Diagnostic, treatment, and follow-up of osteoporosis-position statement of the Latin American Federation of Endocrinology.

The Latin American Federation of Endocrinology position statement on osteoporosis was developed by endocrinologists from 9 countries. It encompasses the definition, diagnosis, treatment, and follow-up of the disease, the identification of barriers to healthcare, and proposals to improve the disease care in the region. INTRODUCTION: There is a gap in the understanding of osteoporosis in Latin America. The objective of this work is to state the position of the Latin American Federation of Endocrinology on osteoporosis care in postmenopausal women to better bridge this gap. METHODS: An experts' panel was formed comprising of 11 endocrinologists from 9 countries. A data search was conducted with a conceptual approach and data selection was based on the hierarchy of the EBHC pyramid. Unpublished data was considered for local epidemiological data and expert opinion for the identification of barriers to healthcare. An expert consensus based on the Delphi methodology was carried out. Experts were asked to respond on a 5-point Likert Scale to two provided answers to guiding questions. RESULTS: Consensus was agreed on the answer for the questions with the higher median on the Likert scale and synthetized on 16 statements covering the definition of osteoporosis, diagnostic approach, treatment options, and follow-up. Besides clinical topics, unmet needs in osteoporosis were identified in relation to local epidemiological data, barriers to treatment, and misclassification of programs within health systems. CONCLUSIONS: Through a process based on recognized methodological tools, FELAEN's position on osteoporosis was developed. This made it possible to state an optimum scenario for the care of the disease and helped to identify knowledge gaps. There is great variability in the approach to osteoporosis in Latin America and barriers in all the stages of healthcare persist.

Endocarditis de Libman-Sacks de válvulas nativas derechas en contexto de síndrome antifosfolípido y lupus eritematoso sistémico: ¡cuando el tratamiento marca la diferencia! / Libman-Sacks endocarditis of right native valves in the context of antiphospholipid syndrome and systemic lupus erythematosus: when treatment makes a difference!

We report the case of a 54 years old woman with antiphospholipid syndrome in irregular therapy, admitted due to exertional dyspnea and orthopnea. The transthoracic echocardiogram showed dilated cardiomyopathy with biventricular systolic dysfunction, pulmonary hypertension and masses related to the pulmonary and tricuspid valve without autonomic movement. The crops and white count were normal, with alteration of the SAF test, in addition, SLE was diagnosed. It was started therapy for heart failure, steroids, rituximab and anticoagulation, with improving of the symptoms. The echocardiographic control showed remission of the tricuspid masses and similar dimensions of the pulmonary mass.

Presentamos el caso de una mujer de 54años con síndrome antifosfolípido en terapia irregular, quien ingresa por disnea de esfuerzo que progresó a ortopnea. El ecocardiograma transtorácico evidenció cardiopatía dilatada con disfunción sistólica biventricular, hipertensión pulmonar y masas relacionadas con válvula pulmonar y tricúspide sin movimiento autonómico. Los cultivos y cuenta blanca estaban normales, con alteración de las pruebas del SAF, haciéndose, además, diagnóstico de lupus eritematoso sistémico. Se inició terapia para insuficiencia cardiaca, esteroides, rituximab y anticoagulantes, mejorando la clínica. El ecocardiograma control mostró remisión de las masas tricuspídeas y similares dimensiones de la masa pulmonar.

Helicobacter pylori identification: a diagnostic/confirmatory method for evaluation.

The Helicobacter pylori extra gastric reservoir is probably the oral cavity. In order to evaluate the presence of this bacterium in patients with periodontitis and suspicious microbial cultures, saliva was collected from these and non-periodontitis subjects. PCRs targeting 16S rRNA gene and a 860 bp specific region were performed, and digested with the restriction enzyme DdeI. We observed that the PCR-RFLP approach augments the accuracy from 26.2 % (16/61), found in the PCR-based results, to 42.6 % (26/61), which is an excellent indicator for the establishment of this low-cost procedure as a diagnostic/confirmatory method for H. pylori evaluation.

Insuficiencia mitral isquémica: utilidad de la ecocardiografía en su evaluación y tratamiento / Ischemic mitral regurgitation: utility of echocardiography in evaluation and treatment

La regurgitación mitral isquémica (RMI) es una complicación común de la enfermedad arterial coronaria que produce insuficiencia cardíaca en un alto porcentaje de pacientes. Puede presentarse como una verdadera emergencia cuando es causada por un infarto del miocardio con ruptura del músculo papilar asociada a shock cardiogénico. La insuficiencia mitral isquémica crónica es una complicación frecuente trasel infarto agudo del miocardio, aparece aproximadamente en 20% de los casos y es mucho más probable en el infarto agudo del miocardio de localización inferior (38%) que en el anterior (10%). Es producida por una integración de varios mecanismos que influyen en su desarrollo y que básicamente están relacionados con remodelado local o global del ventrículo izquierdo, con disfunción y disincronía del mismo. Su evaluación adecuada y rápida puede influir en el éxito de su tratamiento y en el mejor pronóstico de los pacientes. Una indicación quirúrgica precoz, actuando sobre ventrículos menos remodelados, y la innovación en el arsenal de dispositivos y técnicas quirúrgicas permitirán una corrección exitosa y duradera con baja mortalidad hospitalaria. En este sentido, las nuevas exploraciones desarrolladas por la ecocardiografía han adquirido una gran importancia al permitir evaluar la severidad de la insuficiencia mitral, el grado de disfunción local o global del ventrículo izquierdo y el estado del aparato valvular mitral lo que ha hecho del método la exploración más confiable y necesaria en estos pacientes. Revisamos la utilidad y el papel del ecocardiograma en el estudio de la insuficienciamitral isquémica.

Ischemic mitral regurgitation is a common complication of coronary heart disease that leads to heart failure in a high percentage of patients. It can present as a real emergency when it is caused by a myocardial infarction with rupture of a papillary muscle resulting in cardiogenic shock. Chronic ischemic mitral regurgitation is a frequent complication after a myocardial infarction in 20% of cases and it is even more frequent when the myocardial infarction is localized in the inferior wall (38%) than the anterior wall (10%). This complication is the result of the interaction of several mechanisms that are related to local or global remodeling of the left ventricle and associated left ventricle dysfunction and desynchronization. Prompt and precise evaluation can be of vital importance for successful treatment and a better prognosis. Early surgery in less remodeled ventricles, and innovation in devices and surgical techniques will lead to long-lasting successful correction with low in-hospital mortality. Therefore, new developments in echocardiography have acquired substantial significance for the evaluation of the severity of mitral insufficiency, the grade of local or global dysfunction of the left ventricle and the state of the mitral valve apparatus, rendering this method more reliable and indispensable for these patients. We reviewed the utility and role of echocardiography in the evaluation ofischemic mitral regurgitation.

Rol del ecocardiograma en el estudio de la hipertensión arterial pulmonar / Role of echocardiography in the study of pulmonary arterial hypertension

La presencia de una presión arterial pulmonar media >25 mmHg en reposo y >30 mmHg en ejercicio, con una presión en cuña igual o menor de 15 mmHg y una resistencia vascular pulmonar >3 mmHg /L/ min (Uds. Wood) condiciona una entidad clínica heterogenea denominada hipertensión arterial pulmonar que tiene un amplio rango de causas o enfermedades que llevan a cambios estructurales de las pequeñas arterias pulmonares ocasionando un aumento progresivo de la presión arterial pulmonar y de la resistensia vascular pulmonar, produciendo finalmente una sobrecarga del ventrículo derecho, insuficiencia cardíaca y muerte. Es una entidad clínica con síntomas muy inespecíficos en sus etapas más tempranas y se necesita un buen criterio clínico para llegar a su diagnóstico más rápidamente. En este sentido es que adquiere valor el uso de la ecocardiografía, método que permitirá o solo cuantificar los valores de presión arterial pulmonar, sino también determinar la causa del problema, una adecuada evaluación anatómica y funcional del lecho pulmonar y de las cavidades derechas del corazón, predecir el pronostico de estos pacientes y vigilar el efecto terapéutico de tratamientos muy específicos al ayudar a detectar estados preclínicos de la enfermedad. Revisamos la utilidad y el papel del ecocardiograma en el estudio de la hipertensión arterial pulmonar.

The presence of Medium Arterial Pulmonary Pressure >25 mmHg at rest or >30mmHg during exercise associated with a wedge pulmonary pressure equal or less than 15mmHg, and a Pulmonary Vascular Resistance > 3 mmHg/L/min (Wood units) entails a heterogeneous clinical entity known as Pulmonary Arterial Hipertension which has a very wide spectrum of causes or diseases which produce estructural changes in the walls of the small pulmonary arteries causing a progressive increase of the arterial pulmonary pressure as well as the pulmonary vascular resistence, ultimately producing right ventricular overload, heart failure and death. It is a clinical entitywith very unspecific symptoms at the early stages. Wich makes the physician´s good clinical criteria needed to diagnose itsooner. In this way comes to great value the use of echocardiography, method that would allow not only to measure the arterial pulmonary pressure but would help to carify the cause of the disease, getting an adequate anatomical and funtional evaluation of the pulmonary bed and right heart chambers, predict the outcome in these patients by detecting pre-clinic stages of the disease. We reviewed the utility and role of the Echocardiogram in the study of Pulmonary Arterial Hypertension.

Treatment of Papillon-Lefèvre syndrome periodontitis.

BACKGROUND, AIMS: Conventional mechanical treatment of Papillon-Lefèvre syndrome periodontitis has a poor prognosis. This report describes an effective antimicrobial treatment of rapidly progressing periodontitis in an 11-year old girl having Papillon-Lefèvre syndrome. METHOD: Clinical examination included conventional periodontal measurements and radiographic analysis. Occurrence of major suspected periodontopathic bacteria was determined by selective and non-selective culture and by polymerase chain reaction (PCR) identification. Presence of cytomegalovirus and Epstein-Barr type 1 virus was determined by a nested-PCR detection method. Therapy included scaling and root planing, oral hygiene instruction, and systemic amoxicillin-metronidazole therapy (250 mg of each/3 times daily/10 days) which, based on follow-up microbiological testing, was repeated after 4 months. Supportive periodontal therapy took place at 2 visits during a 16-month period. RESULTS: At baseline, 10 of 22 available teeth demonstrated severe periodontal breakdown. At 16 months, probing and radiographic measurements revealed no teeth with additional attachment loss, and several teeth exhibited significant reduction in gingivitis and pocket depth, increase in radiographic alveolar bone height and clinical attachment level, and radiographic evidence of crestal lamina dura. Baseline subgingival microbiota included Actinobacillus actinomycetemcomitans (3.4% of total isolates), Prevotella nigrescens (16.4%), Fusobacteriumnucleatum (14.3%) and Peptostreptococcus micros (10.6%), as well as cytomegalovirus and Epstein-Barr type 1 virus. At termination of the study, culture and PCR examinations showed absence of A. actinomycetemcomitans, P. micros and herpesviruses, and P. nigrescens and F.nucleatum each comprised less than 0.1 % of subgingival isolates. CONCLUSION: This study suggests that controlling the periodontopathic microbiota by appropriate antibiotic and conventional periodontal therapy can arrest Papillon-Lefèvre syndrome periodontitis.

Microbiological features of Papillon-Lefèvre syndrome periodontitis.

Papillon-Lefevre syndrome patients exhibit hyperkeratosis palmo-plantaris and severe periodontitis. The syndrome is an autosomal recessive trait, but the mechanism of periodontal destruction is not known. This report presents the clinical and microbiological features of an 11-year old girl with Papillon-Lefèvre syndrome. Clinical examination included conventional periodontal measurements and radiographic analysis. In samples from 3 deep periodontal lesions, the occurrence of major suspected periodontopathic bacteria was determined by selective and non-selective culture and polymerase chain reaction (PCR) identification, and the presence of cytomegalovirus and Epstein-Barr type 1 virus by a nested-PCR detection method. 10 of 22 available teeth demonstrated severe periodontal breakdown. Major cultivable bacteria included Actinobacillus actinomycetemcomitans (3.4% of total isolates), Prevotella nigrescens (16.4%), Fusobacterium nucleatum (14.3%) and Peptostreptococcus micros (10.6%). A. actinomycetemcomitans, P. nigrescens, Porphyromonas gingivalis and Eikenella corrodens were identified by PCR analysis. The patient's non-affected parents and older brother revealed several periodontal pathogens but not A. actinomycetemcomitans. The viral examination demonstrated cytomegalovirus and Epstein-Barr type 1 virus in the subgingival sample of the Papillon-Lefèvre syndrome patient. The father and brother yielded subgingival cytomegalovirus but not Epstein-Barr type 1 virus. We hypothesize that human herpesviruses in concert with A. actinomycetemcomitans play important rôles in the development of Papillon-Lefèvre syndrome periodontitis.

[Adrenal gland masses and Addison's disease of tuberculous origin: apropos of 2 cases]. / Masas suprarrenales y enfermedad de Addison de origen tuberculoso: a propósito de dos casos.

Two cases of confirmed tuberculous Addison disease, with an increase in size of the adrenal glands are presented. One patient presented also a renal adenocarcinoma; this association is very rare given the small frequency of these diseases. Based on these two cases we emphasize the utility of puncture aspiration with a fine needle (PAFN), echography and TC Scan in the study of Addison disease.