[Imaging in infective endocarditis: Not all is ultrasonography]. / Imágenes en endocarditis infecciosa: No todo es ecocardiografía.

Infective endocarditis (IE) is an entity characterized by endocardial infection and frequent multiorgan complications, resulting in high mortality. It requires a rapid and accurate diagnosis, and a medical or surgical aggressive treatment. Currently, IE diagnosis rests on bacterial, clinical and ultrasonographic criteria. The objective of this article is to update the imaging study in patients with IE, with special emphasis on those non-echocardiographic examinations available in our environment. Last years, advanced imaging had achieved a growing role in IE diagnosis, especially cardiac multislice computed tomography (MSCT) and positron emission tomography/computed tomography (PET/CT), which have been recommended in recent clinical guidelines to be included as part of diagnostic criteria. Cardiac MSCT provides detailed anatomic information of cardiac valves and perivalve tissue, allowing identification of pseudoaneurysm, abscess and valve dehiscence. F18-FDG PET/CT increases sensitivity for IE detection and shows high accuracy in searching for extracranial systemic embolic events. Both MSCT and PET/CT have particular utility in cases of prosthetic valve endocarditis, where cardiac ultrasonography shows lower performance. Brain magnetic resonance imaging (MRI) is the best imaging method for evaluating ischemic/embolic events of central nervous system.

Imágenes en endocarditis infecciosa: no todo es ecocardiografía / Imaging in infective endocarditis: not all is ultrasonography

Resumen La endocarditis infecciosa (EI) es una enfermedad de alta mortalidad, caracterizada por una infección endocárdica y frecuentes complicaciones multiorgánicas, que requiere un diagnóstico rápido y preciso, y un manejo agresivo, ya sea médico o quirúrgico. Su diagnóstico se realiza tomando en cuenta criterios bacteriológicos, clínicos y ecocardiográficos. Es objetivo de este artículo realizar una actualización del estudio imagenológico en paciente con EI, con especial énfasis en aquellos exámenes no ecocardiográficos disponibles en nuestro medio. En los últimos años, estudios de imagen avanzados han adquirido un rol creciente en su estudio inicial, particularmente la tomografía computada multicorte (TCMC) cardiaca y el positron emission tomography/computed tomography (PET/CT), y han sido recomendados como criterios diagnósticos en las guías recientes para el manejo de esta entidad. La TCMC cardiaca proporciona información anatómica detallada de las válvulas cardiacas y tejido perivalvular, identificando pseudoaneurismas, abscesos y dehiscencias valvulares. El PET/CT con F18-fluorodeoxiglucosa (F18-FDG) permite aumentar la sensibilidad en la detección de EI, y pesquisar con alta eficiencia fenómenos embólicos sistémicos, de elevada frecuencia en esta población. Ambos métodos prestan particular utilidad en EI de válvula protésica, donde la ecocardiografía presenta menor rendimiento diagnóstico. La resonancia magnética (RM) cerebral es el mejor método de imagen para descartar eventos isquémicos/embólicos del sistema nervioso central.

Abstract Infective endocarditis (IE) is an entity characterized by endocardial infection and frequent multiorgan complications, resulting in high mortality. It requires a rapid and accurate diagnosis, and a medical or surgical aggressive treatment. Currently, IE diagnosis rests on bacterial, clinical and ultrasonographic criteria. The objective of this article is to update the imaging study in patients with IE, with special emphasis on those non-echocardiographic examinations available in our environment. Last years, advanced imaging had achieved a growing role in IE diagnosis, especially cardiac multislice computed tomography (MSCT) and positron emission tomography/computed tomography (PET/CT), which have been recommended in recent clinical guidelines to be included as part of diagnostic criteria. Cardiac MSCT provides detailed anatomic information of cardiac valves and perivalve tissue, allowing identification of pseudoaneurysm, abscess and valve dehiscence. F18-FDG PET/CT increases sensitivity for IE detection and shows high accuracy in searching for extracranial systemic embolic events. Both MSCT and PET/CT have particular utility in cases of prosthetic valve endocarditis, where cardiac ultrasonography shows lower performance. Brain magnetic resonance imaging (MRI) is the best imaging method for evaluating ischemic/embolic events of central nervous system.

Anticonvulsivantes y su efecto en el metabolismo de la vitamina D: revisión del tema, a propósito de un caso / Anticonvulsants and their effect on the metabolism of vitamin D: literature review with case report

La epilepsia es una enfermedad neurológica frecuente que afecta a cerca de 50.000 millones de personas en el mundo. En Chile, la prevalencia estimada es de 10.8 a 17 por 1.000 habitantes. La primera opción para su tratamiento son los fármacos antiepilépticos (FAE) los cuales logran un aceptable control de enfermedad en la mayoría de los casos, sin embargo, tienen la potencialidad de desencadenar una serie de efectos adversos destacando entre ellos el desarrollo de hipocalcemia (HC) secundaria a hipovitaminosis D (HD), alteración que por lo general es leve y asintomática. Presentamos el caso de una mujer perimenopausica con antecedente de epilepsia en tratamiento con anticonvulsivante que desarrolla hipocalcemia severa. Además revisamos los mecanismos descritos a través de los cuales los FAE afectan el metabolismo de esta vitamina.

Epilepsy is a common neurological disease that affects about 50,000 million people in the world. The estimated prevalence is 10.8 to 17 per 1.000 inhabitants in Chile. The first option for its treatment are antiepileptic drugs (AEDs) which achieve an acceptable control of the disease in most cases, however, they have the potential to trigger a series of adverse effects (AE) highlighting among them the development of hypocalcemia (HC) secondary to hypovitaminosis D (HD), an alteration that is generally mild and asymptomatic. We present the case of a perimenopausal woman with a history of epilepsy under treatment with an anticonvulsant who develops severe hypocalcemia. We also review the mechanisms described through which AEDs affect the metabolism of this vitamin.

Consideraciones en el manejo del adulto con Hiperplasia Suprarrenal congénita clásica por déficit de 21-Hidroxilasa / Management considerations for the adult with congenital adrenal hyperplasia due 21-hydroxylase deficiency

La Hiperplasia Suprarrenal Congénita (HSRC) corresponde a un grupo de defectos genéticos en la síntesis de cortisol. El 95% de ellas son debidas al déficit de 21-hidroxilasa por lo que nos referiremos solo a esta deficiencia. La hiperplasia suprarrenal congénita clásica (HSRC-C) debuta en recién nacidos o lactantes con insuficiencia suprarrenal primaria, diferentes grados de hiperandrogenismo clínico en mujeres y puede coexistir con hipotensión, hiperkalemia e hiponatremia si hay un déficit clínico de aldosterona. El objetivo de este artículo es actualizar el conocimiento y enfoques sugeridos para el manejo de la HSRC-C desde el inicio de sus controles en la etapa adulta. El diagnóstico diferencial en retrospectiva de la HSRC-C y la no clásica (HSRC-NC) a veces resulta difícil ya que esta enfermedad es un espectro fenotípico continuo. La insuficiencia suprarrenal y la dependencia a terapia corticoidal son los eventos principales para diferenciar estas dos patologías que tienen enfoques terapéuticos diferentes. El tratamiento de la HSRC-C en adultos abarca 2 objetivos primarios: la adecuada sustitución de la falla suprarrenal y el control de hiperandrogenismo mediante el uso de corticoides en sus dosis mínimas efectivas. En la mujer existen terapias complementarias para el control del hiperandrogenismo como anticonceptivos y otras que se encuentran en diferentes fases de investigación. Esto permite disminuir las dosis de corticoides en algunos casos. Es importante a la vez abordar tres objetivos secundarios: controlar el riesgo cardiometabólico propio de la enfermedad, evitar el sobre tratamiento corticoidal y manejar la infertilidad. La correcta monitorización del tratamiento en adultos tomando en cuenta los objetivos descritos permite una mejor calidad de vida en estos pacientes. Finalmente el consejo genético debe realizarse en todos los pacientes con HSRC que deseen fertilidad y en sus parejas. El estudio requiere de secuenciación del gen CYP21A2 y debe realizarse en un laboratorio de experiencia.

Congenital Adrenal Hyperplasia (CAH) are a group of genetic defects characterized by impaired cortisol synthesis. 95% of them are due to 21-hydroxylase deficiency. We will discuss only this enzyme's deficiency. Classic congenital adrenal hyperplasia (CAH-C) debuts in newborns or infants with primary adrenal insufficiency, some degree of clinical hyperandrogenism in newborn females, and can coexist with hypotension, hyperkalemia, and hyponatremia if there is a clinical aldosterone deficiency. The objective of this article is to update the knowledge and suggested approaches for the management of CAH-C from the beginning of its controls in the adult stage. The retrospective differential diagnosis of CAH-C and non-classical (CAH-NC) is sometimes difficult because this disease is a continuous phenotypic spectrum. Adrenal insufficiency and dependence on corticosteroid therapy are the main events to differentiate these two pathologies that have different therapeutic approaches. In adults, the treatment of CAH-C must include 2 primary objectives: adequate the replacement of adrenal failure and control of hyperandrogenism, through the use of corticosteroids in their minimum effective doses. In women there are complementary therapies for the control of hyperandrogenism, such as contraceptives and others that are in different phases of research. This makes it possible to reduce the doses of corticosteroids in some cases. It is important at the same time to address three secondary objectives: control the cardiometabolic risk of the disease secondary to corticosteroid treatment, avoid corticosteroid overtreatment and manage infertility. The correct monitoring of treatment in adults and taking in to account the objectives described, allows a better quality of life in these patients. Finally, genetic counseling must be carried out in all patients planning for children, with any type of CAH and in their partners. The study requires sequencing of the CYP21A2 gene and must be performed in a certified laboratory.

Arteritis de células gigantes: actualización y proposición de un algoritmo de estudio

Giant cell arteritis (GCA) is a primary granulomatous systemic vasculitis involving the aorta and its main branches that affects people aged over 50 years with a genetic predisposition. Its main phenotypes are cranial and extracranial involvement, with or without symptoms of polymyalgia rheumatica. These phenotypes can overlap. The extracranial form can be oligosymptomatic and must be sought directly. The main complications of the disease are ischemia of essential territories such as the optic nerve or cerebral circulation, and aneurysmal dilations of the aorta and its large branches. Clinicians must be aware of all the presentation forms of the disease, to start a timely treatment and avoid potentially serious or fatal consequences. To date, the diagnosis of GCA is based on clinical and pathological criteria, with the temporal artery biopsy as the "gold standard" for diagnosis, although its sensitivity is variable. This can lead to an underdiagnosis in patients with negative biopsies or predominant extra-cranial symptoms. The emergence of new and valuable imaging tools substantially improved the timely diagnosis, mainly in subclinical and oligosymptomatic forms. Among them we highlight ultrasonography of the temporal and axillary arteries, Computed Tomography Angiography, Magnetic Resonance Angiography, and PET-CT. These imaging techniques are complementary, and their use is highly recommended. GCA treatment is based on steroidal therapy, often associated with a corticosteroid-sparing immunosuppressive agent. The follow-up is eminently clinical.

[Frequency of malignancy in thyroid incidentalomas detected by whole body 18F-FDG PET/CT]. / Frecuencia de malignidad en incidentalomas tiroideos detectados con tomografía por emisión de positrones/tomografía computada (PET/CT) con F18-FDG de cuerpo entero.

BACKGROUND: Thyroid incidentalomas detected by 18F-Fludeoxyglucose (FDG) PET/CT are defined as an incidental and unexpected thyroid focus present in a patient studied for a non-thyroid disease. AIM: To assess the frequency of malignancy of nodular thyroid incidentalomas, and their association with 18F-FDG avidity (standard uptake value (SUV) max). MATERIAL AND METHODS: Whole body PET/CT performed from December 2008 to December 2017 were reviewed selecting those that showed nodular thyroid foci. Glands with diffuse increased uptake were excluded. Thyroid ultrasonography and fine-needle aspiration cytology (FNAC) performed after PET/CT were reviewed. Bethesda score and SUVmax were correlated. RESULTS: Of 5,100 whole body 18F-FDG PET/CT, 119 showed a thyroid nodular uptake (2.3%). Forty eight percent of these patients were studied with FNAC or surgery, 50% of which (29/58) were confirmed as malignant. Benign nodules showed significantly lower 18F-FDG uptake (n = 20, SUVmax: 3.5 ± 1.7) than Bethesda V-VI (n=24, SUVmax: 8.2 ± 5.2) and thyroid metastases (n=5, SUVmax: 6.3 ± 2.1). The best cut-off value to distinguish between benign and malignant nodules was a SUVmax of 5.0, with a sensitivity of 76% (95% confidence intervals (CI) 56-90%), a specificity of 85% (95% CI 62 - 97%), and positive likelihood ratio of 5 (95% CI 1.8 - 14.6). The size of the thyroid nodule was not predictive of malignancy. CONCLUSIONS: Half of nodular thyroid incidentalomas detected by 18F-FDG PETC/CT are malignant. A nodule with a SUVmax ≥ 5,0 is highly suggestive of malignancy, regardless of its size.

Frecuencia de malignidad en incidentalomas tiroideos detectados con tomografía por emisión de positrones/tomografía computada (PET/CT) con F18-FDG de cuerpo entero / Frequency of malignancy in thyroid incidentalomas detected by whole body 18F-FDG PET/CT

Background: Thyroid incidentalomas detected by 18F-Fludeoxyglucose (FDG) PET/CT are defined as an incidental and unexpected thyroid focus present in a patient studied for a non-thyroid disease. Aim: To assess the frequency of malignancy of nodular thyroid incidentalomas, and their association with 18F-FDG avidity (standard uptake value (SUV) max). Material and Methods: Whole body PET/CT performed from December 2008 to December 2017 were reviewed selecting those that showed nodular thyroid foci. Glands with diffuse increased uptake were excluded. Thyroid ultrasonography and fine-needle aspiration cytology (FNAC) performed after PET/CT were reviewed. Bethesda score and SUVmax were correlated. Results: Of 5,100 whole body 18F-FDG PET/CT, 119 showed a thyroid nodular uptake (2.3%). Forty eight percent of these patients were studied with FNAC or surgery, 50% of which (29/58) were confirmed as malignant. Benign nodules showed significantly lower 18F-FDG uptake (n = 20, SUVmax: 3.5 ± 1.7) than Bethesda V-VI (n=24, SUVmax: 8.2 ± 5.2) and thyroid metastases (n=5, SUVmax: 6.3 ± 2.1). The best cut-off value to distinguish between benign and malignant nodules was a SUVmax of 5.0, with a sensitivity of 76% (95% confidence intervals (CI) 56-90%), a specificity of 85% (95% CI 62 - 97%), and positive likelihood ratio of 5 (95% CI 1.8 - 14.6). The size of the thyroid nodule was not predictive of malignancy. Conclusions: Half of nodular thyroid incidentalomas detected by 18F-FDG PETC/CT are malignant. A nodule with a SUVmax ≥ 5,0 is highly suggestive of malignancy, regardless of its size.

[An update on giant cell arteritis]. / Arteritis de células gigantes: actualización y proposición de un algoritmo de estudio.

Giant cell arteritis (GCA) is a primary granulomatous systemic vasculitis involving the aorta and its main branches that affects people aged over 50 years with a genetic predisposition. Its main phenotypes are cranial and extracranial involvement, with or without symptoms of polymyalgia rheumatica. These phenotypes can overlap. The extracranial form can be oligosymptomatic and must be sought directly. The main complications of the disease are ischemia of essential territories such as the optic nerve or cerebral circulation, and aneurysmal dilations of the aorta and its large branches. Clinicians must be aware of all the presentation forms of the disease, to start a timely treatment and avoid potentially serious or fatal consequences. To date, the diagnosis of GCA is based on clinical and pathological criteria, with the temporal artery biopsy as the "gold standard" for diagnosis, although its sensitivity is variable. This can lead to an underdiagnosis in patients with negative biopsies or predominant extra-cranial symptoms. The emergence of new and valuable imaging tools substantially improved the timely diagnosis, mainly in subclinical and oligosymptomatic forms. Among them we highlight ultrasonography of the temporal and axillary arteries, Computed Tomography Angiography, Magnetic Resonance Angiography, and PET-CT. These imaging techniques are complementary, and their use is highly recommended. GCA treatment is based on steroidal therapy, often associated with a corticosteroid-sparing immunosuppressive agent. The follow-up is eminently clinical.

Valor del PET/CT semicuantitativo (SUVmax) en el estudio de nódulo pulmonar sólido / Value of Semiquantitative PET/CT (SUVmax) in study of solid lung nodule

OBJETIVO: Determinar el rendimiento diagnóstico del PET/CT en el estudio de nódulo pulmonar (NP) utilizando SUVmax. MÉTODO: Se revisó la base de datos de PET/CT, seleccionando aquellos solicitados para estudio de NP sólido. Se incluyeron sólo aquellos NP confirmados como malignos o benignos. Se excluyó NP subsólidos, masas pulmonares (> 3 cm), y pacientes con metástasis conocidas. Se midió SUVmax de las lesiones, determinando mejores valores de corte para malignidad y benignidad. RESULTADOS: De los 140 NP estudiados, el 60% (84/140) fueron confirmados como malignos y el 40% como benignos (100% y 59,6% de confirmación histológica, respectivamente). Un SUVmax ≤ 1,0 mostró sensibilidad 98,8%, valor predictivo negativo (VPN) 96,2%, y Likelihood ratio negativo (LR -) 0,027. Un SUVmax ≤ 2,5 no fue capaz de asegurar razonablemente benignidad con VPN 69,4%, y LR - 0,295. Valores de SUV > 2,5 y 5,0 se asociaron a malignidad en 83% y 93% de los casos, respectivamente (LR+ 3,333 y 8,889). CONCLUSIÓN: El PET/CT presenta alto rendimiento diagnóstico en estimar la naturaleza de un NP Un valor de SUVmax ≤ 1 es altamente predictivo de benignidad, y un valor de SUVmax ≥ 2,5 de malignidad. Valores entre 1,0 y 2,5 no permiten caracterizar eficientemente los NP.

AIM: To establish the diagnostic accuracy of PET/CT in study of solid lung nodule (LN) using SUVmax index. METHOD: We revised PET/CT data base, selecting those scans asked to evaluate a solid LN. Only confirmed malign o benign LN were included. Subsolid LN, lung masses (> 3 cm), and known or suspected lung metastases were excluded. SUVmax was measured in each LN, and best cutoff for malignant and benign lesion was calculated. RESULTS: Of the whole group of 140 LN, 60% were confirmed as malignant, and 40% as benign (100% and 59,6% of histological confirmation, respectively). SUVmax ≤ 1,0 showed sensibility of 98,8%, negative predictive value (NPV) of 96,2%, and negative likelihood ratio (LR —) of 0,027. SUVmax ≤ 2,5 was not able to guarantee reasonably benign nature of LN, showing NPV of 69,4% and LR - of 0,295. SUVmax > 2,5 and > 5,0 was associated to malign lesion in 83% and 93% of cases, respectively (LR + of 3,333 and 8,889). CONCLUSION: PET/CT shows high accuracy estimating the nature of solid LN. SUVmax ≤ 1,0 is highly predictive of benignity, and SUVmax ≥ 2,5 is highly predictive of malignancy. SUVmax values between 1,0 and 2,5 were not able to characterize efficiently LN.

In vitro production of gas methane by tropical grasses / Produccion in vitro de gas metano por gramineas forrajeras tropicales

ABSTRACT Objective. Estimate the production of methane (CH4) by tropical grasses fermented in vitro. Materials and methods. A sample of 20 g dry matter of Cynodon nlemfuensis, Hyparrhenia rufa, Megathyrsus maximus and Digitaria swazilandensis plus 200 ml of culture medium were plated in triplicate flasks sterile stainless steel with CO2 flux, inoculated with 20 ml of ruminal fluid bovine, incubated at 38 °C for 24, 48, 72 and 96 h. Total production of gas, CH4, volatile fatty acids, and pH were evaluated in a completely randomized design with three replicates per treatment and comparison of means with Tukey; the concentration of total and cellulolytic bacteria were analyzed with the Kruskal-Wallis, and the GLM procedure independent data Wilcoxon rank. Results. H. rufa and D. swazilandensis both had the lowest total gas production (p<0.05), while D. swazilandensis had lower production of CH4, increased production of propionic acid (p<0.05) and lower pH 96 hours of incubation (p<0.05). D. swazilandensis showed greater efficiency in energy production due to reduced production of CH4 and increased propionate production. The concentration of total bacteria was similar between treatments (p>0.05), while the concentration of cellulolytic bacteria was lower in C. nlemfuensis y D. swazilandensis when 96 of incubation (p<0.05). Conclusions. The Digitaria swazilandensis, showed favorable conditions to have lower total methane and total gas production.

RESUMEN Objetivo. Estimar la producción de metano (CH4) por gramíneas tropicales fermentadas in vitro. Materiales y métodos. Una muestra de 20 g de materia seca de Cynodon nlemfuensis, Hyparrhenia rufa, Megathyrsus maximus y Digitaria swazilandensis más 200 ml de medio de cultivo se depositaron por triplicado en frascos de acero inoxidable estériles con flujo de CO2, se inocularon con 20 ml de líquido ruminal de bovino e incubaron a 38 °C por 24, 48, 72 y 96 h. Se evaluó producción total de gas, CH4, ácidos grasos volátiles, y pH en un diseño completamente al azar con tres repeticiones por tratamiento y la comparación de medias con Tukey; la concentración de bacterias totales y celulolíticas, se analizaron con la prueba de Kruskal-Wallis, y el procedimiento GLM con datos de rangos independientes de Wilcoxon. Resultados. H. rufa y D. swazilandensis tuvieron la menor producción total de gases (p<0.05), mientras que D. swazilandensis tuvo menor producción de CH4, mayor producción de ácido propónico (p<0.05) y menor pH a las 96 horas de incubación (p<0.05). D. swazilandensis mostró mayor eficiencia en la producción de energía por la menor producción de CH4 y mayor producción de propionato. La concentración de bacterias totales fue similar entre tratamientos (p>0.05), mientras que la concentración de bacterias celulolíticas fue menor en C. nlemfuensis y D. swazilandensis a la hora 96 de incubación (p<0.05). Conclusiones. La Digitaria swazilandensis, mostró condiciones favorables para tener menor producción total de metano y gases totales.

Comparison between merthiolate-iodine-formalin and Kato-Katz methods for the diagnosis of human helminth infections in resource-limited settings.

Diagnosis of intestinal parasites through examination of fresh faecal samples is hampered by its unpleasantness and the urgent need to detect all parasitic forms. In this paper, we compared the standard Kato-Katz (KK) technique with a traditional fixation method, the merthiolate-iodine-formalin (MIF) method. Two hundred and twenty-seven faecal samples from individuals living in a rural setting in Venezuela with high to moderate prevalences of Ascaris lumbricoides (Al), Trichuris trichiura (Tt) and hookworm infections were examined. The 'gold standard' used here was derived from the combination of the outcomes from both methods. KK performed better at detecting Tt, and showed higher sensitivity and negative predictive value for both Tt and Al, probably due to a higher capacity of KK to detect low parasite loads. Both methods showed an almost perfect agreement using the Kappa index. MIF provided a higher median of parasitic loads for low and total egg counts for the three helminths. Differentiating fertile from infertile eggs of Al did not affect the results; infertile eggs were present only at low and intermediate parasitic loads, but absent at high loads. KK was not able to detect high loads of any of the helminths. MIF allowed for the detection of other helminths, such as Strongyloides stercoralis, and protozoan infections, for which KK is not specific. In conclusion, MIF is a simple and inexpensive technique that performs competitively with KK in both laboratory and field work on intestinal helminths, particularly in resource-limited settings.

Compromiso nodal y extranodal detectado con PET/CT en linfoma en etapificación / Nodal and extranodal involvement detected by PET/CT in staging lymphoma

Objective: To describe visible nodal and extra-nodal involvement using PET/CT in the different types and subtypes of lymphoma in staging. Patients and method: PET/CT with F18-FDG were reviewed in patients with lymphoma staging, determining frequency and location of nodal and extra-nodal involvement, and intensity of F18-FDG uptake measured by SUVmax. Results: Of the 102 patients with NHL (average SUVmax 13.0 ± 9.7), 86.3% had nodal involvement (51.9% on both sides of the diaphragm, 24.5% only above the diaphragm), and 66.7% extra-nodal compromise (42.6% bone marrow, 22.1% muscle, 16.2% renal). Of the 30 patients with HL (average SUVmax 14.6 ± 6.0), 100% had nodal involvement (63.3% only above the diaphragm, 36.7% above and below the diaphragm), and 30% had extra-nodal involvement (66.7% bone marrow, 22.2% lung). Conclusion: PET/CT is the method of choice in the staging of lymphoma, allowing the detection of nodal and extra-nodal disease in both HL and NHL.

Objetivo: Describir el compromiso nodal y extranodal visible con PET/CT en los distintos tipos y subtipos de linfoma en etapificación. Pacientes y método: Se revisaron los PET/CT con F18-FDG realizados a pacientes con linfoma en etapificación, determinando frecuencia y localización del compromiso nodal y extranodal, e intensidad de captación de F18-FDG medida mediante SUVmax. Resultados: De los 102 pacientes con LNH (SUVmaxpromedio 13,0±9,7), un 86,3% presentó compromiso nodal (51,9% a ambos lados del diafragma, 24,5% sólo sobre el diafragma) y 66,7% compromiso extranodal (42,6% médula ósea, 22,1% muscular, 16,2% renal). De los 30 pacientes con LH (SUVmax promedio 14,6±6,0), el 100% tuvo compromiso nodal (63,3% sólo sobre el diafragma, 36,7% sobre y bajo el diafragma), y 30% compromiso extranodal (66,7% médula ósea, 22,2% pulmón). Conclusión: El PET/CT es el método de elección en la etapificación del linfoma, permitiendo detectar enfermedad nodal y extranodal, tanto en LH como en LNH.

Standardizing the influenza neuraminidase inhibition assay among United States public health laboratories conducting virological surveillance.

BACKGROUND: Monitoring influenza virus susceptibility to neuraminidase (NA) inhibitors (NAIs) is vital for detecting drug-resistant variants, and is primarily assessed using NA inhibition (NI) assays, supplemented by NA sequence analysis. However, differences in NI testing methodologies between surveillance laboratories results in variability of 50% inhibitory concentration (IC50) values, which impacts data sharing, reporting and interpretation. In 2011, the Centers for Disease Control and Prevention (CDC), in collaboration with the Association for Public Health Laboratories (APHL) spearheaded efforts to standardize fluorescence-based NI assay testing in the United States (U.S.), with the goal of achieving consistency of IC50 data. METHODS: For the standardization process, three participating state public health laboratories (PHLs), designated as National Surveillance Reference Centers for Influenza (NSRC-Is), assessed the NAI susceptibility of the 2011-12 CDC reference virus panel using stepwise procedures, with support from the CDC reference laboratory. Next, the NSRC-Is assessed the NAI susceptibility of season 2011-12 U.S. influenza surveillance isolates (n = 940), with a large subset (n = 742) tested in parallel by CDC. Subsequently, U.S. influenza surveillance isolates (n = 9629) circulating during the next three influenza seasons (2012-15), were independently tested by the three NSRC-Is (n = 7331) and CDC (n = 2298). RESULTS: The NI assay IC50s generated by respective NSRC-Is using viruses and drugs prepared by CDC were similar to those obtained with viruses and drugs prepared in-house, and were uniform between laboratories. IC50s for U.S. surveillance isolates tested during four consecutive influenza seasons (2011-15) were consistent from season to season, within and between laboratories. CONCLUSION: These results show that the NI assay is robust enough to be standardized, marking the first time IC50 data have been normalized across multiple laboratories, and used for U.S. national NAI susceptibility surveillance.

[Positron emission tomography/computed tomography for lung cancer staging]. / Rendimiento del Positron Emission Tomography/Computed Tomography (PET/CT) en etapificación de cáncer pulmonar.

BACKGROUND: PET/CT (Positron Emission Tomography/Computed Tomography) is widely used in nodal and metastatic staging of lung cancer patients. AIM: To analyze PET/CT detection of metastatic disease in patients with lung cancer. MATERIAL AND METHODS: We reviewed retrospectively F18Fluorodeoxyglucose PET/CT scans performed between December 2008 and December 2013. We selected 143 patients aged 30 to 92 years (63% males) with confirmed lung cancer referred for staging, with no previous treatment. We reviewed whole body PET/CT and brain magnetic resonance images. SUVmax (Standardized Uptake Value maximum) of primary pulmonary lesion, hilar/mediastinal nodes, and distant metastases were calculated. RESULTS: Histological types encountered were adenocarcinoma in 55%, squamous-cell in 15%, small-cell in 8%, large-cell in 6% and adeno-squamous in 2%. In 22 cases (15%) histology was not available. Nodal involvement was observed in 60% of patients (44% hilar and 48% mediastinal). Skip metastases (mediastinal involvement without hilum involvement) were encountered in 17% of cases, and were significantly more common among high uptake lung tumors (p < 0.01). Best SUVmax cut-off for node involvement was 4.4 for hilum and 4.0 for mediastinum (sensibility: 86.4%, specificity: 99.8%). Sixty six patients (46.2%) showed distant metastases on PET/CT. The most common metastases were osseous in 22%, adrenal in 16%, hepatic in14%, pulmonary in 14% and cerebral in 12%. PET/CT detected a second unexpected synchronic cancer in eight patients (6%). CONCLUSIONS: PET/CT is accurate for nodal staging using an uptake index as SUVmax. Distant metastases are common, especially in bone, adrenal glands and liver.

Rendimiento del Positron Emission Tomography/Computed Tomography (PET/CT) en etapificación de cáncer pulmonar / Positron emission tomography/computed tomography for lung cancer staging

Background: PET/CT (Positron Emission Tomography/Computed Tomography) is widely used in nodal and metastatic staging of lung cancer patients. Aim: To analyze PET/CT detection of metastatic disease in patients with lung cancer. Material and Methods: We reviewed retrospectively F18Fluorodeoxyglucose PET/CT scans performed between December 2008 and December 2013. We selected 143 patients aged 30 to 92 years (63% males) with confirmed lung cancer referred for staging, with no previous treatment. We reviewed whole body PET/CT and brain magnetic resonance images. SUVmax (Standardized Uptake Value maximum) of primary pulmonary lesion, hilar/mediastinal nodes, and distant metastases were calculated. Results: Histological types encountered were adenocarcinoma in 55%, squamous-cell in 15%, small-cell in 8%, large-cell in 6% and adeno-squamous in 2%. In 22 cases (15%) histology was not available. Nodal involvement was observed in 60% of patients (44% hilar and 48% mediastinal). Skip metastases (mediastinal involvement without hilum involvement) were encountered in 17% of cases, and were significantly more common among high uptake lung tumors (p < 0.01). Best SUVmax cut-off for node involvement was 4.4 for hilum and 4.0 for mediastinum (sensibility: 86.4%, specificity: 99.8%). Sixty six patients (46.2%) showed distant metastases on PET/CT. The most common metastases were osseous in 22%, adrenal in 16%, hepatic in14%, pulmonary in 14% and cerebral in 12%. PET/CT detected a second unexpected synchronic cancer in eight patients (6%). Conclusions: PET/CT is accurate for nodal staging using an uptake index as SUVmax. Distant metastases are common, especially in bone, adrenal glands and liver.

A ten-year experience and follow-up of three hundred patients fitted with the Biomet/Lorenz Microfixation TMJ replacement system.

The purpose of this paper is to present the postoperative results obtained after full temporomandibular joint (TMJ) reconstruction employing the Biomet/Lorenz Microfixation TMJ replacement system (Jacksonville, FL, USA) in 300 patients (201 unilateral, 99 bilateral). Objective data (maximum inter-incisal opening; MIO) and subjective data (function and speech, diet, and pain) were collected preoperatively and at postoperative evaluations performed over a 10-year period (mean 3.5, standard deviation 2.1 years). The MIO measures were obtained using a calliper rule. Subjective data were evaluated using a visual analogue scale with scores ranging from 0 to 5 for each variable. The results were analyzed with the paired t-test (two-sided, α=5%). Each patient showed significant improvements for all of the variables at evaluation on postoperative day 7. The results for MIO, function and speech, and diet, showed improvements at each postoperative evaluation over a maximum of 3 years, with stabilization of the results from the fourth year. Complaints of pain decreased considerably up to the 1-month postoperative evaluation, and no patient reported severe pain at 6 months after surgery. The results presented show that the reconstruction of the TMJ through the installation of the Biomet/Lorenz system prosthesis is a safe and effective option for proper reestablishment of the joint and stomatognathic system function; significant long-term improvements in mandibular range of motion are promoted and pain levels decrease.

¿Qué hay de nuevo en el síndrome de ovario poliquístico? / What’s new in polycystic ovary syndrome

Polycystic ovary syndrome is recognized as a risk factor for the development of type 2 diabetes and metabolic syndrome. The prevalence of the condition is 6 to 10 percent in different populations. Its etiology is not well known and there are genetic and epigenetic phenomena involved. Due to its association with insulin resistance, it has been incorporated as another component of Reaven plurimetabolic syndrome. Therefore polycystic ovary syndrome evolved from an ovarian disease to a multisystem disorder and it must be considered a public health problem.

Caracterización de enfermedad metastásica con PET/CT en cáncer de mama en etapificación y con recidiva postratamiento / Characterization of metastatic disease in recently diagnosed breast cancer and relapsed breast cancer (after treatment), with PET/CT

Objetivo: Describir la enfermedad metastásica detectada por PET/CT en cáncer de mama (CM) y estimar el aporte relativo del PET y del CT interpretados por separado. Pacientes y método. Se separaron dos grupos de pacientes con CM: 1) en etapificación 2) ya tratados con recidiva al PET/CT. Se describieron las lesiones encontradas exclusivamente con PET y exclusivamente con CT. Resultados. Los pacientes en etapificación (n=17) presentaron 88 por ciento adenopatías, 29 por ciento metástasis óseas (MO), 17 por ciento pulmonares, 17 por ciento hepáticas y 11 por ciento en otras localizaciones. Para los pacientes en seguimiento (n=35) estos porcentajes fueron de 54 por ciento, 62 por ciento, 34 por ciento, 31 por ciento y 28 por ciento, respectivamente. El CT detectó más nódulos pulmonares y MO escleróticas que el PET. El PET detectó más adenopatías, MO medulares y lesiones hepáticas. Se encontró cáncer sincrónico en 6 por ciento de los pacientes en etapificación y 11 por ciento en seguimiento. Conclusión. Las pacientes con CM presentaron principalmente metástasis ganglionares y óseas. El estudio híbrido PET/CT detectó más lesiones que el PET y el CT analizados por separado.

Purpose: To describe metastatic disease detected by PET/CT in breast cancer (BC), and to evaluate the relative contribution of PET and CT analyzed separately. Patients and Method. We defined two groups of patients with BC: 1) recently diagnosed with no treatment, 2) with relapse after treatment. We described findings which are visible exclusively with CT and exclusively with PET. Results. In recently diagnosed patients (n=17) 88 percent show lymphadenopathies, 29 percent bone metastases (BM), 17 percent lung metastases, 17 percent hepatic metastases, and 11 percent other localizations. For relapsed patients (n=35) these percentages were 54 percent, 62 percent, 34 percent, 31 percent and 28 percent, respectively. CT detected more lung nodules and sclerotic bone lesions than PET. PET detected more lymphadenopathies, medullary bone and hepatic lesions than CT. There were synchronous cancers in 6 percent of recently diagnosed patients and in 11 percent of relapsed patients. Conclusion. BC patients show mainly lymph nodal and bone metastasis. The PET/CT hybrid study detected more lesions than PET and CT analyzed separately.

Cáncer de recto: diagnóstico, estudio y estadificación / Rectal cancer: diagnosis, study and staging

Rectal cancer is defined as a tumour located between the anal verge and 15 cm within anal verge. In rectal cancer, a precise preoperative staging allows to categorize patients for different available treatments, as well as decide the best surgical treatment. Preoperative staging is performed by several radiological techniques. Currently available procedures are endorectal ultrasound (EUS), computed tomography (CT) magnetic resonance (MRI), positron emission tomography-computed tomography (PET/CT) and intraoperative ultrasound. EUS is a procedure performed by the colorrectal surgeon that allows the evaluation of the depth of tumour invasion as well as lymph node status; nevertheless its main shortcoming is the inability to assess mesorectal fascia involvement. Nowadays, MRI is the best method to assess mesorectal fascia involvement in addition to tumour invasion and lymph nodes involved. CT is a widely available procedure, and its main use is evaluation of distant metastases, with lower accuracy to assess tumour invasion and lymph node status. PET/CT is currently gaining importance, however its role in preoperative staging it's not widely accepted. IOUS allows evaluation of liver metastases during surgery, and therefore determines management and prognosis. Consequently, is necessary for surgeons to maintain an up-to-date knowledge of current methods, its advantages and limitations.

El cáncer rectal se define como el tumor ubicado entre el margen anal y los 15 cm hacia proximal. En el cáncer de recto, una precisa estadificación preoperatoria permite clasificar correctamente a los pacientes para las diversas terapias existentes, así como seleccionar el mejor tratamiento quirúrgico. La estadificación preoperatoria se realiza con el apoyo de métodos imagenológicos. Dentro de los métodos actualmente disponibles están la endosonografía rectal (EUS), tomografía computada (TC), resonancia magnética (RM), tomografía por emisión de positrones (PET/CT) y ultrasonido intraoperatorio (IOUS). La EUS es un método realizado por el cirujano colorrectal, que permite la evaluación de la invasión de la pared, así como también de los linfonodos, sin embargo, su principal limitación es la evaluación del compromiso de la fascia mesorrectal. La RM es, hasta el momento, el mejor método para evaluar el compromiso de la fascia mesorrectal, además de informar el compromiso de pared y una adecuada evaluación de linfonodos comprometidos. La TC es un método ampliamente disponible, cuya principal utilidad es la evaluación de metástasis a distancia. El PET/CT está cobrando actualmente mayor importancia, sin embargo, su uso en estadificación preoperatoria aún no es ampliamente aceptado. La IOUS permite evaluar el compromiso metastásico del hígado durante la cirugía y por lo tanto, determina conducta y pronóstico. Por lo anterior, es necesario un conocimiento actualizado del cirujano en cuanto a esta metodología, sus ventajas y limitaciones.