Encuesta sobre el manejo del nevus displásico por los dermatólogos de la sección Centro de la Academia Española de Dermatología y Venereología (AEDV) / Survey on the Management of Dysplastic Nevus by Dermatologists in the Center-Spain section of the Spanish Academy of Dermatology and Venereology (AEDV)

Antecedentes y objetivos No existen guías clínicas para el manejo del nevus displásico (ND). Determinaremos el porcentaje de dermatólogos de la sección Centro de la Academia Española de Dermatología y Venereología (AEDV) que ampliarían márgenes o tendrían actitud conservadora en un ND, y si los antecedentes personales (AP) y/o familiares (AF) de melanoma modificarían la actitud tomada frente a un paciente sin antecedentes de interés. Material y métodos Se difundió la encuesta a 738 dermatólogos y se recogieron datos de forma anónima del 15 de junio de 2022 al 31 de julio de 2022. Las variables de exposición fueron el grado de displasia (bajo/alto), los márgenes (afecto/libre) y los antecedentes de melanoma (sin antecedentes/AF/AP). Las variables dependientes (actitud) incluyeron observación/márgenes de 1-4mm /márgenes 5-10mm. Resultados Se recibieron 86 respuestas. Si el patólogo informase bordes afectos en un ND de bajo grado, el 60,5% ampliarían márgenes de 1 a 4mm, mientras que si los márgenes están libres el 97,7%, tendrían una actitud conservadora. Si el patólogo informara bordes afectos en un ND de alto grado, solo el 1,2% tendrían una actitud conservadora, porcentaje que se incrementa notablemente si los márgenes están libres (68,6%). El AF o el AP de melanoma no influirían en la actitud de la mayoría. Conclusiones El manejo del ND no es uniforme entre los dermatólogos de la sección centro de la AEDV, especialmente en el caso de ND de bajo grado con bordes afectos y ND de alto grado con bordes libres. El AF o el AP de melanoma no modifican en la mayor parte de los casos la actitud clínica (AU)

Background and objectives There are no clinical guidelines on the management of dysplastic nevus (DN). The aims of this study were to determine the percentage of dermatologists in the center-Spain section of the Spanish Academy of Dermatology and Venereology (AEDV) who would manage a histologically confirmed DN with a watch-and-wait approach or with wider surgical margins and to investigate whether their attitudes would vary depending on whether or not the patient had a personal and/or family history of melanoma. Material and methods We collected data from an anonymous survey sent to 738 dermatologists between June 15 and July 31, 2022. The independent variables were degree of dysplasia (low vs. high), margin status (positive vs. negative), and a personal or family history of melanoma (yes vs. no in both cases). The dependent variables were attitude towards management (watch-and-wait vs. re-excision with a surgical margin of 1 to 4mm or re-excision with a surgical margin of 5 to 10mm). Results We obtained 86 responses to the questionnaire. When pathology indicated a low-grade DN, 60.5% of dermatologists stated they would obtain a surgical margin of 1 to 4mm if the first margins were positive, and 97.7% would watch and wait if the report described negative margins. For high-grade DNs, 1.2% of dermatologists would watch and wait to manage DN with positive margins; 68.8% would use this approach for negative margins. A family or personal history of melanoma had no influence on most of the dermatologists’ attitudes. Conclusions Management strategies for DN among dermatologists from the center-Spain section of the AEDV varied, particularly when faced with low-grade DN with positive margins and high-grade DN with negative margins. A family or personal history of melanoma did not influence clinical attitudes in most cases (AU)

[Translated article] Survey on the Management of Dysplastic Nevus by Dermatologists in the Center-Spain Section of the Spanish Academy of Dermatology and Venereology (AEDV) / Encuesta sobre el manejo del nevus displásico por los dermatólogos de la sección Centro de la Academia Española de Dermatología y Venereología (AEDV)

Background and objectives There are no clinical guidelines on the management of dysplastic nevus (DN). The aims of this study were to determine the percentage of dermatologists in the center-Spain section of the Spanish Academy of Dermatology and Venereology (AEDV) who would manage a histologically confirmed DN with a watch-and-wait approach or with wider surgical margins and to investigate whether their attitudes would vary depending on whether or not the patient had a personal and/or family history of melanoma. Material and methods We collected data from an anonymous survey sent to 738 dermatologists between June 15 and July 31, 2022. The independent variables were degree of dysplasia (low vs. high), margin status (positive vs. negative), and a personal or family history of melanoma (yes vs. no in both cases). The dependent variables were attitude towards management (watch-and-wait vs. re-excision with a surgical margin of 1 to 4mm or re-excision with a surgical margin of 5 to 10mm). Results We obtained 86 responses to the questionnaire. When pathology indicated a low-grade DN, 60.5% of dermatologists stated they would obtain a surgical margin of 1 to 4mm if the first margins were positive, and 97.7% would watch and wait if the report described negative margins. For high-grade DNs, 1.2% of dermatologists would watch and wait to manage DN with positive margins; 68.8% would use this approach for negative margins. A family or personal history of melanoma had no influence on most of the dermatologists’ attitudes. Conclusions Management strategies for DN among dermatologists from the center-Spain section of the AEDV varied, particularly when faced with low-grade DN with positive margins and high-grade DN with negative margins. A family or personal history of melanoma did not influence clinical attitudes in most cases (AU)

Antecedentes y objetivos No existen guías clínicas para el manejo del nevus displásico (ND). Determinaremos el porcentaje de dermatólogos de la sección Centro de la Academia Española de Dermatología y Venereología (AEDV) que ampliarían márgenes o tendrían actitud conservadora en un ND, y si los antecedentes personales (AP) y/o familiares (AF) de melanoma modificarían la actitud tomada frente a un paciente sin antecedentes de interés. Material y métodos Se difundió la encuesta a 738 dermatólogos y se recogieron datos de forma anónima del 15 de junio de 2022 al 31 de julio de 2022. Las variables de exposición fueron el grado de displasia (bajo/alto), los márgenes (afecto/libre) y los antecedentes de melanoma (sin antecedentes/AF/AP). Las variables dependientes (actitud) incluyeron observación/márgenes de 1-4mm /márgenes 5-10mm. Resultados Se recibieron 86 respuestas. Si el patólogo informase bordes afectos en un ND de bajo grado, el 60,5% ampliarían márgenes de 1 a 4mm, mientras que si los márgenes están libres el 97,7%, tendrían una actitud conservadora. Si el patólogo informara bordes afectos en un ND de alto grado, solo el 1,2% tendrían una actitud conservadora, porcentaje que se incrementa notablemente si los márgenes están libres (68,6%). El AF o el AP de melanoma no influirían en la actitud de la mayoría. Conclusiones El manejo del ND no es uniforme entre los dermatólogos de la sección centro de la AEDV, especialmente en el caso de ND de bajo grado con bordes afectos y ND de alto grado con bordes libres. El AF o el AP de melanoma no modifican en la mayor parte de los casos la actitud clínica (AU)

Survey on the Management of Dysplastic Nevus by Dermatologists in the Center-Spain section of the Spanish Academy of Dermatology and Venereology (AEDV). / Encuesta sobre el manejo del nevus displásico por los dermatólogos de la sección Centro de la Academia Española de Dermatología y Venereología (AEDV).

BACKGROUND AND OBJECTIVES: There are no clinical guidelines on the management of dysplastic nevus (DN). The aims of this study were to determine the percentage of dermatologists in the center-Spain section of the Spanish Academy of Dermatology and Venereology (AEDV) who would manage a histologically confirmed DN with a watch-and-wait approach or with wider surgical margins and to investigate whether their attitudes would vary depending on whether or not the patient had a personal and/or family history of melanoma. MATERIAL AND METHODS: We collected data from an anonymous survey sent to 738 dermatologists between June 15 and July 31, 2022. The independent variables were degree of dysplasia (low vs. high), margin status (positive vs. negative), and a personal or family history of melanoma (yes vs. no in both cases). The dependent variables were attitude towards management (watch-and-wait vs. re-excision with a surgical margin of 1 to 4mm or re-excision with a surgical margin of 5 to 10mm). RESULTS: We obtained 86 responses to the questionnaire. When pathology indicated a low-grade DN, 60.5% of dermatologists stated they would obtain a surgical margin of 1 to 4mm if the first margins were positive, and 97.7% would watch and wait if the report described negative margins. For high-grade DNs, 1.2% of dermatologists would watch and wait to manage DN with positive margins; 68.8% would use this approach for negative margins. A family or personal history of melanoma had no influence on most of the dermatologists' attitudes. CONCLUSIONS: Management strategies for DN among dermatologists from the center-Spain section of the AEDV varied, particularly when faced with low-grade DN with positive margins and high-grade DN with negative margins. A family or personal history of melanoma did not influence clinical attitudes in most cases.

Una actualización en el protocolo en cáncer de próstata metastásico hormonosensible / Hormone sensitive protocol for metastatic prostate cancer, an update

Revisar y actualizar los últimos protocolos en cáncer de próstata metastásico hormonosensible para mejorar su manejo clínico en la práctica clínica. Realizar un análisis de los datos y los protocolos más recientes en el cáncer de próstata metastásico hormonosensible según paneles de expertos en este ámbito. Actualmente se necesita un grupo de consenso nominal para unificar y mejorar las recomendaciones para el manejo de pacientes sensibles con cáncer de próstata metastásico. Este documento unifica y mejora el manejo de los pacientes con cáncer de próstata metastásico hormonosensible, con una metodología que combina datos cuantitativos y cualitativos, y basada en la participación de un amplio comité científico designado por la Asociación Española de Urología (AU)

To review and update last protocols in hormone sensitive metastatic prostate cancer for improving clinical management in routine. Evidence analysis available about recent updates protocols in hormone sensitive metastatic prostate cancer according to expert panel of clinicians about this field. A nominal consensus group for unify and improve the recommendations to the management of sensitive metastatic prostate cancer patients is currently needed. This document unifies and improve the management of patients with hormone sensitive metastatic prostate cancer, with a methodology that combines data quantitative and qualitative and based on the participation of a broad scientific committee appointed by the Spanish Association of Urology (AU)

Hormone sensitive protocol for metastatic prostate cancer, an update.

To review and update last protocols in hormone sensitive metastatic prostate cancer for improving clinical management in routine. Evidence analysis available about recent updates protocols in hormone sensitive metastatic prostate cancer according to expert panel of clinicians about this field. A nominal consensus group for unify and improve the recommendations to the management of sensitive metastatic prostate cancer patients is currently needed. This document unifies and improve the management of patients with hormone sensitive metastatic prostate cancer, with a methodology that combines data quantitative and qualitative and based on the participation of a broad scientific committee appointed by the Spanish Association of Urology.

Analysis of clinical indicators of teledentistry management for the elderly population during the covid-19 pandemic in Chile / Análisis de indicadores clínicos del manejo de la teleodontología para la población adulta mayor durante la pandemia del covid-19 en Chile

Objective: To analyze clinical indicators of teledentistry management for the elderly population during the COVID-19 pandemic in Chile. Material and Methods:A pilot teledentistry project was developed for dental care of the elderly in 5 regions of Chile. The data obtained were recorded on the TEGO Platform to be subsequently selected and analyzed by the researchers in terms of clinical management indicators: degree of installed occupancy, degree of available occupation, degree of real occupation, interconsultation indicator per patient attended, urgencies according to reason for consultations, unpostponable prosthetic treatment according to reason for consultations, prevention in relation to granted benefits, prevention in relation to the patients cared for, and project absenteeism indicator. Results: The clinical management indicators obtained were as follows: The average degree of installed occupancy was 67%. The average degree of available occupancy was 78%, which accounts for the clinical time in which there are dental chairs and dentists willing to work. The average real occupancy degree was 86%. The average interconsultation indicator per patient observed was 25%. The indicator of urgencies according to the reason for the consultation was 95%, which indicates that the purpose of the study was fulfilled. The average unpostponable prosthetic treatment according to the reason for consultations was 5%. The prevention in relation to granted benefits reached 39%. Finally, the average indicator of absenteeism was 17%. Conclusion: The measurement of clinical management indicators contributes to meet the Chilean Ministry of Health Explicit Health Guarantees (GES), which are: Access, Timely Attention, Quality and Financial Protection.

Objetivo: Analizar indicadores clínicos del manejo de la teleodontología para la población de adultos mayores durante la pandemia de COVID-19 en Chile. Material y Métodos: Se desarrolló un proyecto piloto de teleodontología para la atención odontológica del adulto mayor en cinco regiones de Chile. Los datos obtenidos fueron registrados en la plataforma TEGO para ser posteriormente seleccionados y analizados por los investigadores en cuanto a indicadores de gestión clínica: grado de ocupación instalada, grado de ocupación disponible, grado de ocupación real, indicador de interconsulta por paciente atendido, urgencias según motivo por consultas, tratamiento protésico improrrogable según motivo de consultas, prevención en relación a las prestaciones otorgadas, prevención en relación a los pacientes atendidos e indicador de ausentismo del proyecto. Resultados: Los indicadores de gestión clínica obtenidos fueron los siguientes: El grado medio de ocupación instalada fue del 67%. El grado medio de ocupación disponible fue del 78%, lo que da cuenta del tiempo clínico en el que hay sillones dentales y odontólogos dispuestos a trabajar. El grado de ocupación real promedio fue del 86%. El indicador medio de interconsultas por paciente observado fue del 25%. El indicador de urgencias según el motivo de la consulta fue del 95%, lo que indica que se cumplió con el propósito del estudio. El promedio de tratamientos protésicos impostergables según el motivo de consulta fue del 5%. La prevención en relación a las prestaciones otorgadas alcanzó el 39%. Finalmente, el indicador promedio de ausentismo fue de 17%. Conclusión: La medición de indicadores de gestión clínica contribuye a cumplir con las Garantías Explícitas en Salud (GES) del Ministerio de Salud de Chile, que son: Acceso, Oportunidad, Calidad y Protección Financiera.

Os impasses ao acesso à intersubjetividade: observações clínicas de um bebê com risco de evolução autística / Impases en el accesoa la intersubjetividad: observaciones clínicas de un bebé con riesgo de evolución autista / Challenge in accessing intersubjectivity: clinical observations of a baby with a risk of autism / Les impasses à l'accès à l'intersubjectivité: observations cliniques d'un bébé à risque d'autisme

O artigo aborda os impasses vividos por um bebê com risco de autismo em seu processo de subjetivação. Estudos afirmam que há bebês que, muito precocemente, recusam-se a estabelecer trocas com o objeto materno, impossibilitando que a mãe entre em um estado de identificação com seu bebê, o que colocaria em pauta que o autismo infantil não se limitaria apenas a uma falha materna, mas se trataria de uma patologia multifatorial. Quais intervenções clínicas seriam necessárias para que a mãe e o bebê possam juntos (re)escrever uma nova narrativa psíquica? Haveria um tipo de intervenção e de manejo clínico específico nos casos de bebês com risco de autismo? E como a psicanálise contemporânea, fundamentada pela leitura da intersubjetividade, nos ajudaria na compreensão da clínica da intervenção precoce?

Este artículo se propone abordar los impases experimentados por un bebé con riesgo autista en su proceso de subjetivación. Existen estudios sobre bebés que precozmente se niegan a establecer intercambios con el objeto materno, imposibilitando que la madre entre en identificación con él, poniendo sobre la mesa que el autismo infantil no se limitaría a una falla materna, sino que se trataría de una patología multifactorial. Se plantea, cuáles intervenciones clínicas son necesarias para que madre y bebé puedan (re)escribir una nueva narrativa psíquica, que posibilite un verdadero encuentro diádico. ¿Habría un tipo específico de intervención y manejo clínico en los bebés con riesgo de autismo? ¿Cómo el psicoanálisis contemporáneo, basado en la lectura de la intersubjetividad y de lo intrapsíquico, ayudaría a entender la clínica de la intervención precoz?

This article addresses the failures of a baby with a risk of autism to develop his subjectivation process. Recent studies show that some babies are not able to develop exchanges with their maternal object, which would show that children autism would not be limited to a failure of the mother to enter into a state of identification with her baby, but would be associated to a multifactorial pathology. In that respect, which clinical interventions would be necessary so that mother and baby can (re)write a new psychic narrative, enabling them to develop a genuine capability to meet together? Is there a type of clinical handling for babies with a risk of autism? How can contemporary psychoanalysis, with focus on intersubjectivity and inter-psychism, could help us to understand early intervention clinic?

Cet article aborde les entraves d'un bébé à risque autistique à développer son processus de subjectivation. Des études récentes montrent que certains bébés ne sont pas capables de développer des échanges avec leur objet maternel, ce qui montrerait que l'autisme infantile ne se limiterait pas seulement à un échec de la mère d'entrer dans un état d'identification avec son bébé, mais qu'il s'agirait d'une pathologie multifactorielle. Ainsi, quelles interventions cliniques seraient nécessaires pour que mère et bébé puissent (ré)écrire ensemble un nouveau récit psychique, qui leur permettrait de développer une véritable capacité à se rencontrer ? Y aurait-il un type de prise en charge clinique spécifique aux bébés à risque d'autisme? Comment la psychanalyse contemporaine, centrée sur l'intersubjectivité et l'inter-psychisme, peut nous aider à comprendre la clinique d'intervention précoce?

Guía de actuación y abordaje frente a intoxicación por dióxido de cloro/clorito de sodio, a partir de la experiencia de los CIAT de América Latina / Guidelines for action and approach to chlorine dioxide/sodium chlorite poisoning based on the experience of the CIATs in Latin America

Resumen El 11 de marzo de 2020, la Organización Mundial de la Salud, declaró la pandemia a nivel mundial por la COVID-19. Ante este escenario, los centros de información y asesoramiento toxicológico (CIAT) de América Latina comenzaron a recibir consultas por exposición/intoxicación a dióxido de cloro/clorito de sodio y sus compuestos relacionados, por desvío de uso, destinado a la prevención y/o tratamiento de la COVID-19 sin aval científico alguno ni contar con registro sanitario para ese fin. A través de la Red de Toxicología de América Latina y el Caribe (RETOXLAC), se comprobó que no eran hechos aislados, sino que se estaba produ ciendo el mismo fenómeno en toda la región y que existían antecedentes de intoxicaciones con dichos productos y alertas desde hace más de una década, con indicaciones no aprobadas, para el tratamiento de distintas patologías como SIDA, cáncer, esclerosis lateral amiotrófica ELA, malaria, autismo, entre otras, sin evidencia. Ante esta realidad, los CIAT presentan una revisión de los signos y síntomas observados según la vía de ingreso, basados en la comunicación de riesgo en salud; proponiéndose pruebas de apoyo al diagnóstico, algoritmo de tratamiento para las intoxicaciones y modelo de ficha clínica para la vigilancia epidemiológica de los casos atendidos. Recomendamos a las autoridades y organismos responsables, reforzar las acciones tendientes a la vigilancia, control y prevención de este tipo de intoxicaciones, producto del mal uso de un desinfectante no autorizado para fines terapéuticos/médicos.

Abstract On March 11th, 2020, the World Health Organization declared a global pandemic due to COVID-19. Faced with this sce- nario, the Poison Control Centers (CIATs for its initials in spanish) in Latin America began to receive consultations for exposure/poi- soning to chlorine dioxide/sodium chlorite and its related compounds for their use aimed to prevent or treat COVID-19 without any scientific endorsement or having a sanitary registry for that purpose. It was found through the Toxicology Network of Latin America and the Caribbean (RETOXLAC) that they were not isolated events but rather that the same phenomenon was occurring throughout the region and that there has been a history of poisoning and alerts with these products for more than a decade with unapproved indications for the treatment of different pathologies such as AIDS, cancer, amyotrophic lateral sclerosis (ALS), malaria, autism, among others, without evidence. In the light of this situation, the CIATs present a review of the signs and symptoms observed ac- cording to the route of exposure based on health risk communication; proposing tests to support the diagnosis, an algorithm for poisoning treatment, and a model of a clinical record for the epidemiological surveillance of the assisted cases. We recommend to the authorities and responsible organisms reinforce the actions aimed at surveillance, control, and prevention of this type of poisoning due to the misuse of an unauthorized disinfectant for therapeutic or medical purposes.

Guía basada en la evidencia. Diagnóstico y manejo del síndrome de Guillain-Barré en diez pasos / Evidence based guidelines. Diagnosis and management of Guillain-Barré syndrome in ten steps

Resumen El síndrome de Guillain-Barré (SGB) es una enfermedad inmunológica del nervio periférico y las raíces nerviosas, poco frecuente, potencialmente mortal y que suele desencadenarse por infecciones. La incidencia del SGB puede aumentar durante el brote de enfermedades infecciosas, tal como se observó en las epidemias del virus Zika en la Polinesia Francesa en 2013 y en América Latina en 2015. El diagnóstico y el manejo clínico del SGB pueden ser complicados ya que su presentación y el curso de la enfermedad son heterogéneos, y actualmente no se cuenta con guías clínicas internacionales. Para respaldar a los médicos, especialmente en el contexto de un brote de una enfermedad infecciosa, hemos desarrollado una guía clínica aplicable en todo el mundo para el diagnóstico y el tratamiento del SGB. La guía se basa en literatura actualizada y el consenso de expertos, y tiene una estructura de diez pasos para facilitar su uso en la práctica clínica. Inicialmente, brindamos una introducción a los criterios de diagnóstico, variantes clínicas y diagnósticos diferenciales del SGB. Los diez pasos luego abordan el reconocimiento y el diagnóstico temprano del SGB, la admisión a la unidad de cuidados intensivos, indicación y selección de tratamiento, seguimiento y tratamiento de la progresión de la enfermedad, predicción del curso clínico, resultados y tratamiento de complicaciones y secuelas.

Abstract Guillain-Barré syndrome (GBS) is a rare, but potentially fatal, immune-mediated disease of the peripheral nerves and nerve roots that is usually triggered by infections. The incidence of GBS can therefore increase during outbreaks of infectious diseases, as was seen during the Zika virus epidemics in 2013 in French Polynesia and in 2015 in Latin America. Diagnosis and management of GBS can be complicated as its clinical presentation and disease course are heterogeneous, and no international clinical guidelines are currently available. To support clinicians, especially in the context of an outbreak, we have developed a globally applicable guideline for the diagnosis and management of GBS. The guideline is based on current literature and expert consensus, and has a ten-step structure to facilitate its use in clinical practice. We first provide an introduction to the diag nostic criteria, clinical variants and differential diagnoses of GBS. The ten steps then cover early recognition and diagnosis of GBS, admission to the intensive care unit, treatment indication and selection, monitoring and treatment of disease progression, prediction of clinical course and outcome, and management of complications and sequelae.

Clinical Management of Intra-Pulp Canal Broken Endodontic Files in Primary Teeth: Literature Review / Manejo clínico de las limas endodónticas fracturadas dentro del conducto pulpar en dientes primarios: Revisión de la literatura

ABSTRACT: Fracture of an endodontic file inside a primary root canal is a rare but critical complication during the pulpectomy treatment, because the mechanical obstruction impedes the optimal cleaning and obturation of the pulp canal, compromising seriously the clinical outcome. This accidental event is mainly associated with over-use and excessive torque of intracanal files. Most clinicians opt to proceed with the extraction of the affected tooth followed by a space maintainer placement. Other practitioners attempt the non-surgical retrieval of the separated fragment through available proven techniques in permanent teeth; however, these methods may involve significant damage to the tooth and surround tissues. On the other hand, preservation of the metallic fragment might affect the treatment prognosis and interfere with the physiological root resorption.

RESUMEN: La fractura de una lima endodóntica dentro de un conducto radicular primario es una complicación rara aunque critica durante el tratamiento de pulpectomía, debido a que la obstrucción mecánica impide la limpieza y obturación óptimas del conducto pulpar, comprometiendo seriamente el resultado clínico. Este evento accidental está principalmente asociado con el sobreuso y torque excesivo de las limas dentro del conducto. La mayoría de los clínicos optan por realizar la extracción del diente afectado, seguido por la colocación de un mantenedor de espacio. Otros practicantes intentan la remoción no quirúrgica del fragmento separado a través de técnicas disponibles probadas en dientes permanentes; sin embargo, estos métodos pueden causar daños significativos al diente y tejidos circundantes. Por otra parte, la preservación del fragmento metálico puede afectar el pronóstico del tratamiento e interferir con el proceso de reabsorción radicular fisiológico.

Artropatías en el adulto mayor / Arthropathies in the elderly

Introducción: Los pacientes mayores de 65 años son la parte de la población más afectada por las enfermedades reumáticas. El diagnóstico reumatológico en los ancianos se complica por las manifestaciones clínicas que imitan los cambios relacionados con la edad. Objetivo: Sintetizar los aspectos generales del manejo clínico, el diagnóstico y la terapéutica de las principales enfermedades reumáticas inflamatorias y no inflamatorias en este subgrupo de población. Desarrollo: Los principales trastornos musculoesqueléticos no inflamatorios que afectan a los adultos mayores son la osteoartritis, la osteoporosis y el dolor de espalda, mientras que las artritis inflamatorias predominantes comprenden la artritis reumatoide, la artropatía cristalina, la polimialgia reumática y las formas inflamatorias de la osteoartritis. Conclusiones: Para el diagnóstico y la terapéutica de las principales enfermedades reumáticas (inflamatorias y no inflamatorias) en este subgrupo de población, es necesario el enfoque multidisciplinar(AU)

Introduction: It is recognized that patients older than 65 years are the part of the population most affected by rheumatic diseases. The rheumatological diagnosis in the elderly is complicated by clinical manifestations, which mimic the changes related to age. Objective: To synthesize the general aspects of clinical management, diagnosis and therapy of the main rheumatic diseases inflammatory and non-inflammatory in this subgroup of the population. Development: The main non-inflammatory musculoskeletal disorders that affect older adults are osteoarthritis, osteoporosis and back pain, while the predominant inflammatory arthritis include rheumatoid arthritis, crystalline arthropathy, polymyalgia rheumatica and the inflammatory forms of osteoarthritis. Conclusions: It is vital for academics to be involved in the rheumatological aspects of aging and call attention to the imperative that is to promote reflective discussion within community medicine to address the impact of musculoskeletal problems that affect function and mobility of the elderly and immune dysregulation in aging, among other issues(AU)

Upcoming Scenarios for the Comprehensive Management of Obstructive Sleep Apnea: An Overview of the Spanish Sleep Network.

Sleep is considered an essential part of life and plays a vital role in good health and well-being. Equally important as a balanced diet and adequate exercise, quality and quantity of sleep are essential for maintaining good health and quality of life. Sleep-disordered breathing is one of the most prevalent conditions that compromises the quality and duration of sleep, with obstructive sleep apnea (OSA) being the most prevalent disorder among these conditions. OSA is a chronic and highly prevalent disease that is considered to be a true public health problem. OSA has been associated with increased cardiovascular, neurocognitive, metabolic and overall mortality risks, and its management is a challenge facing the health care system. To establish the main future lines of research in sleep respiratory medicine, the Spanish Sleep Network (SSN) promoted the 1st World Café experts' meeting. The overall vision was established by consensus as "Sleep as promoter of health and the social impact of sleep disturbances". Under this leitmotiv and given that OSA is the most prevalent sleep disorder, five research lines were established to develop a new comprehensive approach for OSA management: (1) an integrated network for the comprehensive management of OSA; (2) the biological impact of OSA on comorbidities with high mortality, namely, cardiovascular and metabolic diseases, neurocognitive diseases and cancer; (3) Big Data Analysis for the identification of OSA phenotypes; (4) personalized medicine in OSA; and (5) OSA in children: current needs and future perspectives.

Toma de decisiones frente a dolor refractario en paciente oncológica joven / Decisão fazendo contra a dor refratária no paciente oncológico / Decision making on refractory pain in a young oncological patient

Resumen: La gran mayoría de los pacientes oncológicos en etapas avanzadas presentan dolor. La mayoría de éstos son controlados con analgésicos siguiendo la escalera analgésica de la OMS. Sin embargo, un porcentaje de pacientes persisten con dolor. Estos son pacientes con dolor de difícil control que se benefician muchas veces de medidas intervencionistas. Un porcentaje aún menor de pacientes mantiene el dolor como síntoma refractario a pesar de las medidas terapéuticas adecuadas. En estos casos está indicada la sedación paliativa. Se presenta aquí el caso de una paciente joven con dolor refractario que requirió sedación paliativa, en una unidad de cuidados paliativos de una institución privada de Montevideo.

Resumo: A grande maioria dos pacientes com câncer em estágios avançados tem dor. A maioria destes é controlada com analgésicos seguindo a escada analgésica da OMS. No entanto, uma porcentagem de pacientes persiste com dor. Estes são pacientes com dor de difícil controle que freqüentemente se beneficiam de medidas de intervenção. Uma porcentagem ainda menor de pacientes mantém a dor como um sintoma refratário, apesar das medidas terapêuticas adequadas. Nestes casos, a sedação paliativa é indicada. Apresentamos o caso de um paciente jovem com dor refratária que necessitou de sedação paliativa em uma unidade de cuidados paliativos de uma instituição privada em Montevidéu.

Summary: The vast majority of cancer patients in advanced stages feel pain. Most are controlled with analgesics following the WHO analgesic ladder. However, a percentage of patients persist feeling pain. These are patients with difficult-to-control pain who often benefit from interventional measures. An even smaller percentage of patients keep on feeling pain as a refractory symptom despite adequate therapeutic measures. In these cases, palliative sedation is indicated. We present the case of a young patient with refractory pain who required palliative sedation in a palliative care unit of a private institution in Montevideo

Executive summary of clinical practice guideline for the management of invasive diseases caused by Aspergillus: 2018 Update by the GEMICOMED-SEIMC/REIPI.

Aspergillus infection is a significant cause of morbi-mortality in an at-risk population. The Study Group of Fungal Infections (GEMICOMED) from the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC) has reviewed announcements made in invasive aspergillosis management. We have organized our recommendations in such a way as to provide a guide in resolving different clinical situations concerning the entire spectrum of invasive diseases caused by Aspergillus in various populations. Diagnostic approach, treatment and preventions strategies are outlined. It is not our aim that these guidelines supplant clinical judgment with respect to specific patients; however, it is our objective to perform a comprehensive summary of quality of care evidence for invasive aspergillosis management in different settings.

[Clinical perspectives on the management of bleeding in patients on oral anticoagulants: the DECOVER Study (DElphi Consensus on oral COagulation and therapy action reVERsal)]. / Perspectivas clínicas del manejo de la hemorragia en el paciente tratado con anticoagulante oral: estudio DECOVER.

OBJECTIVES: To evaluate the level of agreement between hematologists and emergency medicine physicians regarding the best clinical practices for managing bleeding and anticoagulant reversal. MATERIAL AND METHODS: Nationwide Spanish multicenter Delphi method study with a panel of experts on anticoagulation and the management of bleeding. Two survey rounds were carried out between April and September 2015. Consensus was reached when more than 75% of the panelists scored items in the same tertile. RESULTS: Fifteen hematologists and 17 emergency medicine specialists from 14 Spanish autonomous communities participated. Consensus was reached on the use of both hemodialysis and an activated prothrombin complex concentrate (PCC) to antagonize significant/major bleeding in patients taking dabigatran. Use of an activated PCC was considered sufficient for patients on rivaroxaban or apixaban. The panel did not consider any PCC to be both effective and safe. Tests for activated partial thromboplastin, thrombin, diluted thrombin, and ecarin clotting times were considered useful in patients treated with dabigatran. A specific anti-Xa activity assay was suggested for patients who developed bleeds while treated with rivaroxaban or apixaban. Specific antidotes for direct-acting oral anticoagulants would be useful when severe bleeding occurs according to 97% of the panelists. Such antidotes would substantially change current treatment algorithms. CONCLUSION: The points of consensus were generally in line with clinical practice guidelines, but the Delphi process revealed that there are aspects of the clinical management of bleeding that require unified criteria. The need for specific antidotes for direct-acting oral anticoagulants was emphasized.

OBJETIVO: Evaluar el grado de acuerdo entre hematólogos y urgenciólogos respecto a las mejores prácticas para el manejo de hemorragias y la reversión de la anticoagulación oral. METODO: Estudio Delphi multicéntrico español con médicos expertos en anticoagulación y manejo de hemorragias. Se realizaron dos rondas de preguntas entre abril y septiembre de 2015. Se obtenía consenso cuando el 75% o más de los panelistas puntuaban en el mismo tercil. RESULTADOS: Se encuestó a 15 hematólogos y 17 urgenciólogos de 14 comunidades autónomas. La hemodiálisis y la administración de concentrados de complejo protrombínico (CCP) activado fueron tratamientos consensuados para antagonizar una hemorragia relevante/mayor en pacientes tratados con dabigatrán. Para rivaroxabán y apixabán solo se consideró el CCP. El panel no valoró ningún CCP como eficaz y seguro a la vez. Los tiempos de tromboplastina parcial activado, trombina, ecarina y de trombina diluido se indicaron para pacientes tratados con dabigatrán y la actividad anti-Xa específica para los tratados con rivaroxabán y apixabán cuando presentan una hemorragia. Disponer de un antídoto específico para el tratamiento de los anticoagulantes orales de acción directa (ACOD) sería útil en caso de hemorragia grave (97%) y supondría un cambio sustancial en el algoritmo de tratamiento actual (97%). CONCLUSIONES: Los resultados estuvieron en general alineados con las guías de práctica clínica, pero mostraron que existen áreas de mejora en la unificación de criterios sobre el manejo de los pacientes con hemorragias, y destacan la necesidad de disponer de antídotos específicos para ACOD.

Classificação clínico-laboratorial para manejo clínico de trabalhadores expostos ao benzeno em postos de revenda de combustíveis / Clinical-laboratory classification for clinical management of workers exposed to benzene in gas stations

Resumo Introdução: trabalhadores de postos de revenda de combustíveis estão expostos a compostos orgânicos voláteis, dos quais se destaca o benzeno. O manejo clínico do amplo espectro de sinais e sintomas desses trabalhadores ainda é um desafio para assistência em saúde. Objetivo: apresentar proposta de classificação clínico-laboratorial baseada na análise de hemograma e na avaliação clínica dos trabalhadores, para orientar a conduta dos profissionais de saúde. Métodos: a classificação clínico-laboratorial foi definida a partir de critérios de hierarquização dos resultados das avaliações clínicas e de vigilância à saúde de modo a possibilitar a organização dos procedimentos e fluxos de atenção à saúde. Resultados: a proposta define o manejo clínico com base na classificação dos expostos ao benzeno em quatro níveis de alterações clínico-laboratoriais que determinam os procedimentos compatíveis com o grau da exposição e de seus efeitos à saúde: 1) sem alterações significativas; 2) alterações inespecíficas ou incompletas, 3) alterações clínicas e/ou laboratoriais; 4) alterações sugestivas de benzenismo. Conclusão: a proposta de classificação dos achados clínico-laboratoriais é potencialmente capaz de orientar a conduta médica na avaliação das condições de saúde e dos riscos da exposição ao benzeno e de subsidiar o monitoramento sistemático e contínuo necessário para a definição de rotinas assistenciais para os coletivos de trabalhadores.

Abstract Introduction: gas stations workers are exposed to volatile organic compounds, especially benzene. Clinical management of the broad spectrum of symptoms and signs observed in these workers is still a challenge for health care. Objective: to present a clinical-laboratory classification, based on hemogram analysis and clinical evaluation of workers exposed to benzene, as guidelines for health care professionals. Methods: the clinical-laboratory classification was defined based on priority-setting criteria for the results of clinical evaluations and health surveillance in order to allow the organization of health care flows and procedures. Results: the proposal defines the clinical management based on classification of workers exposed to benzene in four levels of clinical and laboratory alterations that determine procedures according to level of exposure and health effects: 1) without significant alterations; 2) unspecific or incomplete alterations; 3) clinical and/or laboratory alterations; and 4) alterations suggesting benzene poisoning. Conclusion: the proposal for classification of clinical and laboratory findings is potentially able to guide medical practice in the assessment of health conditions and risks of benzene exposure, and subsidize the systematic and continuous monitoring necessary for establishing health care practices offered to workers.

Manejo clínico e as produções de saber na cultura como destinos da pulsão de saber / Clinical management and knowledge productions in the culture as destinies of the drive to know

O tema deste trabalho é o manejo da técnica psicanalítica e as produções de saber na Cultura na obra freudiana. Nossa hipótese é que ambos são destinos da pulsão de saber, apontada por Freud em "Três ensaios sobre a teoria da sexualidade". O objetivo foi revisar textos sobre a técnica, publicados entre 1910 e 1915, e textos sobre cultura de 1927 a 1933 para verificar como Freud trabalhou o saber em torno desses temas. Encontramos tanto nos textos tardios sobre a cultura como nos artigos sobre a técnica o caráter investigativo do sujeito. A pesquisa nos leva a destacar, na obra freudiana, uma nova inflexão quanto às relações entre o sujeito e o saber, na medida em que revela aí o papel do desejo.(AU)

This theme of this study is the management of the psychoanalytical technique and the productions of knowledge within Culture in Freudian works. Our hypothesis here is that both of them are destinies of the drive to know, pointed out by Freud in "Three essays on the Theory of Sexuality." the objective was to review texts about technique, published between 1910 and 1915, and others on culture between 1927 and 1933 in order to verify how Freud discussed knowledge within these themes. In both the later texts about culture and in the articles about technique, we have come across the subject's investigative character. Thus, it is our understanding that psychoanalysis research provides evidence of a subject knowing in the practice and in the culture, which makes the drive to know very operative in Freud's work.(AU)

Manejo clínico da pré-hipertensão / Pre-hypertension clinical management

Há uma evidente mudança de paradigma em relação ao entendimento da elevação da pressão arterial como consequência de uma série de alterações estruturais e funcionais em nossas artérias. Pequenos aumentos nos valores pressóricos concorrem ao longo de vários anos para o aumento da morbimortalidade cardiovascular. Nesse contexto, discute-se, hoje, a necessidade de, além do tratamento não medicamentoso, utilizar fármacos anti-hipertensivos em alguns cenários da pré-hipertensão (PH). Talvez a perspectiva seja de atuar impedindo a elevação da pressão arterial sem ter de aguardar que danos ao nosso sistema cardiovascular já tenham acontecido

There is a clear paradigm shift in understanding the elevation of blood pressure because of a series of structural and functional changes in our arteries. Small increases in blood pressure values contribute over several years to the increase of cardiovascular morbidity and mortality. In this context, nowadays we discuss the need, in addition to non-drug treatment, of antihypertensive drugs in some scenarios of prehypertension. Perhaps the perspective is of acting to prevent the elevation of blood pressure without having to wait for damage to our cardiovascular system that has already happened.

Spanish consensus for the management of patients with advanced radioactive iodine refractory differentiated thyroid cancer.

BACKGROUND: Approximately one third of the patients with differentiated thyroid cancer (DTC) who develop structurally-evident metastatic disease are refractory to radioactive iodine (RAI). Most deaths from thyroid cancer occur in these patients. The main objective of this consensus is to address the most controversial aspects of management of these patients. METHODS: On behalf of the Spanish Society of Endocrinology & Nutrition (SEEN) and the Spanish Group for Orphan and Infrequent Tumors (GETHI), the Spanish Task Force for Thyroid Cancer, consisting of endocrinologists and oncologists, reviewed the relevant literature and prepared a series of clinically relevant questions related to management of advanced RAI-refractory DTC. RESULTS: Ten clinically relevant questions were identified by the task force. In answering to these 10 questions, the task force included recommendations regarding the best definition of refractoriness; the best therapeutic options including watchful waiting, local therapies, and systemic therapy (e.g. kinase inhibitors), when sodium iodide symporter (NIS) restoration may be expected; and how recent advances in molecular biology have increased our understanding of the disease. CONCLUSIONS: In response to our appointment as a task force by the SEEN and GHETI, we developed a consensus to help in clinical management of patients with advanced RAI-refractory DTC. We think that this consensus will provide helpful and current recommendations that will help patients with this disorder to get optimal medical care.

Tumores raros en niños y adolescentes / Rare tumors in children and adolescents

Los tumores infrecuentes están definidos como cánceres pediátricos con una incidencia anual <2 casos por millón. Aunque son percibidos como raros, constituyen el 15% de todos los cánceres en menores de 20 años y 30% de todos los tumores de pacientes entre 15 y 19 años. Se han desarrollado proyectos cooperativos nacionales e internacionales pediátricos con el fin de mejorar el manejo clínico y la investigación básica en estos tumores. Revisamos los procesos desarrollados y las dificultades que se han enfrentado, como bajas tasas de registro y participación en bancos de tumores y estudios clínicos. Esta experiencia inicial ha permitido desarrollar estrategias alternativas que permitirían implementar una iniciativa similar para América Latina. La experiencia demuestra la factibilidad de cooperación multidisciplinaria a nivel nacional y sugiere que se pueden realizar estudios internacionales, que aumenten nuestro entendimiento de la biología de estos tumores, mejorando los resultados de tratamiento de niños y adolescentes con cánceres infrecuentes.

Although perceived as rare, infrequent tumors, defined as childhood solid malignancies with an annual incidence < 2/million and not considered in other clinical trials, account for 15% of all cancers in patients younger than age 20 and for 30% of all tumors in patients ages 15 to 19. National and international cooperative projects on rare paediatric tumours have been developed to improve the clinical management and basic research on these tumors. We reviewed the process developed and the problems it had to face, as low rates of registration, low levels of participation in tumor banking, and clinical trials. This initial experience has allowed to develop alternative strategies that could help to launch a latinamerican initiative. Experience demonstrates the feasibility of a national multidisciplinary cooperation and suggests that international studies can be performed, increasing our knowledge to understand the biology and improving the treatment results of young patients with rare cancers.