadays, a review is made about the therapeutic approach to hyperglycemia and steroid-induced Diabetes.

Síndrome de intolerancia a múltiples medicamentos / Syndrome of intolerance to multiple medicines

El síndrome de intolerancia a múltiples medicamentos (MDIS, por sus siglas en inglés) se caracteriza por la intolerancia a dos o más medicamentos no relacionados. Tiene una prevalencia baja y es común en pacientes con polifarmacia. A pesar de que las reacciones adversas a los medicamentos son muy frecuentes, es raro que los pacientes debuten con este síndrome, el cual tiene implicaciones clínicas de leves a graves que afectan su vida; de acuerdo con esto varían el abordaje y su manejo. La sintomatología presentada varía desde síntomas gastrointestinales como reflujo gastroesofágico, dolores musculares y cefalea, hasta síntomas cutáneos; estos son los más frecuentes, tales como urticaria y erupciones maculopapulares o presentaciones menos comunes como el síndrome de Stevens-Johnson. El MDIS es causado por una amplia variedad de fármacos; por ello el conocimiento del síndrome, así como un adecuado interrogatorio de los antecedentes del paciente, es necesario para realizar un diagnóstico oportuno e instaurar un manejo adecuado y preventivo, evitando reacciones adversas que pongan en riesgo su vida. Con los hallazgos del cuadro clínico en la paciente, y basados en los antecedentes alérgicos presentados anteriormente a diferentes medicamentos no relacionados entre ellos, más la presentación de un rash maculopapular generalizado posterior a la administración de trimetoprim/sulfametoxazol se realiza el diagnóstico de MDIS. Se decide cambiar de medicamento por fosfomicina, con una consecuente evolución favorable. (AU)

Controversia justificada acerca de los esteroides particulados epidurales / A justified controversy about epidural particulate steroids

Introducción: La administración epidural de esteroides constituye un pilar del tratamiento del dolor radicular cervical y lumbosacro. Objetivo: Describir los mecanismos fisiológicos y características farmacológicas de los corticosteroides utilizados en el tratamiento del dolor, así como las complicaciones derivadas de la administración epidural de esteroides particulados. Métodos: Se realizó una revisión no sistemática de la literatura en bases de datos científicas como Cochrane Database of Systematic Reviews, Pubmed/Medline, EMBASE, Scopus, Web of Science, EBSCOhost, ScienceDirect, OVID y el buscador académico Google Scholar, en los meses de julio a septiembre del año 2020. Desarrollo: Los corticoides utilizados en la medicina del dolor son derivados de la prednisolona. Estos se clasifican en particulados (de depósito, de suspensión) o no particulados (de dilución), en función de la presencia o ausencia de un componente molecular sólido (moléculas tipo éster, insolubles en agua). Los fármacos más empleados son la dexametasona, betametasona, triamcinolona y metilprednisolona. Conclusiones: La administración epidural de esteroides particulados está relacionada con la incidencia de complicaciones graves, aunque poco frecuentes, como paraplejía, tetraplejía, infarto de la médula espinal, hemorragia y edema cerebral. La evidencia disponible muestra una efectividad analgésica similar a los compuestos no particulados. Por lo tanto, no se recomienda su utilización rutinaria durante el abordaje del espacio epidural(AU)

Introduction: Epidural administration of steroids is a cornerstone for the treatment of cervical and lumbosacral radicular pain. Objective: To describe the physiological mechanisms and pharmacological characteristics of the corticosteroids used for pain treatment, as well as the complications derived from the epidural administration of particulate steroids. Methods: A nonsystematic review of the literature was carried out, from July to September 2020, in scientific databases such as Cochrane Database of Systematic Reviews, Pubmed/Medline, EMBASE, Scopus, Web of Science, EBSCOhost, ScienceDirect, OVID and the academic search engine Google Scholar. Development: The corticoids used in pain medicine are derived from prednisolone. These are classified into particulate (deposit, suspension) or non-particulate (dilution), depending on the presence or absence of a solid molecular component (ester-type molecules, insoluble in water). The most commonly used drugs are dexamethasone, betamethasone, triamcinolone, and methylprednisolone. Conclusions: The epidural administration of particulate steroids is related to the incidence of serious, although infrequent, complications, such as paraplegia, tetraplegia, spinal cord infarction, hemorrhage and cerebral edema. Available evidence shows analgesic effectiveness similar to that of non-particulate compounds. Therefore, its routine usage is not recommended during the managment of the epidural space(AU)