Desde la pérdida de la fuerza hasta el compromiso sistémico: serie de casos del síndrome POEMS / From limb weakness to a systemic involvement: Poems syndrome case two report and review of the literature

El síndrome POEMS es un trastorno paraneoplásico raro y poco frecuente, que se presenta principalmente en la sexta década de la vida, caracterizado por el compromiso multisistémico con predominio de neuropatía desmielinizante. Abarca diversas y heterogéneas manifestaciones clínicas y su diagnóstico requiere un alto índice de sospecha. Se presentan dos casos de pacientes que consultaron por cuadros poco frecuentes en los que la pérdida de la fuerza orientó al acercamiento de una afectación multisistémica que concluyó con el diagnóstico de esta enfermedad(AU)

POEMS syndrome is a rare and infrequent paraneoplastic syndrome, which occurs mainly in the sixth decade of life, characterized by multisystem involvement with a predominance of demyelinating neuropathy, which encompasses diverse and heterogeneous clinical manifestations and whose diagnosis requires a high index of suspicion. We present two cases of patients who consulted due to unusual symptoms and whose loss of strength led to an approach due to multisystem involvement that concluded with the diagnosis of this disease(AU)

Variaciones anatómicas de la silla turca en radiografías laterales de cráneo. Hospital "Faustino Pérez", 2017-2018 / Anatomic variants of sella turcica in lateral crania radiographies. Hospital "Faustino Pérez¨, 2017-2018

RESUMEN Introducción: diversos autores reflejan que la morfología de la silla turca constituye un factor predisponente para algunas enfermedades. Por ejemplo, se considera que existe correlación entre la morfología de esta estructura anatómica y varias patologías; como el síndrome de la silla turca vacía, síndrome de Williams, paladar hendido, entre otras. Objetivo: describir las variaciones anatómicas de la silla turca que se observan en las radiografías laterales de cráneo del Hospital Universitario "Faustino Pérez" de la ciudad de Matanzas, en el período de enero del 2017 a enero del 2018. Materiales y métodos: el universo fue 140 radiografías laterales de cráneo, de estas 85 pertenecieron al sexo femenino y 55 al masculino. Las variables estudiadas fueron edad, sexo y variaciones anatómicas de la silla turca. Se emplearon métodos teóricos y empíricos. Resultados: se observó un predominio de la variación anatómica de la silla turca en forma de U, en ambos sexos. Seguido de la forma de J, predominando la variación en forma de U en el grupo etario de 41 a 50 años y la forma de J en los pacientes mayores de 60 años. Conclusiones: es imprescindible el conocimiento de la anatomía normal de la silla turca y de sus variaciones anatómicas, tanto para las especialidades quirúrgicas como para las no quirúrgicas. Un análisis exhaustivo de la morfología de esta estructura es necesario para establecer parámetros que excluyan determinadas patologías.

ABSTRACT Introduction: several authors declare that sella turcica morphology is a predisposing factor to several diseases. For example, it is considered that there is a correlation between the morphology of this anatomical structure and several pathologies like empty sella turcica syndrome, Williams syndrome, cleft palate and others. Objective: to describe the anatomical variants of sella turcica observed in side cranial radiographies of the University Hospital ¨Faustino Perez¨ of Matanzas, in the period January 2017-January 2018. Materials and methods: the universe was 140 side cranial radiography: 85 belonged to female patients and 55 to male patients. The studied variables were age, sex and sella turcica anatomical variables. Theoretic and empirical methods were used. Results: it was observed a predominance of the U-shaped sella turcica anatomical variant in both sexes, followed by the J-shaped one. The U-shaped form predominated in the 41-50-years-old age-group and the J-shaped form in patients elder than 60 years. Conclusions: it is essential to know sella turcica normal anatomy and its anatomical variables, both for the surgical specialties and for the non-surgical ones. It is necessary the exhaustive analysis of this structure to establish parameters excluding several pathologies.

Prevalência e fatores associados ao prejuízo cognitivo em idosos de instituições filantrópicas: um estudo descritivo / Prevalence and factors associated with cognitive impairments in the elderly of charity asylums: a descriptive study

Resumo O objetivo deste estudo foi avaliar a prevalência e os fatores associados ao prejuízo cognitivo em uma amostra de idosos residentes em instituições filantrópicas. Trata-se de um estudo transversal e descritivo, com 98 idosos institucionalizados. Os dados sociodemográficos e clínicos foram obtidos nos prontuários. A cognição foi avaliada através do: Mini Exame do Estado Mental, enquanto a manutenção de independência referente às atividades fundamentais (por exemplo: banhar-se, vestir-se, etc.) foi avaliada através do Índice de Katz. Por fim, avaliou-se o desempenho físico através da Short Physical Perfomance Batter. Para a análise estatística, testes não paramétricos foram utilizados. Houve 27,6% de idosos com déficit cognitivo. O prejuízo cognitivo não esteve associado às variáveis sociodemográficas, à independência referente, às atividades fundamentais, bem como ao desempenho físico. Verificou-se maior prevalência de doenças endócrinas, de transtornos mentais e de realização de tratamento psiquiátrico nos idosos com prejuízos cognitivos. A proporção de idosos com alterações cognitivas é semelhante à de outros estudos. Entre as variáveis avaliadas não foram identificados fatores de risco significativos associados à cognição.

Abstract The current transversal and descriptive study evaluates the prevalence and factors associated with cognitive liabilities in a sample of 98 elderly people residents of philanthropic institutions. The sociodemographic and clinical data were retrieved from the patients´ clinical charts. The cognition was assessed by the Mental State Mini-Exam, while the maintenance of independence regarding basic activities (such as bathing, putting on clothes, and others) was evaluated using the Katz Index. The Short Physical Performance Battery exam assessed their physical performance. Non-parametric tests were employed for the statistical analysis. Cognitive impairment was registered in 27.6% of the elderlies and was not associated with sociodemographic variables, independence in basic activities, and physical performance. We verified a high prevalence of endocrine diseases, mental disorders, and psychiatric treatment in the elderlies with cognitive impairments. The percentage of elderly with cognitive alterations is similar to those found in the literature. We identified no significant risk factors associated with cognition among the evaluated variables.

Incidencia de enfermedades endocrinas en caninos entre los años 2013-2016 en un hospital veterinario universitario de Chile / Incidence of endocrine diseases in canines between 2013-2016 in a universitary hospital in Chile

It has been shown that there is an association between air pollution and cardiovascular mortality. In bone pathology, studies show that air pollution is associated with a risk of developing osteoporosis and osteoporotic fracture associated with MP2.5 and nitrogen dioxide (NO2 ). The aim of our study was to determine whether or not there is an association between air pollution and osteoporotic disease, associating the incidence of femoral neck fracture in individuals aged 50 years or more and the contamination present in the several cities. Our results showed no statistically significant association between air pollution, evaluated using PM10 and PM2.5 as indicators, and the average annual incidence of osteoporotic hip fracture, comparing the most polluted cities and the less polluted cities of Chile

¿Paradojas en la atención a la sexualidad de personas con enfermedades endocrinas? / Paradox in the care of sexuality of people with endocrine diseases?

El impacto sexual provocado por las endocrinopatías se ha documentado en la literatura científica, pero se le brinda escasa atención desde los espacios de salud. Se propone reflexionar sobre algunos aspectos relacionados con esta realidad a partir del análisis de los procesos de atención de salud, de la investigación y de las políticas sociales, utilizando como perspectiva transversal la determinación y el carácter sociocultural e histórico de la sexualidad, la salud, la ciencia y la tecnología. El artículo se organiza en cuatro subacápites interrelacionados: 1) los campos del saber sobre la sexualidad de personas con endocrinopatías; 2) algunos determinantes de la invisibilización del tema en los espacios asistenciales (tales como la hegemonía de las especialidades biomédicas, las representaciones sociales respecto a las categorías cuerpo, enfermedad y sexualidad, la perspectiva médico-paciente, y la insuficiente capacitación de los proveedores de salud sobre estos temas); 3) el proceso de investigación y algunos de sus paradigmas fundamentales; y 4) la situación de las políticas y programas relacionados con la sexualidad de personas con endocrinopatías. Se concluye apostando por principios como la multi-inter-trans-disciplina, la participación social, la necesidad de integrar diferentes saberes y de flexibilizar los paradigmas científicos, y la apropiación social de los productos resultantes del proceso científico en cualquiera de sus expresiones, como bases para visualizar y prestar atención a temas de salud como la sexualidad de personas con endocrinopatías(AU)

Sexual impact caused by endocrinopathies has been documented in the scientific literature, but little attention is paid in the health circles. The article was intended to make reflections on some aspects of these realities, on the basis of the analysis of processes of health care, research and social policies, using determination and sociocultural and historical character of sexuality, health, science and technology as cross perspective. The article was organized in four interrelated subsections: 1) fields of knowledge about sexuality of people with endocrinopathies; 2) some determinants of the invisibility of the topic in assistance sites (such as hegemony of biomedical specialties, social representations in respect to the categories body, disease and sexuality; the physician-patient perspective and the poor training of health providers on these topics); 3) the research process and some of its fundamental paradigms; and 4) the situation of the policies and programs related to sexuality of people with endocrinopathies. The article was concluded by committing to the principles of multi-inter-transdiscipline, social involvement, need of integrating different know-how and of making scientific paradigms more flexible, and the social appropriation of resulting products of the scientific process in any expression, as foundations to visualize and to pay attention to health topics like sexuality of people with endocrinopathies(AU)

Alterações Ósseas e do Sistema Estomatognático associadas a Doenças Endócrino Metabólicas / Cambios en los huesos y del sistema estomatognático asociadas con las enfermedades endocrino-metabólicas / Diseases Bone Changes and changes in the Stomatognathic System Associated with Metabolic Endocrine Diseases

Introdução: a prevalência de doenças endócrino-metabólicas tem aumentado nos últimos anos com a melhoria da expectativa de vida da população. Diabete Melittus, hipotireoidismo, hipertireoidismo, hipoparatireoidismo e hiperparatireoidismo podem levar as alterações no sistema estomatognático, contudo, a literatura ainda é limitada nesta área. Objetivo: Abordar as características e o processo fisiopatológico de doenças endócrino-metabólicas, com destaque para as alterações ósseas e do sistema estomatognático. Metodologia: Os dados foram coletados através da seleção de artigos sobre alterações ósseas e do sistema estomatognático associadas ao hipotireoidismo, hipertireoidismo, hipoparatireoidismo, hiperparatireoidismo e diabete mellitus, publicados nos bancos de dados, Bireme, MEDLINE e Scielo. Resultados: Foram coletados 73 artigos publicados na literatura entre os anos 1995 e 2012, dos quais 40 foram selecionados por se enquadrar no tema proposto. A literatura consultada demonstrou que alterações dos níveis séricos dos hormônios tireoidianos e do paratormônio, assim como diabete mellitus, influenciam no metabolismo ósseo. Atrasos na esfoliação e erupção dentária, no crescimento e desenvolvimento ósseo são observados no hipotireoidismo, enquanto o hipertireoidismo apresenta densidade óssea mineral diminuída, osteoporose dos ossos maxilares, esfoliação acelerada dos dentes decíduos e erupção prematura dos permanentes. No hipoparatireoidismo, observa-se osteoesclerose, dentição hipoplásica e reduzida remodelação óssea. Intensa atividade osteoclástica, ausência de lâmina dura e tumor marrom podem estar presentes no hiperparatireoidismo. Diabete mellitus pode ocasionar oesteoporose, doença periodontal e hipoplasia de esmalte. Embora conhecidas, a magnitude e as causas destas alterações no sistema estomatognático ainda são pouco elucidadas. Conclusões: É imprescindível que o cirurgião dentista tenha conhecimento sobre as manifestações locais ou sistêmicas associadas a estas desordens endócrino-metabólicas que podem acometer os pacientes, para que possa reconhecê-las e contribuir com o seu diagnóstico e tratamento precoces(AU)

Introducción: La prevalencia de las enfermedades endocrino-metabólicas se ha incrementado en los últimos años por el incremento de la esperanza de vida de la población. La diabetes mellitus, hipotiroidismo, hipertiroidismo, hipoparatiroidismo e hiperparatiroidismo pueden presentar alteraciones en el sistema estomatognático, sin embargo, los estudios encontrados en la literatura son todavía limitados en esta área. Objetivo: abordar las características y procesos fisiopatológicos de estas enfermedades y los cambios especialmente en los huesos y del sistema estomatognático. Métodos: los datos fueron recolectados a través de la selección de artículos sobre las alteraciones óseas del sistema estomatognático en pacientes afectados con el hipotiroidismo, el hipertiroidismo, el hipoparatiroidismo, el hiperparatiroidismo y la diabetes mellitus, publicada en las bases de datos, BIREME, SciELO y MEDLINE. Resultados: se recolectaron 73 artículos publicados entre los años 1995 y 2012, de los cuales 40 fueron seleccionados por la relación con el tema de interés para nuestro propósito. La literatura ha demostrado que los cambios en los niveles séricos de la hormona tiroidea y paratiroidea, y la diabetes mellitus afectan el metabolismo óseo. En el hipotiroidismo se observan retrasos en la exfoliación y erupción de los dientes, en el crecimiento y desarrollo óseo. El hipertiroidismo, hay disminución de la densidad mineral ósea, osteoporosis de los huesos de la mandíbula, exfoliación acelerada de los dientes temporales y erupción prematura de los permanentes. En el hipoparatiroidismo, se observan osteosclerosis, dientes hipoplásicos, y remodelación ósea reducida. Puede estar presente intensa actividad de los osteoclastos, ausencia de la lámina dura y tumor pardo en el hiperparatiroidismo. La diabete mellitus puede causar oesteoporosis, enfermedad periodontal e hipoplasia del esmalte. Aunque conocidas, la magnitud y las causas de estos cambios en el sistema estomatognático aún no están claros.Conclusiones: es esencial que el dentista tenga conocimiento de las manifestaciones locales o sistémicas asociadas con estos trastornos endocrinos y metabólicos para que pueda reconocerlos y ayudar en el diagnóstico precoz y el tratamiento(AU)

Introduction: the prevalence of endocrine-metabolic diseases has increased in recent years due to improvement of the life expectancy of the population. Diabetes mellitus, hypothyroidism, hyperthyroidism, hypoparathyroidism and hyperparathyroidism may present alterations in the stomatognathic system; however, some studies found in literature are still limited in this area. Objective: to address the characteristics and pathophysiological process of these diseases, especially bone changes and in the stomatognathic system. Methods: data were collected through the selection of articles about bone alterations of the stomatognathic system associated with hypothyroidism, hyperthyroidism, hypoparathyroidism, hyperparathyroidism, and diabetes, published in databases, BIREME, MEDLINE and SciELO. Results: seventy three articles published between 1995 y 2012 were revised, and 40 were selected on the basis of their association with the topic of interest. It has shown that changes in serum levels of thyroid and parathyroid hormones, and diabetes mellitus have an impact on bone metabolism. Delays in tooth eruption and exfoliation, bone growth and development are observed in hypothyroidism, whereas decreased bone mineral density, jawbones osteoporosis, accelerated exfoliation of deciduous teeth and premature eruption of permanent teeth were observed in hyperthyroidism. In hypoparathyroidism, there were osteosclerosis, hypoplastic teeth, and reduced bone remodeling. Intense osteoclastic activity, brown tumors and the absence of lamina dura in hyperparathyroidism may be observed. Diabetes mellitus can cause osteoporosis, periodontal disease and enamel hypoplasia. Although they are known, the magnitude and causes of these changes in the stomatognathic system are still unclear. Conclusions: it is essential that dentist can recognize the local or systemic manifestations associated with these endocrine and metabolic disorders and help to early diagnosis and treatment(AU)

Agent Orange Exposure and Prevalence of Self-reported Diseases in Korean Vietnam Veterans / 예방의학회지

OBJECTIVES: The aim of this study was to evaluate the association between Agent Orange exposure and self-reported diseases in Korean Vietnam veterans. METHODS: A postal survey of 114 562 Vietnam veterans was conducted. The perceived exposure to Agent Orange was assessed by a 6-item questionnaire. Two proximity-based Agent Orange exposure indices were constructed using division/brigade-level and battalion/company-level unit information. Adjusted odds ratios (ORs) for age and other confounders were calculated using a logistic regression model. RESULTS: The prevalence of all self-reported diseases showed monotonically increasing trends as the levels of perceived self-reported exposure increased. The ORs for colon cancer (OR, 1.13), leukemia (OR, 1.56), hypertension (OR, 1.03), peripheral vasculopathy (OR, 1.07), enterocolitis (OR, 1.07), peripheral neuropathy (OR, 1.07), multiple nerve palsy (OR, 1.14), multiple sclerosis (OR, 1.24), skin diseases (OR, 1.05), psychotic diseases (OR, 1.07) and lipidemia (OR, 1.05) were significantly elevated for the high exposure group in the division/brigade-level proximity-based exposure analysis, compared to the low exposure group. The ORs for cerebral infarction (OR, 1.08), chronic bronchitis (OR, 1.05), multiple nerve palsy (OR, 1.07), multiple sclerosis (OR, 1.16), skin diseases (OR, 1.05), and lipidemia (OR, 1.05) were significantly elevated for the high exposure group in the battalion/company-level analysis. CONCLUSIONS: Korean Vietnam veterans with high exposure to Agent Orange experienced a higher prevalence of several self-reported chronic diseases compared to those with low exposure by proximity-based exposure assessment. The strong positive associations between perceived self-reported exposure and all self-reported diseases should be evaluated with discretion because the likelihood of reporting diseases was directly related to the perceived intensity of Agent Orange exposure.

Avaliação dos principais efeitos endócrinos tardios em crianças e adolescentes sobreviventes ao tratamento de neoplasias malignas / Evaluation of the main late endocrine effects in children and adolescents after treatment of malignancies

OBJETIVO: Relatar os efeitos endócrinos tardios em crianças e adolescentes após tratamento oncológico e associá-los à doença de base e ao tratamento. SUJEITOS E MÉTODOS: Foram realizadas avaliações clínicas e laboratoriais visando à detecção de distúrbios endócrinos em 320 pacientes após terapia oncológica, seguidos por seis anos. RESULTADOS: Em 94 pacientes, detectaram-se: 32 pacientes apresentaram baixa estatura (nove em tratamento com hormônio de crescimento), 14 tiveram puberdade precoce (10 em uso de análogo de GnRH) e 19 revelaram ser portadores de distúrbios de tireoide (12 com hipotireoidismo, seis com nódulos de tireoide e um com tireoidite linfocitária crônica). Obesidade foi encontrada em 18 deles. Seis com diabetes insípido e cinco com puberdade atrasada, três com pan-hipopituitarismo. Houve associação entre a radioterapia e a presença de endocrinopatias. CONCLUSÃO: Noventa e quatro de 320 (30 por cento) dos pacientes fora de terapia apresentaram alteração endócrina, o que enfatiza a importância do seguimento precoce e regular, possibilitando-lhes, com tratamento, melhor qualidade de vida.

OBJECTIVE: To report the main endocrine effects after cancer treatment in children and adolescents and associate them to the disease and its treatment. SUBJECTS AND METHODS: Clinical and lab evaluation for endocrinopathy was performed in 320 patients after cancer therapy have been followed for six years. RESULTS: The most prevalent endocrine late effects in patients were: 32 patients had short stature, nine of them were under growth hormone therapy. Precocious puberty was found in 14 patients, 10 of them received GnRH analog. Thyroid diseases were present in 19 patients (12 with hypothyroidism; six with thyroid nodules/cysts; one with chronic lymphocytic thyroidytis). Obesity was found in 18 patients. Six presented insipidus diabetes, five delayed puberty and three panhypopituitarism. Radiation was associated with the appearance of the aforementioned endocrinopathies. CONCLUSION: Ninety four of 320 (30 percent) patients presented endocrine late effects which emphasize the importance for these patients to be regularly followed-up in order to precociously diagnose endocrine late effects and provide them a better quality of life.

Prevalencia de patología endocrinológica: estudio retrospectivo en un centro de atención de adolescentes en Santiago / Prevalence of endocrinologycal pathology: retrospective study in a medical center of adolescents from Santiago

En el presente trabajo se estudia la prevalencia de patología endocrina en un grupo de mujeres adolescentes que acuden espontáneamente en un policlínico de ginecología. Se revisaron las fichas clínicas de todas las pacientes que consultaron durante el período de junio 1997 a agosto 1998 en el policlínico de ginecología infanto juvenil de CEMERA (Centro de Medicina Reproductiva y Desarrollo Integral del Adolescente). Se evaluaron en total 170 jóvenes con edad promedio de 16 años y 6 meses. Se definió un grupo de 58 pacientes (34 por ciento) que tuvo sospecha clínica inicial de enfermedad endocrina, de este grupo hubo 46que hicieron exámenes complementarios (24 ecografía y 22 ecografía más perfil hormonal). Se confirmó el diagnóstico de patología endocrina en 39 pacientes (67 por ciento) destacando los diagnósticos de síndrome de ovario poliquístico (12), poliquistosis ovárica por ecografía (11), amenorrea hipotalámica (4), insulinorresistencia (6), patología tiroidea (3), anorexia/bulimia (2), hiperprolactinemia (1). Analizando la correlación entre presentación clínica y el hallazgo de enfermedad endocrina se encuentra como indicadores de patología la presencia de sobrepeso/obesidad (46 por ciento), ciclos menstruales irregulares (69 por ciento), amenorrea secundaria (25 por ciento), hiturismo/acné (34 por ciento), acantosis nigricans (12 por ciento) y bocio (8 por ciento). Se concluye que existe una alta prevalencia de enfermedades endocrinas en las pacientes adolescentes evaluadas. Los allazgos clínicos permiten la sospecha inicial con alto grado de certeza, lo que ayuda a orientar adecuadamente el estudio diagnóstico

Fibrilaçäo atrial crônica no idoso / Aspects Chronic atrial fibrillation in elderly patients

Purpose - To evaluate the different aspects of chronic atrialfibrillation (CAF) in elderly patients. Methods - Forty nine patients with CAF (18 men) aged 66 to 87 years (76,1 years on average) were studied. Their evaluation consisted of clinical examination, blood tests, electrocardiogram, chest X-Ray and echocardiogram. Results - The frequency of CAF in the outpatient Geriatric Clinic was 4.8% and it rose with aging. Cardiocirculatory diseases were observed in 39 (79.6%) patients: 25 (51.0%) had systemic arterial hypertension, 11 (22.4%) had mitral valve disease and six (11.2%) had aortic valve disease. Thirty patients had diseases of other systems, eight (16.3%) of whom were diabetic and seven (14.3%) had hyperthyroidism. Vascular brain disease was observed in four (8.2%) patients. Electrocardiographic changes other than CAF were observed in 41 (83.7%) patients. Changes in the ST-T segment were the morefrequent, being observed in 28 (57.1%) patients, followed by left ventricular hypertrophy in 15 (30.1%). Cardiomegaly was seen in 36 (78.3%) out of 46 patients who did the chest radiography. An echocardiogram was performed in 35 patients, being found normal in seven (20.0%). In the remaining cases, the abnormality morefrequently seen was the left atrial enlargment, seen in 16 (45.7%) patients. Four patients didn't show clinical, electrocardiographic, radiological or echocardiographic evidence of cardiocirculatory disease and in these, the thyroidfunction was normal. Digitalis therapy was used in 37 patients. Of the remaining 12,10 had normal ventricular frequency without the use of the drug...

Morbilidad y mortalidad en el Hospital San Juan de Dios, Bogota, enero-junio 1987 / Morbidity and mortality in Hospital San Juan de Dios, Bogota, january-june 1987

El estudio comprende el analisis de la morbilidad y la mortalidad en muestras seleccionadas de 2300 pacientes atendidos en Consulta Externa, 1444 en el Servicio de Urgencias y en el total de 6386 egresos. En la Consulta Externa 63.6% fueron mujeres y el grupo de edad de 15 y mas anos abarco 93.9%. En el Servicio de Urgencias 57.5% correspondio a mujeres y 65.5% fue para el grupo de 15 a 44 anos de edad. en los egresos 65% fueron hombres y 61% correspondieron al grupo de 15 a 44 anos. La Lista Basica de Tabulacion indica mayor consulta de mujeres con enfermedades del aparato muscular y conectivo y con enfermedades endocrinas inmunes y metabolicas, en tanto que en los hombres la mayor consulta fue por otras razones. La enfermedad cardiaca hipertensiva fue la principal causa especifica de morbilidad, seguida por la diabetes mellitus, faringitis, cojuntivitis y artritis reumatoidea. En urgencias los dos primeros grupos de morbilidad por sexo fueron: signos, sintomas y estados morbosos mal definidos y enfermedades de otras partes del aparato digestivo. El trauma fue el principal problema de hospitalizacion con 17.8% de los egresos siendo los dos primeros gurpos: otros accidentes, incluso efectos tardios y traumatismos internos intracraneales que incluyen los de los nervios. El tratamiento quirurgico represento 80% y el promedio de estancia de los siete primeros gurpos fue 9.6 dias; la tasa de mortalidad hospitalaria 8.6%; las remisiones por otras instituciones 12.4% por consulta externa y 11.2% por el servicio de urgencias