S0001-600220100003 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022010000300001 El mejor Presidente de la República Vargas Araya Armando ,Escritor y periodista 07 2010 2010 52 132 133
S0001-600220100003 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022010000300002 Uso de animales de experimentación en la investigación biomédica en Costa Rica Using Experimental Animal in Biomedical Research in Costa Rica Granados-Zúñiga Jorge ,Universidad de Costa Rica Escuela de Medicina Departamento de Bioquímica 07 2010 2010 52 134 136

El progreso en la investigación médica y biológica ha dependido en gran medida del uso de animales experimentales Dada la importancia que históricamente han tenido los animales como reactivos biológicos en la investigación biomédica se consolidó la ciencia del animal de experimentación. Ésta persigue la obtención de animales biológicamente estandarizados mediante la selección colectiva de características anatómicas, fisiológicas, ecológicas y sanitarias.

The progress in medical and biological research has relied heavily on the use of experimental animals. Given the importance animals have had historically as biological reagents, the science of experimental animals was created and is consolidated in biomedical research. It seeks to obtain biologically standardized animals by selecting their collective anatomical, physiological, ecological and health characteristics.

 animales experimentación investigación biomédica Costa Rica animals experimentations biomedical investigation Costa Rica Festing MFW Overend P Das RG Borja MC Berdoy M The Design of Animal Experiments The Design of Animal Experiments 2002 The Royal Society of Medicine Press Giráldez Dávila A Zúñiga JM Zúñiga JM Tur Marí JA Milocco SN Piñeiro González R 1. La ciencia del animal de laboratorio y el procedimiento experimental Ciencia y tecnología en protección y experimentación animal Ciencia y tecnología en protección y experimentación animal 2001 Madrid McGraw-Hill Pazos L Reyes L Caiza F León E Módulo 1: Introducción a la ciencia de animales de experimentación Módulo 1: Introducción a la ciencia de animales de experimentación 2009 San José Universidad de Costa Rica, Laboratorio de Ensayos Biológicos Ma C Animal models of disease Modern drug discovery 2004 7 6 Kaufman SR Scientific problems with animal models Perspectives on Medical Research 1993 4 Granados-Zúñiga J Información sobre el uso de animales de laboratorio indicada en artículos científicos Revista de Biología Tropical 1997 45 3 Granados Zúñiga J Pazos Sanou L Legislación para el uso de animales de laboratorio en Costa Rica Medicina Legal de Costa Rica 1998 15 2 Ley No. 7451 Bienestar de los animales La Gaceta 13 d e di 236 San José Decreto Ejecutivo No. 26668 Reglamento a los Artículos 3, 10, 11, 12 y 13 de la Ley para el Bienestar de los Animales (Ley No. 7451) La Gaceta 04 d e ma 44 San José
S0001-600220100003 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022010000300003 Avances en el desarrollo de las vacunas neumocócicas conjugadas Update on Pneumococcal Conjugate Vaccines Chan-Acón Wendy Abdelnour Arturo Soley-Gutiérrez Carolina Arguedas-Mohs Adriano ,Instituto de Atención Pediátrica ,Universidad de Ciencias Médicas 07 2010 2010 52 137 147

El Streptococcus pneumoniae se encuentra entre los mayores patógenos causantes de infecciones invasoras y no invasoras en los dos extremos de la vida: en niños menores de 5 años y en personas mayores de 65 años de edad. Las principales manifestaciones asociadas a infecciones neumocócicas son: neumonía, bacteriemia febril, septicemia, otitis media y meningitis. Esta bacteria es uno de los principales agentes involucrados en la mortalidad infantil, con un estimado de 1, 000,000 de muertes globales por año, en niños menores de 5 años de edad, la mayoría provenientes de países en vías de desarrollo, por lo que es considerada como un serio problema para la salud pública alrededor del mundo. En el 2000 se introdujo al mercado de los Estados Unidos de Norte América, la primera vacuna neumocócica conjugada, que a diferencia de la ya disponible vacuna neumocócica polisacárida, es capaz de proporcionar una respuesta inmune efectiva para la protección de niños menores de 2 años. La eficacia reportada para la vacuna conjugada heptavalente en los ensayos clínicos iniciales fue de un 97.4% contra la enfermedad neumocócica invasora producida por los serotipos incluidos en la vacuna (4, 9V, 14, 19F, 23F, 18C y 6B). En la actualidad diferentes entidades regulatorias, incluyendo la Agencia Europea de Medicamentos (EMEA), han autorizado la comercialización de la vacuna conjugada 10-valente, en la que, además de los serotipos descritos para la vacuna 7-valente, se incluyen los serotipos 1, 5 y 7F; de estos diez serotipos, ocho se encuentran conjugados con la proteína transportadora D, un elemento que se encuentra en la porción externa del Haemophilus influenzae. La otra nueva vacuna conjugada que está en fase de análisis por diferentes entidades regulatorias, incluyendo la Administración de Alimentos y Drogas de los Estados Unidos (FDA) y la EMEA, pero que ya fue aprobada en Chile, es la que contiene 13 serotipos: los diez de la vacuna 10-valente y los serotipos 3, 6A y 19A. En el caso de la vacuna 13-valente, todos los serotipos están conjugados con el transportador CRM197. Estas nuevas formulaciones pretenden ampliar la cobertura contra el S. pneumoniae, incluyendo serotipos frecuentes en países en vías de desarrollo (serotipo 1 y 5) y serotipos emergentes luego de una década de la vacunación con la vacuna 7-valente, como son: 3, 6A, 17F y 19A.

Streptococcus pneumoniae is one of the major pathogens causing invasive and non invasive infections in children younger than 5 years as well as in the elderly. Primary clinical syndromes associated with pneumococcal infections are pneumonia, bacteremia, acute otitis media and meningitis. This microorganism contributes importantly to morbidity and mortality among children under 5 years of age, it is estimated that 1,000, 000 deaths occurs per year in that age range alone, mostly from developing countries, thus becoming a serious public health problem around the globe. In year 2000 the first heptavalent conjugated pneumococcal vaccine was licensed in the United States of America, it differed from the already available polysaccharide pneumococcal vaccine, by its ability to provide an effective immune response for the protection of children under the age of 2. The efficacy of the heptavalent conjugated vaccine reported in initial clinical trials was 97, 4% against invasive pneumococcal disease related to vaccine serotypes (4, 9V, 14, 19F, 23F, 18C and 6B). Different health authorities worldwide, including the European Medicines Agency (EMEA) had approved the introduction of a 10-valent formulation which includes all 7 PCV7 serotypes plus serotypes 1, 5 and 7F; 8 serotypes are conjugated with protein D as a novel carrier, an element found in the outer core of the non-typeable Haemophilus influenzae. Another new conjugated vaccine is being assessed by several regulatory entities such as the Food and Drug Administration (FDA) and EMEA and in Chile is already approved. This 13-valent formulation includes the 10 serotypes contained in the 10-valent vaccine plus serotypes 3, 6A and 19A, all conjugated to the carrier protein CRM197. These new formulations pretend to enhance vaccine coverage against S. pneumoniae including the frequent serotypes in developing countries (1 and 5) and emerging serotypes such as serotypes 3, 6A, 17F and 9A after a decade of PCV7 immunization.

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IPV/PRP-T Hib and hepatitis B vaccines in infants 2-7 months of age Vaccine 2006 24 Tichmann-Schumann I Soemantri P Behre U Disselhoff J Mahler H Maechler G Immunogenicity and reactogenicity of four doses of diphtheria-tetanus-three component acellular pertussis-hepatitis B-inactivated polio virus Haemophilus influenzae type b vaccine coadministered with 7-valent pneumococcal conjugate Vaccine Pediatr Infect Dis J 2005 24 Reinert P Guy M Girier B Szelechowski B Baudoin B Deberdt P The safety and immunogenicity of an heptavalent pneumococcal polysaccharide conjugate vaccine (Prevenar) administered in association with a whole-cell pertussis-based pediatric combination vaccine (DTP-IPV/PRP-T) to French infants with a two-, three-, and four-month schedule Arch Pediatr 2003 10 Schmitt HJ Faber J Lorenz I Schmole-Thoma B Ahlers N The safety, reactogenicity and immunogenicity of a 7-valent pneumococcal conjugate vaccine (7VPnC) concurrently administered with a combination DTaP-IPV-Hib vaccine Vaccine 2003 21 Eskola J Kilpi T Palmu A Jokinen J Haapakoshi J Herva E Efficacy of a pneumococcal conjugate vaccine against acute otitis media N Engl J Med 2001 344 Black S Shinefield H Fireman B Lewis E Ray P Hansen JR Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children: Northern California Kaiser Permanente Vaccine Study Center Group Pediatr Infect Dis J 2000 19 Choo S Seymour L Morris R Quataert S Lockhart S Cartwright K Immunogenicity and reactogenicity of a pneumococcal conjugate vaccine administered combined with a Haemophilus influenzae type B conjugate vaccine in United Kingdom infants Pediatr Infect Dis J 2000 19 Vesikari T Wysocki J Chevallier B Karvonen A Czajka H Arsène JP Immugenicity of the 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) compared to the licensed 7vCRM vaccine Pediatr Infect Dis J 2009 2 Knuf M Szenborn L Moro M Christian P Bermal N Bernard L Immugenicity of rotunely used childhood vaccines when coadministered with the 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) Pediatr Infect Dis J 2009 2 Wysocki J Tejedor JC Grunert D Konior R García J Knuf M Immugenicity of the 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) when coadministered with different Neiseria meningitidis serogroup C conjugate vaccines Pediatr Infect Dis J 2009 2 Kieninger D Kueper K Juergens C Ahlers N Baker S Girdina P Safety & immunologic non-inferiority of 13-valent pneumococcal conjugate vaccine compared to 7-valent pneumococcal conjugate vaccine with routinely vaccines in healthy infants. 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Boston, Estados Unidos de Norteamérica Shinefield HR Black S Ray P Chang I Lewis N Fireman B Safety and immunogenicity of heptavalent pneumococcal CRM197 conjugate vaccine in infants and toddlers Pediatr Infect Dis J 1999 18 Esposito S Pugni L Bosis S Proto A Cesati L Bianchi C Immunogenicity, safety and tolerability of heptavalent pneumococcal conjugate vaccine administered at 3, 5 and 11 months post-natally to pre- and full-term infants Vaccine 2005 23 Black SB Cimino CO Hansen J Lewis E Ray P Corsaro B Immunogenicity and safety of measles-mumps-rubella, varicella and Haemophilus influenzae type b vaccines administered concurrently with a fourth dose of heptavalent pneumococcal conjugate vaccine compared with the vaccines administered without heptavalent pneumococcal conjugate vaccine Pediatr Infect Dis J 2006 25 Scheifele DW Halperin SA Smith B Ochnio J Meloff K Duarte- Monteiro D Assessment of the compatibility of co-administered 7valent pneumococcal conjugate, DTaP. IPV/PRP-T Hib and hepatitis B vaccines in infants 2-7 months of age Vaccine 2006 24 De Aristegui FJ Cos AB Zurimendi CA Alday EMV Alzua RJ De la Fuente JE Evaluation of the safety and immunogenicity of pneumococcal seven-valent conjugate vaccine (Prevenar) administered in previously unvaccinated Spanish children aged 24 to 36 months Vaccine 2005 23 Chevallier B Vesikari T Brzostek J Knuf M Bermal N Aristegui J Safety and Reactogenicity of the 10-Valent Pneumococcal Non-typeable Haemophilus influenzae Protein D Conjugate Vaccine (PHiD-CV) When Coadministered With Routine Childhood Vaccines Pediatr Infect Dis J 2009 28 Direct and indirect effects of routine vaccination of children with 7-valent pneumococcal conjugate vaccine on incidence of invasive pneumococcal disease-United States, 1998-2003 MMMWR Morb Mortal Wkly Rep 2005 54 Grijalva C Nuorti J Arbogast P Martin S Edwards K Griffin M Decline in pneumonia admissions after routine childhood immunisation with pneumococcal conjugate vaccine in theUSA: a time-series analysis Lancet 2007 369 Palmu A Verho J Jokinen J Karma P Kilpi T The Seven-Valent Pneumococcal Conjugate Vaccine Reduces Tympanostomy Tube Placement in Children Pediatr Infect Dis J 2004 23 Jansen AG Hak E Veenhoven RH Damoiseaux RA Schilder AG Sanders EA Pneumococcal conjugate vaccines for preventing otitis media Cochrane Database Syst Rev 2009 15 Grijalva C Poehling K Nuorti JP Zhu Y Martin S National Impact of Universal Childhood Immunization With Pneumococcal Conjugate Vaccine on Outpatient Medical Care Visits in the United States Pediatrics 2006 118 Prymula R Peeters P Chrobok V Kritz P Novakova E Kaliskova E Pneumococcal capsular polysaccharides conjugated to protein D for prevention of acute otitis media caused by both Streptococcus pneumoniae and non-typeable Haemophilus influenzae: a randomized double-blind efficacy study Lancet 2006 367 Bogaert D Veenhoven RH Slujier M Wannet WJ Rijkers GT Mitchell TJ Molecular Epidemiology of pneumococcal colonization in response to pneumococcal conjugate vaccination in children with recurrent acute otitis media J Clin Microbiol 2005 43 Shouval D Greenberg D Givon-Lavi N Porat N Dagan R Serotype coverage of invasive and mucosal pneumococcal disease in Israeli children younger than 3 years by various pneumococcal conjugate vaccines Pediatr Infect Dis J 2009 28 Dagan R Sikuler-Coheb M Zamir O Janco J Givon-Lavi N Effect of a conjugate pneumococcal vaccine on the occurrence of respiratory infections and antibiotic use in day-care center attendee Pediatr Infect Dis J 2001 20 Isaacman D Fletcher M Fritzell B Ciuryla V Schranz J Indirect effects associated with widespread vaccination of infants with heptavalent pneumococcal conjugate vaccine (PCV7; Prevenar) Vaccine 2007 25 Direct and indirect effects of routine vaccination of children with 7-valent pneumococcal conjugate vaccine on incidence of invasive pneumococcal disease - United States, 1998-2003 MMWR 2005 54 Hicks L Harrison L Flannery B Hadler J Schaffner W Incidence of pneumococcal disease due to non-pneumococal conjugate vaccine (PCV7) serotypes in the United States during the era of widespread PCV7 vaccination, 1998-2004 J Infect Dis 2007 196 Poehling K Talbot T Griffin M Craig A Whitney C Invasive pneumococcal disease among infants before and after introduction of pneumococcal conjugate vaccine JAMA 2006 295 Pletz M Maus U Norbert K Welte T Lode H Pneumococcal vaccines: mechanism of action, impact on epidemiology and adaption of the species Int J Antimicrob Agents 2008 32 García-Sicilia J Nuevas vacunas antineumocócicas: Más allá del neumococo Rev Esp Quimioterap 2007 20 Beall B McEllistrem MC Gertz GE Wedel S Boxrud DJ González AL Pre- and postvaccination clonal compositions of invasive pneumococcal serotypes for isolates collected in the United States in 1999, 2001, 2002 J Clin Microbiol 2006 44 Singleton RJ Hennessy TW Bulkow LR Hammitt LL Zulz T Hurlburt DA Invasive pneumococcal disease caused by nonvaccine serotypes among Alaska native children with high levels of 7-valent pneumococcal conjugate vaccine coverage JAMA 2007 297 Pelton S Hout MA Finkelstein JA Bishop C Hsu K Kellenberg Huang S Emergence of 19A as Virulent and Multidrug Resistant Pneumococcus in Massachusetts Following Universal Immunization of Infants With Pneumococcal Conjugate Vaccine Pediatr Infect Dis J 2007 26 De Roux A Schmöle-Thoma B Siber G Hackell J Kuhnke A Ahlers N Comparison of pneumococcal conjugated polysaccharide vaccines in the ederly adults: conjugate vaccine elicits improved antibacterial immune reponses and immunological memory Clin Infect Dis 2008 46 Dagan R Impact of pneumococcal conjugate vaccine on infections caused by antibiotic-resistant Streptococcus pneumoniae Clin Microbiol Infect 2009 15 ^sSuppl 3 Moraga F Enfermedad neumocócica en la era vacunal y emergencia de serotipos: ¿Tendencias temporales y reemplazo de serotipos? Enferm Infecc Microbiol Clin 2009 27 Dagan R Givon-Lavi N Leibovitz E Greenberg D Porat N Introduction and proliferation of multidrug-resistant Streptococcus pneumoniae serotype 19A clones that cause acute otitis media in an unvaccinated population J Infect Dis 2009 199 Schrag SJ Beall B Dowell SF Limiting the spread of resistant pneumococci: biological and epidemiologic evidence for the effectiveness of alternative interventions Clin Microbiol Rev 2000 13 Kyaw MH Lynfield r Schaffner W Craig AS Hadler J Reingold A Effect of introduction of the pneumococcal conjugate vaccine on drug resistant Steptococcus pneumoniae N Engl J Med 2006 354 Stephens DS Zughaier SM Whitney CG Baughman WS Barker L Incidence of macrolide resistance in Streptococcus pneumoniae after introduction of the pneumococcal conjugate vaccine: population-based assessment Lancet 2005 365 Richter SS Heilmann KP Dohrn CL Riahi F Beekmann SE Doern GV Changing epidemiology of antimicrobial-resistant Streptococcus pneumoniae in the United States, 2004-2005 Clin Infect Dis 2009 48 Farrell DJ Klugman KP Pichichero M Increased antimicrobial resistance among nonvaccine serotypes of Streptococcus pneumoniae in the pediatric population after the introduction of 7-valent pneumococcal vaccine in the United States Pediatr Infect Dis J 2007 26 Ficha técnica o resumen de las características del producto: Synflorix suspensión inyectable Ficha técnica o resumen de las características del producto: Synflorix suspensión inyectable
S0001-600220100003 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022010000300004 Sensibilidad y especificidad de la prueba de esfuerzo y el estudio de perfusión miocárdica con SESTAMIBI para detección de enfermedad arterial coronaria, en el Hospital San Juan de Dios Sensitivity and Specificity of Treadmill Test and Myocardial Perfusion Imaging with SESTAMIBI in the detection of Coronary Artery Disease at the Hospital San Juan de Dios Solís-Barquero Juan Pablo Tortós-Guzmán Jaime ,Caja Costarricense de Seguro Social Hospital San Juan de Dios Servicio de Cardiología 07 2010 2010 52 148 153

Objetivo: La coronariopatía arterio esclerótica continúa siendo la principal causa de mortalidad mundial y Costa Rica no escapa a esta realidad. La prueba de esfuerzo, la imagen de perfusión con SESTAMIBI y la angiografía coronaria son métodos que permiten detectar esta entidad. El país no cuenta con datos sobre la información que proporcionan estas pruebas. El objetivo del estudio es determinar la rentabilidad diagnóstica de cada una de ellas. Métodos: Es un estudio observacional, analítico de cohorte. Se incluyeron pacientes con factores de riesgo cardiovascular, que tuvieran prueba de esfuerzo, estudio de perfusión miocárdica y angiografía coronaria realizadas en el Hospital San Juan de Dios, desde 2003 a 2007. Se calculó la sensibilidad y especificidad de estos estudios. También se llevó a cabo un análisis con una estadística descriptiva de las características de la muestra y de los diferentes factores de riesgo cardiovascular. Resultados: Se incluyeron 83 pacientes en el estudio, 75% hombres. Los principales factores de riesgo encontrados fueron dislipidemia (84%) e hipertensión arterial (70%). La prueba de esfuerzo tuvo una sensibilidad del 40% y una especificidad del 57%; el estudio de perfusión miocárdica con SESTAMIBI tuvo una sensibilidad del 66% y una especificidad del 71%. La mayoría de los pacientes tuvieron afección de uno o dos vasos coronarios, con lesiones mayores al 90%, y especialmente en la arteria descendente anterior. Conclusión: Los factores de riesgo convencionales se presentaron en un alto porcentaje de la población estudiada. La prueba de esfuerzo mostró una baja sensibilidad y especificidad, sin embargo, coincide con el rango descrito en la literatura. El estudio de perfusión miocárdica con SESTAMIBI mostró un rendimiento diagnóstico significativamente superior (p =0.05).

Aim: Coronary artery disease is the first cause of mortality around the world, and Costa Rica does not escape from this reality. The treadmill test, myocardial perfusion imaging with SESTAMIBI, and coronary angiography are methods for detecting this disease. Our country does not have its own data regarding these tests. The aim of this study is to determine the diagnostic performance of each one. Methods: The present is an observational, analytic, cohort study. Patients included were those with cardiovascular risk factors that underwent a treadmill test, myocardial perfusion imaging, and a coronary angiography at the Hospital San Juan de Dios, from 2003 to 2007. Sensitivity and specificity were calculated. Adescriptive statistic analysis of the different risk factors was carried out. Results: Eighty three patients were included in the study; 75% men and 25% women. The most frequently found risk factors were dyslipidemia (84%), and hypertension (70%). The treadmill test had a sensitivity of 40%, and specificity of 57%. Myocardial perfusion imaging with SESTAMIBI had a sensitivity of 66% and specificity of 71%. The majority of the patients had lesions in 1 or 2 coronary arteries, with more than 90% obstruction, mostly in the anterior artery descending. Conclusion: A high prevalence of conventional risk factors was present in this population. The treadmill test showed a low sensitivity and specificity, according with the literature. The myocardial perfusion imaging had a significant (p =0.05) better diagnostic performance than the treadmill test.

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S0001-600220100003 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022010000300005 Análisis sobre el uso de exámenes preoperatorios en pacientes sometidas a cirugías programadas en el Servicio de Ginecología del Hospital "Dr. Rafael Ángel Calderón Guardia", durante 2009 Analysis of Preoperative Test Screening in Patients Undergoing Elective Surgery at the Gynaecology Service of the "Rafael Ángel Calderon Guardia" Hospital during 2009 Leal-Mateos Manrique Madrigal-Solís Juan B ,Hospital Dr. Rafael A. Calderón Guardia Servicio de Ginecología y Obstetricia 07 2010 2010 52 154 158

Objetivo: Evaluar el uso de los exámenes preoperatorios en las pacientes sometidas a cirugía programada en el Servicio de Ginecología del Hospital "Dr. Rafael Angel Calderón Guardia", durante 2009. Métodos: Se realizó un estudio observacional analítico de corte transversal. Se analizaron 272 historias clínicas de pacientes operadas entre el 1 de enero y el 3 de junio de 2009. Las variables analizadas fueron: edad; cantidad y tipo de enfermedades coexistentes antes de la cirugía; cantidad y tipo de exámenes preoperatorios realizados, faltantes y adicionales, y tipo de cirugía realizada. La determinación sobre la cantidad y tipo de exámenes preoperatorios necesarios en cada paciente, según las patologías de fondo que padecen, se hizo con base en las guías emitidas por la Sociedad Americana de Anestesiólogos de 2002. Resultados: El promedio de exámenes preoperatorios por paciente fue de 4,3 (DS+ 2,1).Únicamente, al 44,9% (IC 95% 38,8-51,0) de las pacientes se les realizaron de forma completa los exámenes requeridos por el ASA, según su morbilidad. El promedio de exámenes faltantes fue de 1,7 (DS +1,1) por paciente. Al 93% (IC 95% 89,3-95,7) de las pacientes se les realizaron de forma adicional un promedio de 2,5 (DS+1,6) exámenes preoperatorios. El 9,5% de los exámenes perioperatorios realizados de forma adicional mostraron resultados anormales. Solo en el 7,6% (IC 95% 2,5-16,8) de los expedientes de las pacientes que presentaron resultados anormales se mostró alguna acción dirigida a corregir estas anormalidades y únicamente al 3% (IC 95% 0,4-10,5) de ellas se les suspendió la cirugía. Conclusión: La investigación evidenció el uso inadecuado de los exámenes preoperatorios, no solo porque aproximadamente a la mitad de las pacientes se les realizaron de forma incompleta, sino también porque a la mayoría de ellas se les solicitó una cantidad considerable de pruebas sin justificación.

Aim:To analyze the use of routine preoperative tests in patients undergoing elective gynecologic surgery at the Rafael Ángel Calderón Guardia Hospital during 2009. Methods: This is a cross-sectional observational study. Two hundred seventy two medical records were analyzed of patients who underwent surgery between January 1st 2009 and June 3rd of 2009. The variables studied were: age, coexisting morbidity, amount and type of additional preoperative tests performed and amount and type of preoperative missing tests according to the 2002 guidelines of the American Society of Anaesthesiologists (ASA). Results: The mean of preoperative tests preformed for each patient was 4,3 (SD + 2,1). According to the ASA guidelines, only 44,9% (CI: 95% 38,8-51,0) of the patients had all the preoperative test completed. In addition 55,1% (CI: 95% 49,0-61,2) of the patients missed at least 1 of the preoperative needed tests. The mean of the preoperative tests missing in this case was 1,7 (SD +1,1). On the other hand, 93% (CI: 95% 89,3-95,7) of the patients had undergone at least 1 unnecessary preoperative test according to their morbidity. The mean of this additional preoperative test was 2,5 (SD +1,6). Nine point five percent of the total of unnecessary preoperative tests showed abnormal results. Only 7,6% (CI: 95% 2,5-16,8) of the medical records of these patients showed some corrective action. Three percent (CI: 95% 0,4-10,5) of the surgeries were cancelled for this reason. Conclusion: This study showed the incorrect use of preoperative tests in the Gynecology Service of the Calderón Guardia Hospital.

 exámenes preoperatorios ginecología preoperative tests gynaecology Cohn S The role of medical consultant Med Clin N Am 2003 87 Practice advisory for preanesthesia evaluation: A report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation Anesthesiology 2002 96 Fleisher LA Beckman JA Brown KA Calkins H Chaikof EL Fleischmann KE ACC/AHA guidelines for preoperative cardiovascular evaluation and care for noncardiac surgery J Am Coll Cardiol 2007 50 Lin PS Vasilev SA Preoperative evaluation Perioperative and supportive care in gynecologic oncology Perioperative and supportive care in gynecologic oncology 2000 ^eNew York Wile-Lyss Macpherson DS Preoperative laboratory testing: Should any test be "routine" before surgery? Med Clin N Am 1993 77 Fisher SP Cost-effective preoperative evaluation and testing Chest 1999 115 ^sSupplement Johnson BE Porter J Preoperative evaluation of the gynecologic patient Obstet Gynecol 2008 111 Sweitzer BJ Sweitzer BJ Overview of preoperative evaluation and testing Preoperative assessment and management Preoperative assessment and management 2008 2 ^ePhiladelphia Lippincott Williams & Wilkins Kaplan EB Sheiner LB Boeckmann AJ Roizen MF Beal SL Cohen SN The usefulness of preoperative laboratory screening JAMA 1985 253 Blery C Szatan M Fourgeaux B Charpak Y Darne B Chastang CL Evaluation of a protocol for selective ordering of preoperative test The Lancet 1986 Macpherson DS Snow R Lofgren RP Preoperative screening: Value of preoperative test Ann Intern Med 1990 113 Chung F Yuan H Yin L Vairavanathan S Wong DT Elimination of preoperative testing in ambulatory surgery Anesth Analg 2009 108 Roizen MF More preoperative assessment by physician and less by laboratory test N Eng J Med 2000 342 Roizen MF The compelling rationale for less preoperative testing Can J Anaesth 1988 35 Smetana GW Macpherson DS The case against routine preoperative laboratory testing Med Clin N Am 2003 87
S0001-600220100003 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022010000300006 Factores asociados a la infección hospitalaria de la herida operatoria en pacientes de cirugía limpia electiva en el Hospital "Dr. Rafael Ángel Calderón Guardia" de Costa Rica Factors Associated with Surgical Wound Infection in Patients for Elective Clean Surgery at the Hospital"Dr. Rafael Ángel Calderón Guardia, Costa Rica Guevara-Rodríguez Moraima Romero-Zúñiga Juan José ,Caja Costarricense de Seguro Social Hospital Dr. Rafael Ángel Calderón Guardia ,UNA Escuela de Medicina Veterinaria Programa de Investigación en Medicina Poblacional 07 2010 2010 52 159 166

Objetivo: Las infecciones hospitalarias de la herida operatoria (IHHO) se ubican entre las primeras 3 causas de infección hospitalaria en el mundo, con altos costos sociales y médicos. Este estudio tiene como objetivo identificar y cuantificar factores de riesgo para IHHO de un hospital de Costa Rica. Métodos: Estudio de cohorte en 488 pacientes, intervenidos entre abril y junio de 2006. Los pacientes fueron divididos en 2 grupos: aquellos en los que se restringió el tránsito de personas en la sala, grupo A, y aquellos en que no se restringió, grupo B. El análisis se realizó en 2 grandes fases: descriptiva y analítica. En la primera, se calcularon medidas de frecuencias (absolutas y relativas); y la segunda fase se efectuó en 2 etapas, ambas por regresión logística no condicional, análisis univariado y análisis multivariado. Resultados: Hubo una incidencia global del 35,2% (172/488) IHHO. La incidencia acumulativa en los no expuestos fue del 31,8% (76/239), mientras que en los expuestos fue del 38,6% (96/249) (p=0.12) Únicamente las cirugías de órgano y hueso/articulación presentaron mayor riesgo de IHHO (OR 2,42; IC 95% 1,5 - 3,8); las cirugías en las salas de tránsito irrestricto y la diabetes no se asociaron con la infección. Conclusión: La diabetes y la profundidad del plano quirúrgico deben incluirse en el perfil del paciente con riesgo de IHHO; además, aunque no hubo asociación epidemiológica, la diferencia porcentual en la incidencia de IHHO según la exposición, en un hospital con miles de intervenciones al año, sugiere la restricción del tránsito de personas ajenas a la cirugía.

Aim: Surgical wound infection (SWI) is one of the most frequent causes of nosocomial infection world wide, leading to important social and medical costs. This study aims to identify and quantify risk factors for SWI in a costarican hospital. Methods: A cohort study of 488 elective patients, operated between April and June 2006, was carried out. The patients were divided in 2 groups, those in which operating room traffic was restricted, group A, and those in which it was not, group B. The statistical analysis was performed in 2 major phases: descriptive and analytical; in the first one, measures of frequency (absolute and relative) were calculated. In the second one, a logistic procedure was done in 2 steps, univariate and multivariate. Results: An overall incidence of 35.2 % (172/488) of SWI was found. The cumulative incidence in group A reached 31.8% (76/239), while in group B it was 38.6% (96/249) (p=0.12). Only the surgical procedures of organs and bone/joint presented higher risk of SWI (OR 2.42; 95% CI: 1.5-3.8), while surgeries in the rooms of unrestricted transit and diabetic patients had no association with the infection. Conclusion:Diabetes and depth of surgery should be taken into account in the profile of patients with increased risk of suffering SWI; furthermore, even though there was no epidemiological association between restricted operative roon traffic and not restricted, and SWI, although the difference in incidence of SWI, was not statistically significant, it is advisable to restrict the transit of persons in operating rooms, according to international standards.

 infección hospitalaria infección de herida operatoria estudio de cohorte factores de riesgo infection surgical wound infection cohort study risk factors El control de las enfermedades transmisibles El control de las enfermedades transmisibles 2005 18 O.P.S Practical guidelines for infection control in healthcare facilities Practical guidelines for infection control in healthcare facilities 2004 ^eAtlanta CDC Garner JS Guideline for isolation precautions in hospitals: The Hospital infection control practices advisory committee Infect Control Hosp Epidemiol 1996 17 Vegas AA Jodra VM Garcia ML Nosocomial infection in surgery wards: a controlled study of increased duration of hospital stays and direct cost of hospitalization Eur Journal Epidemiology 1993 9 McDermott W Rogers DE Social ramifications of ontrol of microbial disease Johns Hopkins Med J 1982 151 Zerr KJ Furnary AP Grunkemeier GL Bookin S Kanhere V Starr A Glucose control lowers the risk of wound infection in diabetes after open heart operations Ann Thorac Surg 1997 63 CDC CDC 2002 Comité de Control y Prevención de Infecciones Nosocomiales, Hospital Dr. Rafael Ángel Calderón Guardia Comité de Control y Prevención de Infecciones Nosocomiales, Hospital Dr. Rafael Ángel Calderón Guardia 2006 Microsoft Office Excel 2007 Microsoft Office Excel 2007 Hosmer DW Lemeshow S Applied logistic regression Applied logistic regression 1989 1 Ed. Wiley-Interscience EGRET 2.0: User´s manual: electronic version EGRET 2.0: User´s manual: electronic version 1999 Seropian R Reynolds BM Wound infections after preoperative depilatory versus razor preparation Wound infections after preoperative depilatory versus razor preparation 1971 121 Cáceres FM Díaz LA Incidencia de infección hospitalaria, ESE Hospital Universitario Ramón González Valencia, 1995-2000 MEDUNAB 2002 5 Howorth FM Prevention of airbone infection during sugery Lancet 1985 325 Gaspar C Calvente MJ Fernández C Fereres J Air microbiology monitoring in plenum ventilated operating rooms: Proposed Standards Enferm Infecc Microbiol Clin 1997 15 Pratt RJ Pellowe C Loveday HP Robinson N Smith GW Barrett S The epic project: developing national evidence-based guidelines for preventing healthcare associated infections: Phase I: Guidelines for preventing hospital-acquired infections. Department of Health (England) J Hospital Infections 2001 47 ^sSuppl Nichols RL Smith JW Garcia RY Walterman RS Holmes JWC Current practices of preoperative bowel preparation among North American colorectal surgeons Clin Infect Dis 1997 24 Wenzel RP Osterman CA Donowitz LG Hoyt JW Sande MA Martone WJ Identification of procedure-related nosocomial infections in high risk patients Rev Infection Diseases 1981 3 Horan TC Gaynes RP Martone WJ Jarvis WR Emori TG CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections 1992 13 Mandell G Gordon D Bennett J Principles and practice of infectious disease Principles and practice of infectious disease 2005 6 Churchil Livingstone Ludwig KA Carlson MA Condon RE Prophylactic antibiotics in surgery Annu Rev Med 1993 44
S0001-600220100003 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022010000300007 Caracterización del uso de antieméticos en el postoperatorio en pacientes adultos sometidos a cirugía durante el periodo enero-mayo 2009, en el Hospital Clínica Bíblica de Costa Rica Characterization of the Use of Antiemetics in the Postoperative Period in Adult Patients Undergoing Surgery During January to May 2009 in a private hospital Clínica Bíblica in Costa Rica Apuy-Roldán Natalia Chaverri-Fernández José Miguel Monge-Aguilera Mónica Zavaleta-Monestel Esteban ,Universidad de Costa Rica Facultad de Farmacia ,Hospital Clínica Bíblica Farmacia ,Universidad de Costa Rica Facultad de Farmacia 07 2010 2010 52 167 172

Objetivo: Evaluar y caracterizar el abordaje farmacoterapéutico antiemético en el periodo postoperatorio en pacientes adultos sometidos a cirugía en el Hospital Clínica Bíblica (hospital privado en Costa Rica). Métodos: Se seleccionaron pacientes (con edades entre 18 y 75 años) sometidos a cirugía, en quienes se había utilizado algún antiemético profiláctico al proceso quirúrgico, excluyéndose los pacientes que permanecieran hospitalizados menos de 24 horas tras la cirugía. Resultados: Dentro de la terapia profiláctica antiemética utilizada en este Hospital, se incluyó: granisetrón, metoclopramida, dexametasona, dimenhidrinato, entre otros; el granisetrón fue el antiemético más utilizado en un 81% de los casos, solo o en combinación. El uso de la dexametasona junto con el granisetrón fue la combinación más utilizada en un 57%. Sin hacer asociación al procedimiento quirúrgico, las náuseas y vómitos postoperatorios se presentaron en un 12% con el granisetrón, en un 25% con la metoclopramida, en un 9% con el dimenhidrinato, en un 13% con la dexametasona y en un 14% con otros antieméticos. Las cirugías que presentaron más incidencia de NVPO fueron las cirugías ortopédicas en un 30%, y las cirugías laparoscópicas en un 28%. En los casos en los que se utilizó fentanyl como anestésico, se presentaron vómitos en un 18% de los pacientes, mientras que en los casos en que no se utilizó fentanyl, el porcentaje de NVPO fue del 9%. Conclusión: A pesar del amplio uso de antieméticos profilácticamente, las náuseas y vómitos postoperatorios siguen presentándose en los pacientes de este Hospital. No se ha encontrado un algoritmo que permita prevenir totalmente las náuseas y vómitos postoperatorios, a pesar de la gran cantidad de conocimientos adquiridos en este campo. Se debe tomar en cuenta el riesgo individual de cada paciente y la satisfacción de este. Se debe continuar con la investigación en este tema para poder así unificar y mejorar los criterios de tratamiento de las náuseas y vómitos postoperatorios.

Aim: To evaluate and characterize the pharmaco-therapeutic approach with antiemetics during the postoperative, in adult patients undergoing surgery at a private hospital in Costa Rica (Hospital Clinica Biblica) Methods:This is an observational, prospective and cohort study. Those patients who had surgery and received antiemetic prophylaxis before the procedure were selected (ages between 18 and 75 years) excluding those who had hospitalization shorter than 24 hours. Results: Prophylactic antiemetic therapy in this private hospital utilizes granisetron, metoclopramide, dexamethasone, and dimenhydrinate, Granisetron, either alone or in combination, was the most used antiemetic in 81%. The combination most commonly used was dexamethasone and granisetron (57%). Without considering the surgical procedure, the incidence of postoperative nausea and vomiting (PONV) was 12% in patients taking granisetron, 25% with metoclopramide, 9% with dimenhydrinate, 13% with dexamethasone and 14% with other antiemetics. On the other hand, looking at the procedure, the incidence of PONV in patients undergoing orthopedic surgery was by 30%, and 28% in those after laparoscopic surgery Finally, in cases in which fentanyl was used as an anesthetic 18% of the patients presented PONV, whereas in patients cases were fentanyl was not used, the rate of was 9%. Conclusion: Despite the widespread use of prophylactic antiemetics, PONV is still seen in the patients at this private hospital. In spite of the wealth of knowledge in this field, physicians have not yet found an algorithm capable of the total prevention of PONV. Individual risks and patient`s satisfaction should be taken into account. Further research on this matter must continue in order to unify and improve criteria of PONV treatment.

 náusea vómito postoperatorio anestésicos antieméticos náusea y vómito postoperatorio nausea vomiting postoperative anesthetics antiemetics postoperative nausea and vomiting González E Delgado M Estudio comparativo de la eficacia entre difenidol, ondansetrón y metoclopramida para la prevención y tratamiento de la náusea y el vómito postoperatorios en pacientes sometidos a intervención quirúrgica de oído y mastoides Rev Esp Med Quir 2008 13 Bel I Gambús P Estratificación del riesgo, profilaxis y tratamiento de las náuseas y vómitos postoperatorios Rev Esp Anestesiol 2006 Ho K Chiu J Multimodal antiemetic therapy and emetic risk profiling Ann Acad Med Singapore 2005 34 Kushwaha B Chakraborty A Agarwal J Malick A Bhushan S Bhattacharya P Comparative study of granisetron and ondansetron alone and their combination with dexamethasone, for prevention of PONV in middle ear surgery Internet Journal of Anesthesiology 2007 13 Wattwil M Thorn S Lovqvist A Dexamethasone is as effective as ondasetron for the prevention of postoperative nausea and vomiting following breast surgery Acta Anaesthesiol Scand 2003 47 Montejo K González I Perdomo J González E Domech A Prevención de las náuseas y vómitos postoperatorios Revméd electrón 2007 29 4 Rincón D Valero J Prevención de la náusea y el vómito postoperatorios Rev Col Anest 2007 35 Fujii Y The Utility of antiemetics in the prevention and treatment of postoperative nausea and vomiting in aatients scheduled for laparoscopic cholecystectomy Current Pharmaceutical Design 2005 11 Teran L Hawkin J The effectiveness of inhalation isopropyl alcohol vs granisetron for the prevention of postoperative nausea and vomiting AANA J 2007 75 Hamdan G Midazolam: Un antiemético efectivo después de la cirugía cardíaca Anesth Analg 2004 99 Sánchez M López L Pueyo F Carrascosa F Ortega A A comparison of three antiemetic combinations for the prevention of postoperative nausea and vomiting Anesth Analg 2002 95 De la Torre A Rubial M Anestesia en cirugía ambulatoria: Criterios de alta hospitalaria ANALES Sis San Navarra 1999 22 Oksuz H Zencirci B Ezberci M Comparison of the effectiveness of metoclopramide, ondasetron, and granisetron on the prevention of nausea and vomiting after laparoscopic cholecystectomy J Laparoendosc Adv Surg Tech A 2007 17 Lee A Gin T Lau A Floria F A Comparison of patients and health care professionals preferences for symptoms during immediate postoperative recovery and the management of postoperative nausea and vomiting Anesth Analg 2005 100 Fujii Y Prophylaxis of postoperative nausea and vomiting in patients scheduled for breast surgery Clin Drug Invest 2006 26 Hannaoka K Toyooka H Ohashi Y Efficacy of profilactic intravenous granisetron in postoperative emesis in adults J Anesth 2004 18 Kovac A Management of postoperative nausea and vomiting in children Pediatr Drugs 2007 9 Ramírez D Ros J Prevención de las náuseas y vómitos postoperatorios en cirugía ginecológica mediante tres dosis fijas de metoclopramida, droperidol o placebo Rev Esp Anestesiol 2001 48 McKeage K Simpson D Wagstaff A Intravenous droperidol: A review of its use in the management of postoperative nausea and vomiting Drugs 2006 66 Piper S Suttner S Röhm K Maleck W Larbig E Boldt J Dolasetron, but not metoclopramide prevents nausea and vomiting in patients undergoing laparoscopic cholecystectomy Can J Anesth 2002 49 Abali H Elik I Tropisetron, ondansetron, and granisetron for control of chemotherapy-induced emesis in turkish cancer patients: A comparison of efficacy, side-effect profile, and cost Cancer Invest 2007 25 Quaynor H Raeder J Incidence and severity of postoperative nausea and vomiting are similar after metoclopramide 20mg and ondansetron 8mg given by the end of laparoscopic cholecystectomies Rev Acta Anaesthesiol Scand 2002 46 Gupta V Wakhloo R Lahori V Prophylactic antiemetic therapy with ondansetron, granisetron and metoclopramide in patients undergoing laparoscopic cholecystectomy under general anaesthesia Internet Journal of Anesthesiology 2007 14 Aapro M Thuerlimann B A randomized double-blind trial to compare the clinical efficacy of granisetron with metoclopramide both combined with dexamethasone in the prophylaxis of chemotherapy-induced delayed emesis Ann Onc 2003 14 Apfel C Korttila K Abdalla M Kerger H Turan A Vedder I Zernak C A factorial trial of six Interventions for the prevention of postoperative nausea and momiting N Engl J Med 2004 350 Hamadani M Chaudhary L Awan F Khan J Kojouri K Ozer H Management of platinum-based chemotherapy induced acute nausea and vomiting: is there a superior serotonin receptor antagonist? J Oncol Pharm Practice 2007 13 Elhakim M Nafie M Mahmoud K Atef A Dexamethasone 8 mg in combination with ondansetron 4 mg appears to be the optimal dose for the prevention of nausea and vomiting after laparoscopic cholecystectomy Can J Anesth 2002 49 Smith I Walley G Bridgman Omitting fentanyl reduces nausea and vomiting, without increasing pain, after sevoflurane for day surgery Eur J Anaesthesiol 2008 25
S0001-600220100003 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022010000300008 Propuesta de un sistema de estadiaje de tumores de mediastino: A Proposal Staging System for Mediastinals Tumors Salazar-Vargas Carlos Araya-Castro Pablo Rodríguez-Jiménez Lidia Umaña-Umaña Rafael A ,Caja Costarricense de Seguro Social Hospital Dr. Rafael A. Calderón Guardia ,Clínica Imágenes Santa Fé ,Caja Costarricense de Seguro Social Hospital San Juan de Dios 07 2010 2010 52 173 176

El mediastino es un compartimento que aloja tumores de variado origen histológico, dada la diversidad de órganos y estructuras que lo ocupan o lo transitan. Debido a la gran capacidad de la cavidad torácica, los pacientes se presentan frecuentemente con tumores de gran tamaño, a veces ya invadiendo órganos vitales, complicando el estado clínico, el eventual manejo anestésico y los procedimientos quirúrgicos necesarios. Actualmente no existe un método común para categorizar pacientes con tumores mediastinales. Lo que hoy se hace es estudiar las imágenes y describir la masa, indicando sus dimensiones y relaciones, y de ahí se deduce la gravedad o no de la situación. De existir un sistema, los médicos tratantes podrían comunicarse, describir y entender bien cada lesión, el grado de respuesta al tratamiento y el pronóstico de cada paciente. Siguiendo el TNM, se propone un método de estadiaje para pacientes con tumores mediastinales, utilizando algunas modificaciones importantes, utilizando las letras: T/ I / N / M. La T no representa las medidas lineales de la masa como en ese sistema, sino que más bien expresa la relación del volumen del tumor con el de la cavidad torácica del mismo individuo (T= R: Vol Tum / Vol Tórax). Estos datos se obtienen directamente del tomógrafo, o bien, calcularse según el software de cada equipo de tomografía. Usualmente el estudio tomográfico de un tumor mediastinal comprende una gran cantidad de cortes realizados a milímetros de distancia entre sí. Primero se determina el rango del coeficiente de atenuación en unidades Hounsfield del tumor, y en cada corte se dibuja el perímetro de éste. Se pide a la computadora que sume todos los volúmenes con el rango de unidades que cubran el tumor, y se obtiene así el volumen de la masa. De igual manera, se determina el coeficiente del aire que rodea el tumor (representa los pulmones) y se obtiene el volumen de la cavidad ocupado por éste. El volumen total de la cavidad torácica será la suma del volumen del aire más el del tumor. La relación se obtiene al dividir el volumen tumoral por el torácico total. El corazón, la tráquea y los grandes vasos, comunes a todos, no se toman en cuenta. La I indica invasión de cualquier estructura, sea vena cava, tráquea, aorta, etc. La disminución o compromiso de la luz en <50%, se indica con una a y con una b si es >50%. La N se refiere a la presencia o no de ganglios linfáticos, particularmente en tumores no linfomatosos, y la M a la existencia o no de metástasis. El estadio del túmor de cada paciente puede determinarse según sea su combinación letras, como se indica en el texto.

The mediastinum is an anatomic compartment that frequently lodges tumors of different histology, given the diversity of organs and structures that either occupy it or go through it, in one or another direction. Since the chest cavity is so large, is not uncommon to see patients presenting with pretty big tumors, sometimes invading vital organs, complicating their clinical status, anesthetic management and needed surgical procedures. Currently a common staging system applicable to patients with mediastinal tumors does not exist; the size of the mass and its relationships to neighboring organs is described from the imaging studies. If a TNM like system existed for mediastinal tumors, treating physicians could communicate and asses a particular lesion better, follow its response to treatment and could best define a prognosis for the patients. Based on the TNM system we propose herein an staging system for mediastinal tumors, utilizing the letters: T/I/N/M. The letter T expresses the relationship of volume of tumor, with the volume of the continent chest cavity; these volumes may be easily obtained from the CT scanner depending on its software. Otherwise the perimeter of the mass is drawn in the axial cuts, which are several millimeters thick and its density range is read in Hounsfield units. The computer determines the total volume of tissue slices comprised between the established density limits, and that constitutes the tumor volume in cubic centimeters. The volume of the chest cavity is obtained from the volume of the lungs, which is given by the amount of air filling them. The sum of it plus the tumor volume will give the whole chest cavity volume. Dividing tumor volume by the total chest volume, gives the relationship or T. Since we all have heart, trachea and great vessels their volume is not computed. The letter I, implies invasion, and the invaded organ is mentioned, such as cava, aorta, etc. If its lumen is <50% compromised a letter a) is added and if >50% a letter b) The letter N, reflects involvement or not of lymph node, particularly in non lymphomatous growths and the letter M, the presence or abscense of metastatic deposits. Tumor staging can be determined according to a combination of letters, exhibiting the more advanced, a larger proportion of tumor volume, vital organ invasion, lymph node enlargement and the presence of metastasis.

 tumores de mediastino estadiaje sistema TNM mediastinal tumors staging TNM system Navarro M García L Salazar C Análisis y seguimiento de pacientes con tumores de mediastino egresados de los hospitales metropolitanos de Costa Rica durante 1996 Acta Méd Costarric 2003 45 TNM classification of malignant tumors TNM classification of malignant tumors 2009 7 ^eReino Unido Wiley-Blackwell Masaoka A Monden Y Nakahara K Tanoika T Follow-up study of thymomas with special reference to their clinical stage Cancer 1981 48 Moran CA Suster S Primary germ cell tumors of the mediastinum: I. Analysis of 322 cases with special emphasis on teratomatous lesions and a proposal for histopathologic classification and clinical staging Cancer 1997 80 Kabay S Ozden H Yucel M Tefekli A.H Gulbandilar E Musnumanoglu AH Estimation of the tumor volume and tumor ratio on computer tomography in patients with renal cell carcinoma: a stereological study J Health Sc 2007 53 Staging Manual in Thoracic Oncology Staging Manual in Thoracic Oncology 2009 Orange Park^eFla Editorial Rx Press Mountain Clifton F A New International Staging System for Lung Cancer Chest 1986 89
S0001-600220100003 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022010000300009 Enfermedad por Hemoglobina H: primer caso de la variante de hemoglobina H tipo (-&#945;3.7/ --SEA) en Costa Rica. Hemoglobin H Disease: First Case of Hemoglobin H Variant Type (-&#945;<3.7/ --SEA) in Costa Rica Cartín-Sánchez Walter Valverde-Muñoz Kathia Suárez-Vargas Carlos López-Villegas Jorge ,Laboratorio de Estudios Especializados e Investigación ,Hospital Nacional de Niños Dr. Carlos Sáenz Herrera Servicio de Hematología 07 2010 2010 52 177 179

La enfermedad por Hemoglobina H es la forma más común de talasemia intermedia y posee muchas características que requieren cuidadosa consideración en su manejo clínico. En la mayoría de los casos, la enfermedad por Hemoglobina H resulta de un estado doble heterocigoto producido por una deleción tipo &#945;0 que remueve ambos genes de &#945;-globina en uno de los cromosoma 16 y de una deleción tipo &#945;+ en uno de los genes de &#945;-globina en el otro cromosoma 16, resultando en una condici&#963;n tipo (--/-&#945;). El exceso de cadenas &#946; de globina precipita y forma una hemoglobina anormal característica; la hemoglobina H (Hb H), un tetrámero de &#946; globina (&#946;4). Los pacientes con hemoglobina H que se encuentran en estado compensado pueden tener niveles de hemoglobina entre 9 y 10 g/dL, sin embargo durante las crisis hemolíticas, que se desarrollan durante o después de infecciones agudas con fiebres altas, la hemoglobina puede llegar a disminuir significativamente y los pacientes pueden desarrollar shock y fallo renal.Aún cuando la esplenectomía eleva la hemoglobina significativamente, no se recomienda porque la mayoría de los pacientes tienen un nivel aceptable de hemoglobina mientras se encuentren compensados. Se presenta el primer caso descrito en Costa Rica de enfermedad por hemoglobina H variante del sudeste asiático (-&#945;3.7/ --SEA).¹

Hemoglobin H (Hb H) disease is the most common form of thalassemia intermedia and has many features that require careful consideration in its management. In the majority of cases, the disease results from double heterozygosity for &#945;0thalassemia due to deletions that remove both linked &#945;globin genes on one chromosome 16, and deletional &#945;+ from single &#945;-globin gene deletions on the other chromosome 16 resulting in a (--/-&#945;) condition. The excess &#946; globin chain precipitates and forms a characteristic abnormal hemoglobin: hemoglobin H a &#946; globin tetramer (&#946;4). In a steady state, patients with Hb H disease have hemoglobin levels around 9 to 10 g/dL however, during a hemolytic crisis, which frequently occur in or after acute infections causing high fever, the hemoglobin may drop significantly and the patients can develop shock or renal shutdown. Even though splenectomy leads to significant elevation of hemoglobin levels, it is not recommended because the majority of patients do well with said steady-state hemoglobin levels. We present here the first case of hemoglobin H (-&#945;3.7/ --SEA) southeast Asia variant described in Costa Rica.¹

 hemoglobina H alfa talasemia anemia hemolítica hemoglobin H alpha-thalassemia hemolytic anemia Sáenz GF Rodríguez W Síndromes talasémicos: Nuevos conceptos y estado actual del conocimiento en Costa Rica Act Méd Costarric 2006 48 Fuchaeron S Viprakasit V Hb H disease: clinical course and disease modifiers Hb H disease: clinical course and disease modifiers 2009 New Orleans^eLuisiana American Society of Hematology. Education Program Book Chui DH Waye JS Hydrops fetalis caused by alpha-thalassemia: an emerging health care problem Blood 1998 91 Chui DH Fucharoen S Chan V Hemoglobin H disease: not necessarily a benign disorder Blood 2003 101 Lau YL Chan LC Chan YY Prevalence and genotypes of alpha- and beta-thalassemia carriers in Hong Kong - implications for population screening N Engl J Med 1997 336 Higgs DR Steinberg MH Forget BG Higgs DR Weatheall DJ Molecular basis of alpha thalassemia Disorders of Hemoglobin Disorders of Hemoglobin 2009 Sec. Ed. Cambridge University Press
S0001-600220100003 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022010000300010 Cartas al editor , 07 2010 2010 52 180 181
S0001-600220100003 Acta Médica Costarricense Acta méd. costarric 0001-6002 Colegio de Médicos y Cirujanos de Costa Rica S0001-60022010000300011 Investigación Costarricense en Revistas Extranjeras , 07 2010 2010 52 182 183