Concordancia de la utilización de teriparatide o ácido zoledrónico en pacientes con osteoporosis con recomendaciones internacionales, en una empresa de salud de Colombia / Concordance in the use of teriparatide or zoledronic acid in patients with osteoporosis with international recommendations, in a health company of Colombia

RESUMEN Introducción: Los bifosfonatos son la primera línea de tratamiento para la osteoporosis; siendo el zolendronato el más efectivo. La teriparatide (agente anabólico), dado su alto costo, debería restringirse al tratamiento de pacientes más afectados y luego de un adecuado tratamiento con bifosfonatos. Objetivo: Establecer el porcentaje de pacientes con osteoporosis, en tratamiento con teriparatide o ácido zoledrónico en Colombia, que se ajusta a recomendaciones de organizaciones internacionales. Método: Estudio de utilización de medicamentos retrospectivo, enero 2012-diciembre 2015, en pacientes con osteoporosis y en tratamiento con teriparatide o ácido zoledrónico. Se revisó información sociodemográfica y clínica, y el grado de concordancia del uso de teriparatide o ácido zoledrónico con recomendaciones de tres guías clínicas internacionales: National Osteoporosis Foundation, National Institute for Health and Clinical Excellence y Scottish Intercollegiate Guidelines Network. Resultados: Se incluyeron 103 pacientes, edad promedio en años (desviación estándar) 78 (10,4), 74,8% mujeres. La osteoporosis posmenopáusica (61,2%) y osteoporosis no especificada (20,4%), ambas con o sin fractura patológica, fueron los diagnósticos principales. En el 36,9%, la utilización de teriparatide y ácido zoledrónico fue acorde a las recomendaciones de las guías revisadas. La utilización de estos medicamentos en diagnósticos diferentes a osteoporosis posmenopáusica (43,7%) o como farmacoterapia inicial (36,9%) fueron las principales causas para ausencia de concordancia. Conclusiones: Sólo en el 36,9% de los casos revisados, la utilización de teriparatide o ácido zoledrónico se ajusta a las guías de organizaciones internacionales. La ausencia de concordancia se debe, especialmente a uso en diagnósticos diferentes a osteoporosis posmenopáusica y como farmacoterapia inicial.

ABSTRACT Introduction: Bisphosphonates are the first-line treatment of osteoporosis in which zoledronate is the most effective. Teriparatide (anabolic agent), due to high cost, should be restricted to the treatment of the most affected patients and after adequate treatment with bisphosphonates. Objective: To establish the percentage of patients with osteoporosis, in treatment with teriparatide or zoledronic acid in Colombia, that meet international organizations recommendations. Method: Retrospective drug utilization study, January 2012-December 2015, in patients with osteoporosis and treatment with teriparatide or zoledronic acid. The socio-demographic and clinical information and the degree of concordance of teriparatide or zoledronic acid use with recommendations from three international clinical guidelines were reviewed: National Osteoporosis Foundation, National Institute for Health and Clinical Excellence, and Scottish Intercollegiate Guidelines Network. Results: 103 patients were included, average age in years (standard deviation) 78 (10.4), 74.8% women. Postmenopausal osteoporosis (61.2%) and unspecified osteoporosis (20.4%), both with or without pathological fracture, were the main diagnoses. In 36.9%, the use of teriparatide and zoledronic acid was accord with the guidelines recommendations revised. The use of these drugs in diagnoses different to postmenopausal osteoporosis (43.7%) or initial pharmacotherapy (36.9%) were the main causes for concordance absence. Conclusions: Only 36.9% of the reviewed cases, the use of teriparatide or zoledronic acid was accord with international organizations guideliness. Concordance absence is due especially both to the use in diagnoses different to postmenopausal osteoporosis and initial pharmacotherapy.

Is there a relevance of suction drainage in non-septic wrist surgery?

INTRODUCTION: No rational argument leads to conclude to the benefit or the innocuousness of drainage in non-septic wrist surgery. HYPOTHESIS: The goal of this study was to validate the hypothesis that for those indications drainage is unnecessary. MATERIAL AND METHOD: We reviewed 1001 consecutive cases, concerning 885 patients, 58 years old in average. RESULTS: Out of 1001 procedures, 9 patients were operated on both sides, 145 were operated twice of which 130 for the implantation and then the removal of surgical material. None were reoperated for hematomas. Three patients were initially treated for an osteosynthesis using an anterior plate of distal radius and secondarily reoperated due to sepsis, one of them twice. The material was removed from two patients. The average time of tourniquet for those 3 osteosynthesis was significantly superior (84.33min) to the average time for the 595 other anterior distal radius plates (45.35min). CONCLUSION: The results of our study show that suction drainage in non-septic wrist surgery is unnecessary. LEVEL OF EVIDENCE: III descriptive retrospective study.

Results of conservative treatment of volar plate sprains of the proximal interphalangeal joint with and without avulsion fracture.

The prognosis of isolated volar plate sprains of the proximal interphalangeal (PIP) joint is related to the extension deficit. Some consider an associated avulsion fracture as a sign of severity. The goal of this study was to find out whether the outcomes of conservative treatment in PIP volar plate injury was impacted by the presence of an avulsion fracture. Our series included 75 patients, 27 years old on average, of which 58 were men. All sprains were stable. The X-rays were normal in 52 cases (group 1); an avulsion fracture was found in 23 cases (group 2). The patients were treated by buddy taping during the day and a straight finger splint at night for 3 weeks. At the last follow-up, no significant difference was found between the two groups regarding pain, extension/flexion range of motion or edema. The results of this study show that the prognosis of conservative treatment of PIP volar plate injuries does not depend on the presence of an avulsion fracture.

Establishing a reproducible protocol for measuring index active extension strength.

The goal of this study was to establish a reproducible protocol to measure active extension strength in the index finger. The secondary objectives consisted in correlating the independent or associated index extension strength to the other fingers force of contraction of the extensor indicis propius with hand dominance. The population studied consisted of 24 healthy volunteers, including 19 women and 20 right-handed individuals. The independent and dependent index extension strength in each hand was measured three times with a dynamometer by three examiners at Day 0 and again at Day 7. Intra and inter-examiner reproducibility were, respectively, >0.90 and >0.75 in all cases. The independent extension strength was lower than the dependent one. There was no difference between the independent index extension strength on the dominant and non-dominant sides. The same was true for the dependent strength. Our results show that our protocol is reproducible in measuring independent and dependent index extension strength. Dominance did not come into account. LEVEL OF EVIDENCE: II.

The role of self-efficiency toward pain following surgical treatment of carpal tunnel syndrome.

Some very poor results after carpal tunnel syndrome (CTS) surgery are difficult to explain. The main hypothesis of this study was that a relationship exists between self-efficiency toward pain and the difference between pre-operative and post-operative pain. The secondary hypothesis was that a relationship exists between self-efficiency toward pain and the pre-operative and post-operative QuickDASH score. The records of 64 patients operated for purely subjective CTS were reviewed. The evaluation consisted in determining self-efficacy beliefs from two PSEQ2 questions (1: I can still accomplish most of my goals in life, despite the pain; 2: I can live a normal lifestyle, despite the pain), pain levels and the QuickDASH score. There was an inversely proportional relationship between the pre-operative PSEQ2 and pain on one hand, and post-operative pain and the pre-operative QuickDASH score on the other hand. We found no correlation between the pre-operative PSEQ2 and post-operative QuickDASH score. Self-efficiency beliefs as measured by PSEQ2 help to predict pain levels after surgical CTS treatment in the absence of sensory and/or motor deficits and/or associated morbidity.

Resistance of primary microsurgical repair of palmar digital nerves to finger mobilization: A cadaver study.

The aim of this study was to assess the resistance of microsurgically repaired proper palmar digital nerves (PPDN) to mobilization. Thirty-nine PPDN from fresh forearms cadavers were transected and then sutured using 10/0 nylon. After skin closure, each finger was forcefully flexed and extended 10 times. Out of the 39 repaired nerves, two were elongated and four were ruptured; this amounts to a 15.38% complication rate. We recommend immobilization of nerve repairs, although this contradicts most recent studies.

Technical feasibility of robot-assisted minimally-invasive neurolysis of the lateral cutaneous nerve of thigh: About a case.

To limit the risk of iatrogenic neuroma and recurrence after surgical treatment of meralgia paresthetica, some authors have recently developed a technique of endoscopic neurolysis of the lateral cutaneous nerve of thigh (LCNT) below the level of the inguinal ligament. We report the case of a robot-assisted endoscopic technique underneath the inguinal ligament. A 62-year-old patient suffering of idiopathic meralgia paresthetica for the past 18 months received a Da Vinci robot-assisted minimally-invasive 10cm long neurolysis, of which 1/3 was situated above the level of the inguinal ligament and 2/3 below it. The patient was discharged the following day without complications. At 6-months follow-up the pain was rated 0/10 compared to 5/10 pre-operatively. Robot-assisted endoscopic neurolysis of the LCNT retains the advantages of conventional endoscopy and enables to approach the nerve in the most frequently compressed zone underneath the inguinal ligament. The three-dimensional view offered by robotic surgery facilitates the dissection. The superiority of this technique remains to be demonstrated by comparing it to conventional techniques.

Conceptos esenciales de la EPOC, prevalencia e impacto en América Latina / Essential concepts, prevalence, and impact of COPD in Latin America / Conceitos essenciais da EPOC, prevalência e impacto na América Latina

La enfermedad pulmonar obstructiva crónica es un proceso frecuente, prevenible y tratable. Se caracteriza por la limitación del flujo aéreo progresiva y parcialmente reversible que puede o no estar acompañada de síntomas, exacerbaciones y comorbilidades; su tratamiento implica tomar medidas farmacológicas y no farmacológicas, busca aliviar síntomas y retrasar la progresión y prevenir las exacerbaciones, estas últimas, en su mayoría, de origen infeccioso, deterioran la calidad de vida, la función pulmonar y aumentan la mortalidad y los costos. Constituye un problema mayor de salud pública y una de las principales causas de morbimortalidad cuya carga se extiende más allá de los pacientes, es también una de las principales causas de años de vida ajustados a discapacidad. Se calcula que 80 millones de personas en el mundo padecen formas moderadas y severas y más de tres millones de personas murieron por la misma en 2005. Las exacerbaciones son especialmente significativas pues deterioran el pronóstico del paciente y su calidad de vida de manera proporcional a la severidad de la exacerbación tanto a corto como a largo plazo, pues se asocian con un más acelerado deterioro de la función pulmonar y con una recuperación más retardada e interrumpida, y, aumentan la necesidad de consultas no programadas y hospitalizaciones y con ello los costos. En EE.UU se proyecta que los costos totales por EPOC para 2010 fueron de 49.9 billones de dólares, en Colombia se ha estimado un costo promedio por exacerbación de 98 dólares que pueden ascender a casi 700 dólares en las hospitalizaciones.

Chronic obstructive pulmonary disease is a frequent, preventable, and treatable process. It is characterized by progressive, partially reversible airway flow obstruction that can be associated with symptoms, exacerbations, and comorbidities. Its treatment involves both pharmacologic and non-pharmacologic measures and aims to alleviate symptoms, delay disease progression, and prevent exacerbations; the latter are mainly infectious in origin and deteriorate pulmonary function, life quality, and increase mortality and costs. Globally, it constitutes a major public health issue and is one of the main causes of morbimortality in which the burden extends beyond the patients; it is also one of the main causes of disability-adjusted life years in developed and in developing countries. It has been estimated that 80 million people in the world have moderate to severe forms of COPD while over 3 million died of this cause in 2005. Exacerbations are especially significant because the deterioration of the patient's prognosis and quality of life is proportional to the severity of the exacerbation. In the US, it has been projected that the total costs of COPD for 2010 were about 49.9 billion dollars, while in Colombia it has been estimated that the average cost for an exacerbation is about 98 dollars and can rise up to nearly 700 dollars when hospitalization is required.

A doença pulmonar obstrutiva crónica é um processo frequente, evitável e tratável. Se caracteriza pela limitação do fluxo aéreo progressiva e parcialmente reversível que pode ou não estar acompanhada de sintomas, exacerbações e co-morbilidades; seu tratamento implica tomar medidas farmacológicas e não farmacológicas, busca aliviar sintomas e retrasar a progressão e prevenir as exacerbações, estas últimas, em sua maioria, de origem infeccioso, deterioram a qualidade de vida, a função pulmonar e aumentam a mortalidade e os custos. Constitui um problema maior de saúde pública e uma das principais causas de morbimortalidade cuja carga se estende além dos pacientes, é também uma das principais causas de anos de vida ajustados a incapacidade. Se calcula que 80 milhões de pessoas no mundo padecem formas moderadas e severas e mais de três milhões de pessoas morreram pela mesma em 2005. As exacerbações são especialmente significativas pois deterioram o prognóstico do paciente e sua qualidade de vida de maneira proporcional à severidade da exacerbação tanto a curto como a longo prazo, pois se associam com um mais acelerado deterioro da função pulmonar e com uma recuperação mais retardada e interrompida, e, aumentam a necessidade de consultas não programadas e hospitalizações e com isto os custos. Nos E.U.A se projeta que os custos totais por EPOC para 2010 foram de 49.9 bilhões de dólares, na Colômbia se há estimado um custo médio por exacerbação de 98 dólares que podem ascender a quase 700 dólares nas hospitalizações.

Surgery improves survival in elderly with breast cancer. A study of 465 patients in a single institution.

INTRODUCTION: Breast cancer treatment in elderly patients is controversial. This single-centre study was conducted to review the treatment and outcomes for octogenarian women treated for breast cancer. METHODS: Data from all patients aged 80 years or more with primary breast cancer treated at our institution between 1995 and 2012 were included. Patients with carcinoma in-situ (stage 0) and advanced breast cancer (stage IV) were excluded. RESULTS: The study population consisted of 369 patients (median age 84 years). A total of 277 (75%) patients underwent surgical treatment (PST) and 92 (25%) received primary endocrine treatment (PET). Prognostic factors (HER-2, tumour grade, lymphovascular invasion and subsequent adjuvant therapy) were homogeneously distributed in both groups. PST and PET were stratified according to stage: 273 (66%) patients with early stage disease (I, IIA, IIB) and 96 (34%) with locally advanced disease (IIIA, IIIB, IIIC). Patients were followed-up for a median of 63 months. In patients with early stage disease, the mean breast cancer-specific survival (BCSS) was 109 months (95% CI = 101-115) in PST patients, and 50 months (95% CI = 40-60) in PET patients (P < 0.01). Conversely, for patients with locally advanced breast cancer, there was no significant difference in BCSS between the surgical and non-surgical groups. In the PST group, BCSS and disease-free survival were significantly better among patients who underwent standard surgical treatment than among those who received suboptimal treatment. There were no differences in the Charlson comorbidity index scores between the PST and PET groups. CONCLUSION: In women ≥80 years with early-stage breast cancer, standard surgical treatment was associated with a better BCSS when compared with PET.

The superparamagnetic iron oxide is equivalent to the Tc99 radiotracer method for identifying the sentinel lymph node in breast cancer.

BACKGROUND: Preoperative injection of Tc99 is standardly performed before sentinel lymph node biopsy (SLN) for breast cancer. Multiple questions have arisen concerning appropriate technique for SLNBs including site of injection, timing and injection material. The aim of this study was to assess the concordance between a new method, superparamagnetic iron oxide (SPIO) and the Tc99 radiotracer to identify the SLN in early breast cancer. MATERIAL AND METHODS: Between July 2013 and March 2014, 120 patients with clinically node negative early breast cancer were included in the study. Patients were injected the day before the radiotracer for lymphoscintigraphy and injected the SPIO subareolar intraoperatively. SLN was excised if it was radioactive, magnetic or palpable. Patients signed an inform consent. RESULTS: There was no drainage by either technique in 2 patients, so this leaves 118 patients for further analysis. Detection rate by Tc 99 was successful in 113 (95.7%%) patients and by SPIO in 116 (98.3%). Concordance rates per patient between techniques was 98.2%. The SLN was positive in 36 (30%) patients. Of this, SLN positivity was detected by both techniques in 32 patients. Mean number of SLNs by 99Tc and SPIO were 1.9 and 2.21 respectively (p = 0.001). DISCUSSION: Detection of SLNs with SPIO allows for easy identification of axillary nodes, at a frequency not inferior to the radiotracer. It is an oncologically safe procedure, facilitates patients and operative room management and can be used to reliably identify SLNs in breast cancer.

Bovine enterovirus 2: complete genomic sequence and molecular modelling of a reference strain and a wild-type isolate from endemically infected US cattle.

Bovine enteroviruses are members of the family Picornaviridae, genus Enterovirus. Whilst little is known about their pathogenic potential, they are apparently endemic in some cattle and cattle environments. Only one of the two current serotypes has been sequenced completely. In this report, the entire genome sequences of bovine enterovirus 2 (BEV-2) strain PS87 and a recent isolate from an endemically infected herd in Maryland, USA (Wye3A) are presented. The recent isolate clearly segregated phylogenetically with sequences representing the BEV-2 serotype, as did other isolates from the endemic herd. The Wye3A isolate shared 82 % nucleotide sequence identity with the PS87 strain and 68 % identity with a BEV-1 strain (VG5-27). Comparison of BEV-2 and BEV-1 deduced protein sequences revealed 72-73 % identity and showed that most differences were single amino acid changes or single deletions, with the exception of the VP1 protein, where both BEV-2 sequences were 7 aa shorter than that of BEV-1. Homology modelling of the capsid proteins of BEV-2 against protein database entries for picornaviruses indicated six significant differences among bovine enteroviruses and other members of the family Picornaviridae. Five of these were on the 'rim' of the proposed enterovirus receptor-binding site or 'canyon' (VP1) and one was near the base of the canyon (VP3). Two of these regions varied enough to distinguish BEV-2 from BEV-1 strains. This is the first report and analysis of full-length sequences for BEV-2. Continued analysis of these wild-type strains should yield useful information for genotyping enteroviruses and modelling enterovirus capsid structure.

An integrated malaria control program with community participation on the Pacific Coast of Colombia.

The study focuses on integrated malaria control in 23 communities on the Pacific Coast of Colombia, with several elements of an ecosystem approach to human health, including malaria-related sociopolitical, ecological, and economic factors. The program fostered community participation. The program presented here had 2 components: implementation and research. The first was conducted in 23 communities, 21 of which lacked adequate health services in terms of education, community participation, prompt diagnosis and complete treatment, and vector control. Research focused on specific vector control measures and the current national health services decentralization process. The project: 1) created a malaria prevention culture in the community; 2) avoided deaths from malaria (no fatal cases in the 3-year period, compared to 5-8 deaths a year previously); 3) avoided cases of cerebral malaria (no cases, as compared to 90-110 per year previously); 4) reduced malaria incidence by 45.36%; 5) decreased length of sick leave from 7.52 to 3.7 days; 6) established a permanent network of microscope technicians and 2-way radio communications; 7) integrated work by local, regional, and outside institutions; 8) demonstrated efficacy of insecticide-impregnated bednets to reduce malaria transmission.

PCR with Paracoccidioides brasiliensis specific primers: potential use in ecological studies.

The precise microenvironment of Paracoccidioides brasiliensis has not yet been discovered perhaps because the methods used are not sensitive enough. We applied to this purpose the polymerase chain reaction (PCR) using three sets of specific primers corresponding to two P. brasiliensis genes. This fungus as well as several other fungi, were grown and their DNA obtained by mechanical disruption and a phenol chloroform isoamylalcohol-based purification method. The DNA served for a PCR reaction that employed specific primers from two P. brasiliensis genes that codify for antigenic proteins, namely, the 27 kDa and the 43 kDa. The lowest detection range for the 27 kDa gene was 3 pg. The amplification for both genes was positive only with DNA from P. brasiliensis; additionally, the mRNA for the 27 kDa gene was present only in P. brasiliensis, as indicated by the Northern analysis. The standardization of PCR technology permitted the amplification of P. brasiliensis DNA in artificially contaminated soils and in tissues of armadillos naturally infected with the fungus. These results indicate that PCR technology could play an important role in the search for P. brasiliensis' habitat and could also be used in other ecological studies.

Molecular cloning, nucleotide sequencing, and characterization of a 27-kDa antigenic protein from Paracoccidioides brasiliensis.

A gene encoding a 27-kDa antigenic protein from Paracoccidioides brasiliensis was cloned, sequenced, and characterized. A cDNA library of the mycelial phase was produced and packed in Uni-Zap-XR vector, lambda Zap II synthesis kit (Stratagene, La Jolla, Ca). The screening of the library was carried out using a pool of sera from paracoccidioidomycosis patients that had proven reactive in serological testing. Among 44,000 immuno-screened clones from the library, 2 were positive (clones 2 and 3). The former was not characterized further. The latter has a 1-kb DNA insert with an open reading frame encoding a protein of 259 amino acids with a predicted molecular mass of 28.6 kDa (27 kDa by SDS-PAGE). This protein corresponds to a 25-kDa protein in antigenic preparations of P. brasiliensis as determined by Western blot analysis. Comparison of the transcribed sequence with different gene banks failed to reveal a high degree of homology with other proteins. The cloned DNA fragment was easily expressed in Escherichia coli without the need of induction by isopropyl-beta-D-thiogalactopyranoside. These findings suggest that the gene encodes a P. brasiliensis-specific protein.

In search of the natural habitat of Paracoccidioides brasiliensis.

Paracoccidioides brasiliensis (Pb) is the dimorphic fungus responsible for paracoccidioidomycosis (PCM), one of the most important systemic mycosis in Latin America where the disease is geographically restricted. The natural habitat of the causative agent remains undetermined. We are planning to use PCR-based technology in order to amplify specific DNA fragments. The high sensitivity of this technique may allow us to detect the natural habitat of Pb. In this study, we prepared a cDNA library from which we cloned a protein of approximately 27 kDa MW. When this recombinant antigenic protein was tested by the immunoblot technique, it was able to recognize antibodies in the sera of 91% of the PCM patients studied. No cross reactions were observed with sera from patients with other systemic mycoses. Presently we are sequencing and characterizing this clone, in order to design specific primers for amplification of Pb DNA.

Cytologic diagnosis of amniotic fluid embolus. Report of a case.

This paper reports a case of a primigravid woman with the presumptive diagnosis of amniotic fluid embolus who had a blood sample aspirated from the right heart. The blood specimen was sent to the cytology laboratory, processed and then examined for squames and lanugo. The laboratory procedure and results are described.

Premalignant lesions of the cervix in women of Cali, Colombia.

A detailed histologic study was made of uterine cervices from 441 autopsy specimens from the population of Cali, Colombia. Women in this city have one of the highest registered incidence rates of cancer of the uterine cervix. The following prevalence (in percent) of lesions in adult women was found: cervicitis, 79; reserve cell hyperplasia, 14; squamous metaplasia, 41; dysplasia, 9. Contrary to expectations, no increase in prevalence of these lesions was found with age, lower socioeconomic status, or number of pregnancies. A similar study of a sample of hysterectomies performed for uterine prolapse showed approximately the same results. The findings suggest that promotional factors are more important than initiator factors in uterine cervical carcinogenesis.