Resumen El control biológico en caña de azúcar en Venezuela se ha logrado establecer como una medida única, con resultados óptimos del uso de parasitoides y entomopatógenos para el control de los taladradores del género Diatraea, y, posteriormente, de la candelilla Aeneolamia spp., ambas plagas claves del cultivo. Para los taladradores, se logró después de liberaciones sistemáticas de la mosca amazónica Lydella minense desde un inicio, a mediados del siglo XX y luego con el establecimiento de la avispa bracónida Cotesia flavipes, a partir de 1987. Para el control biológico de Aeneolamia varia, plaga que implicaba la aplicación frecuente de insecticidas, después de la introducción del uso del hongo entomopatógeno Metarhizium anisopliae desde 1977, se ha establecido como medida eficiente para el control de sus adultos, aunque las ninfas eran menos controladas. Este aspecto se resolvió mediante la introducción del nematodo entomopatógeno Heterorhabditis bacteriophora en 2004, el cual se viene utilizando en forma general, y prácticamente ya se tienen las medidas biológicas para evitar la aplicación de insecticidas. Como ejemplo se tiene a la Azucarera Río Turbio, aunque en las últimas zafras ha tenido una reducción en sus áreas, por diferentes factores. Durante los últimos 58 años, la infestación de Diatraea muestra una reducción de 15 a 3.18 %, con lo cual se salvan 170 552.62 toneladas métricas (TM), con un valor de US$ 49 196 045 y un costo del control biológico de US$ 1 187 189 lo que se traduce en un beneficio-costo de US$ 41.44. Antes del establecimiento del control biológico, Aeneolamia se controlaba exclusivamente con insecticidas químicos, aplicados al follaje para los adultos y al suelo para las ninfas. Simultáneamente desde entonces, se ha utilizado el hongo M. anisopliae producido por empresas nacionales, hasta cubrir 87 000 ha, entre 1986 y 1990. También, desde 2004 se inició la utilización de nematodos entomopatógenos para el control de ninfas de Aeneolamia.

Abstract The biological control in sugarcane in Venezuela has been established as a unique measure, having optimal results of the use of parasitoids and entomopathogens for the control of borers of the genus Diatraea, and later of the candelilla Aeneolamia spp., both key pests of the crop. For borers it was achieved after systematic releases of the Amazonian fly Lydella minense from the middle of the last century and then with the establishment of the braconid wasp Cotesia flavipes from 1987. For the biological control of Aenolamia varia, pest that involved the frequent application of insecticides, after the introduction of the use of the entomopathogenic fungus Metarhizium anisopliae since 1977, has been established as an efficient measure for the control of its adults, however, the nymphs were less controlled. This aspect was resolved through the introduction of the entomopathogenic nematode Heterorhabditis bacteriophora in 2004, which has been widely used as a biological measure to avoid the application of insecticides. As an example, we have the Azucarera Río Turbio, although in the last harvests it has had a reduction in its areas due to different factors. During the last 58 years, Diatraea infestation shows a reduction of 15 to 3.18 %, which saves 170 552.62 metric tons with a value of US$ 49 196 045 and a cost of biological control of US$ 1 187 189 which translates into a benefit-cost of US$ 41.44. Before the establishment of biological control, Aeneolamia was controlled exclusively with chemical insecticides applied to foliage for adults and soil for nymphs. Simultaneously since then, the entomopathogenic fungus M. anisopliae produced by national companies has been used and this entomopathogen was used on 87 000 hectares between 1986 and 1990. Also since 2004, the methodology of using entomopathogenic nematodes to control Aeneolamia nymphs began.

Abstract This article reflects upon the constitutional politics of the Anthropocene within the Chilean constituent process. In that regard, it describes the emergence, consolidation and deficiencies of environmental constitutionalism and explains the elements of a new epistemic framework for the constitutionalism of the Anthropocene. After some thoughts on the constitutional regulation for the Anthropocene, it proposes a general clause that allows the Chilean State to address the challenges that the Anthropocene raises upon constitutional law.

Resumen Este artículo reflexiona sobre la política constitucional del Antropoceno en el marco del proceso constituyente chileno. Para ello, describe el auge, consolidación y deficiencias del constitucionalismo ambiental, y plantea diversas premisas para elaborar un marco epistémico del constitucionalismo del Antropoceno. Después de algunas consideraciones sobre la regulación constitucional en esta nueva era geológica, el artículo propone una cláusula general que permita al Estado chileno abordar los desafíos que el Antropoceno plantea al Derecho Constitucional.

The diverticular disease is a prevalent condition with a great economic and medical repercussion. Despite the multiple guidelines available to protocolize diagnosis and treatment, there is not unanimity in its management. We have carried out an updated review with the aim of analyzing new studies of the disease, to manage it properly and to carry out the most appropriate treatment at each time. Diverticular disease has an inherited component (40%) and it is directly related to low fiber diet, obesity, consumption of red meat, inactivity, alcohol and NSAIDs. Due to its nonspecific symptoms, it is difficult to make a differential diagnosis. Ultrasound and abdominal CT are appropriate methods for diagnosis and early colonoscopy is recommended (4th-8th week) after acute symptoms. The most followed classification is the Hinchey Score. There is no clear evidence of the superiority of any drug in the treatment of symptomatic diverticulosis. Acute uncomplicated diverticulitis can be managed on an outpatient and the use of antibiotics is not necessary in patients without risk factors. Conservative management tends to be used in complicated diverticulitis, although in Hinchey III and IV the treatment is surgical, recommending resection of the affected area and, if possible, anastomosis with or without a protective stoma. Washing and draining is not recommended in the Hinchey III. Treatment must be agreed on an individual basis since surgical treatment is not recommended due to the number of recurrences or the age of the patient.

Resumen La enfermedad diverticular es muy prevalente con gran repercusión económica y médica. A pesar de las múltiples guías para protocolizar el diagnóstico y tratamiento no existe unanimidad en su manejo. Hemos realizado una revisión actualizada con el objetivo de analizar los nuevos estudios de esta enfermedad, para manejarla adecuadamente y realizar el tratamiento más adecuado en cada momento. La enfermedad diverticular tiene un componente hereditario (40%) y presenta una relación directa con la dieta pobre en fibra, la obesidad, el consumo de carne roja, la inactividad, el alcohol y los AINEs. Por su clínica inespecífica, es difícil realizar un diagnóstico diferencial. La ecografía y el TC abdominal son métodos apropiados para el diagnóstico y se recomienda una colonoscopia de manera precoz (4ᵃ-8ᵃ semana) tras el cuadro agudo. La clasificación más seguida es la de Hinchey. En el tratamiento médico de la diverticulosis sintomática no se ha demostrado evidencia clara de ningún medicamento. La diverticulitis aguda no complicada se puede manejar ambulatoriamente y no es necesario el uso de antibióticos en pacientes sin factores de riesgo. En la diverticulitis complicada se tiende a un manejo conservador, aunque en el Hinchey III y IV el tratamiento es quirúrgico, recomendando la resección de la zona afecta y si es posible anastomosis con o sin estoma de protección. No se recomienda el lavado y drenaje en el Hinchey III. Hay que consensuar tratamiento de forma individualizada ya que no se recomienda tratamiento quirúrgico por el número de recurrencias ni por edad del paciente.

Abstract Patients with hypecalcemic crisis usually stabilize with medical treatment and rarely require urgent surgical treatment. Woman with a nonspecific clinic of abdominal pain, diagnosed late of hypercalcemic crisis due to primary hyperparathyroidism. Medical treatment and peritoneal dialysis were not effective, requiring urgent parathyroidectomy with determination of intraoperative parathormone. The preoperative location of the adenoma was concordant for scintigraphy and ultrasound. Hypercalcemic crisis due to primary hyperparathyroidism without response to medical treatment requires urgent parathyroidectomy. Preoperative adenoma location and intraoperative parathormone are essential for curative surgical treatment.

Resumen Los pacientes con crisis hipecalcémica suelen estabilizarse con tratamiento médico y rara vez precisan tratamiento quirúrgico urgente. Se presenta el caso de una mujer con clínica inespecífica de dolor abdominal, diagnosticada tardíamente de crisis hipercalcémica por hiperparatiroidismo primario. El tratamiento médico y la diálisis peritoneal no fueron efectivos, por lo que precisó paratiroidectomía urgente con determinación intraoperatoria de hormona paratiroidea. La localización preoperatoria del adenoma fue concordante para gammagrafía y ecografía. La crisis hipercalcémica por hiperparatiroidismo primario sin respuesta al tratamiento médico precisa paratiroidectomía urgente. El diagnóstico de localización preoperatorio y la hormona paratiroidea intraoperatoria son indispensables para un tratamiento quirúrgico curativo.

Objetive: Ambulatory or overnight stay surgery have been consolidated in many different procedures. However, its use in thyroid and parathyroid surgery is still controversial. The aim of this report is to present the results of 6 years of ambulatory patients undergoing surgery of the thyroid or parathyroid glands. Material and Methods: Prospective observational study of patients who underwent hemithyroidectomy or selective parathyroidectomy in the ambulatory program from January 2011 to December 2016. All patients included met the general criteria of ambulatory surgery. During the first years nodules bigger than 3 cm and patients classified as ASA III were excluded. Patients arrive at hospital the morning of surgery. After the operation, patients pass to the post-anesthesia care unit and then to the hospitalization room. 8 hours after surgery patients are discharged home if they meet the criteria. Results: 270 patients were operated, 159 of them met the inclusion criteria. The overall applicability rate was 59%. The acceptance rate was 83.6% and the substitution index was 49.2%. The unwanted hospital admission was 10.4% for the parathyroidectomy and 17.6% for the hemithyroidectomy. Any patient presented major complications at home. The satisfaction rate was high or very high for 94% of the patients. Conclusion: Selective parathyroidectomy and hemithyroidectomy performed by experienced surgeons in selected patients can be safely and effectively carried out in ambulatory surgery (outpatient). It would be possible to improve the substitution index by increasing the application and acceptability ratios.

Resumen Objetivo: La cirugía mayor ambulatoria (CMA) y con estancia inferior a 24 horas (overnight stay) se ha consolidado en muchas patologías aunque en cirugía tiroidea y paratiroidea resulta controvertido. El objetivo es valorar nuestros resultados en cirugía del tiroides y paratiroides en régimen de CMA durante un periodo de 6 años. Material y Métodos: Estudio observacional prospectivo de pacientes con indicación de hemitiroidectomía o paratiroidectomía enfocada en régimen CMA entre enero de 2011 y diciembre de 2016. Los pacientes cumplían criterios de CMA. En los primeros años se excluyeron los nodulos tiroideos mayores de 3 cm y los pacientes ASA III. Los pacientes ingresaron la mañana de la intervención, tras el acto quirúrgico pasaron a la Unidad de Recuperación Posquirúrgica y posteriormente a sala de hospitalización. Tras 8 h, si cumplían criterios, fueron dados de alta. Resultados: Se intervinieron 270 pacientes, la tasa de aplicabilidad global fue del 59%, la tasa de aceptabilidad global del 83,6% y el índice de sustitución del 49,2%. El índice de ingresos no deseados fue del 10,4% para la paratiroidectomía y del 17,6% en la cirugía del tiroides. Ningún paciente presentó complicaciones mayores en su domicilio. El grado de satisfacción fue alto o muy alto en el 94% de los pacientes. Conclusiones: La paratiroidectomía enfocada y la hemitiroidectomía realizada por cirujanos expertos en pacientes seleccionados, es segura y efectiva en régimen ambulatorio. Es posible mejorar el índice de sustitución ambulatorio aumentando la tasa de aplicabilidad y aceptabilidad.

Background: lymphangiomas are rare benign tumors of the lymphatic system, being more common in the pediatric population. Intra-abdominal localization is very rare; only 1 % of lymphangiomas appear in the retroperitoneum. We report a case of a rare tumor because of its location and the elderly age of presentation. Retroperitoneal lymphangioma is a rare tumor with an unertain pathogenesis. Diagnosis is usually confirmed by imaging studies , e.g., US, MRI or CT. Although they are benign tumors, complete surgical resection is the treatment of choice. With this treatment, complications like infection, perforation or bleeding are prevented. Our case is unusual because of the retroperitoneal location of the tumor and the late age of presentation.

Los linfangiomas son tumores benignos raros del sistema linfático, más comunes en la población pediátrica. La localización intraabdominal es muy infrecuente: tan solo el 1% de los linfangiomas aparece en el retroperitoneo. Se describe una tumoración quística infrecuente tanto por su localización como por la edad de presentación. Los linfangiomas retroperitoneales son tumores raros y su etiopatogenia es incierta. El diagnóstico se realiza mediante estudios de imagen; las técnicas de elección son la ultrasonografía (USG), la resonancia magnética (RM) o la tomografía computarizada (TC). A pesar de que se trata de tumores de naturaleza benigna, la exéresis quirúrgica completa es el tratamiento de elección para prevenir complicaciones como la sobreinfección, la rotura o el sangrado. Nuestro caso resulta infrecuente tanto por la localización retroperitoneal del tumor como por la tardía edad de presentación.

It is not uncommon for atypical cases of postinfectious glomerulonephritis (PIGN) to be confused with C3 glomerulonephritis (C3GN) due to considerable overlap of their clinical and histopathological features. We present a case of a 42-year-old man who was hospitalized with hematuria and worsening renal function after an episode of pharyngitis. Following a complete negative serological examination, the indolent clinical course associated with the findings of diffuse proliferative and exudative glomerulonephritis with dominant C3 staining and subendothelial and mesangial electron-dense deposits on the kidney biopsy were fundamental for the final diagnosis. The genetic test identified two mutations involved in the alternative complement pathway. Steroids and mycophenolate mofetil were initiated with improved renal function. This case alerts us that the presence of atypical clinical or histological features of apparent PIGN should raise suspicion of C3 glomerulopathy (C3G) because only a correct diagnosis will allow adequate treatment and a better long-term prognosis

Paraproteinemias are characterized by the abnormal expansion of a plasma cell clone with overproduction of a monoclonal (M) immunoglobulin. In rare cases (1%) two distinct M proteins can be identified (biclonal gammopathy). Renal manifestations are frequent and can present with several histological patterns. Prognosis and treatment are similar to monoclonal gammopathies varying according to extent of disease and response to therapy. We report a case of a 72-year-old man with a prior history of hypertension, dyslipidemia, and prostate cancer with bone metastasis under treatment with leuproline, cyproterone, and nonsteroidal anti-inflammatory drugs who was found to have anemia, acute kidney injury, and hypercalcemia. After clinical evaluation and workup, a biclonal multiple myeloma (IgG kappa and IgA lambda) and a cast nephropathy were diagnosed. The patient was started on renal replacement therapy and on CyBorDex treatment cycle protocol for two years with remission of multiple myeloma but without renal function recovery. During this period, there was no prostate cancer progression. This case report alerts us to the rarity of a biclonal multiple myeloma especially in a patient with advanced prostate cancer but also to the fact that not all osteolytic lesions are secondary lesions

Introduction: The objective and structured clinical evaluation (OSCE) is a test that evaluates the clinical competences. Subjects and methods: An online questionnaire was conducted. Results: The organizational assessment of the test was 8.96 and the overall experience of the students was 7.91. The stations of greater difficulty were those of writing of reports. Conclusion: The ECOE questionnaire offers valuable information on perceived quality perceived by the student, which allows for future improvement plans.

Introducción: La evaluación clínica objetiva y estructurada (ECOE) es una prueba que evalúa las competencias clínicas. Sujetos y métodos.: Se realizó un cuestionario online. Resultados.: La valoración organizativa de la prueba fue de 8,96 (sobre 10), y la experiencia global de los estudiantes, de 7,91 (sobre 10). Las estaciones de mayor dificultad fueron las de redacción de informes. Conclusión: La ECOE ofrece una valiosa información de la calidad percibida por el alumno, lo que permite plantear futuros planes de mejora.

Axenfeld-Rieger syndrome is a congenital disease with an estimated prevalence of one in 200,000 individuals. This is an ophthalmic disorder related to anterior segment dysgenesis, which may be present from the neonatal period. It is associated with extraocular affectations such as cranial dimorphism, maxillofacial or dental anomalies. Cardiological or pituitary manifestations are less common. The congenital heart disease in Axenfeld-Rieger syndrome has been described in very few cases in the literature. We report a 7-year-old patient with Axenfeld-Rieger syndrome and mild mitral insufficiency since the age of 3 years, which is progressing to moderate mitral regurgitation at the present time. The cardiologic follow up may be indicated in patients with Axenfeld-Rieger syndrome.

El síndrome de Axenfeld-Rieger es una enfermedad congénita con una prevalencia estimada de 1 cada 200 000 individuos. La afectación oftálmica con la disgenesia del segmento anterior es la que define la enfermedad. Se puede presentar desde el período neonatal. Se asocia con afectaciones extraoculares, como dismorfismo craneal y anomalías maxilofaciales o dentarias; otras manifestaciones menos frecuentes son las cardiológicas o hipofisarias. La aparición de cardiopatia no congénita en el síndrome de Axenfeld-Rieger ha sido descrita en muy pocos casos en la literatura. Presentamos un paciente de 7 años de edad que presentó síndrome de Axenfeld-Rieger, con insuficiencia mitral ligera desde los 3 años que progresó a insuficiencia mitral moderada en la actualidad. El seguimiento cardiológico estaría indicado en pacientes con síndrome de Axenfeld-Rieger.

A síndrome do anticorpo antifosfolipídico é uma patologia que se manifesta pela presença de eventos trombóticos arteriais ou venosos associados a autoanticorpos antifosfolípidicos em circulação. As lesões vasculares induzidas pelos anticorpos resultam numa constelação de complicações neurológicas, cardiovasculares, obstétricas e renais. O envolvimento renal é frequente e reflecte a extensão do processo trombótico nas vascularização renal. Contudo, para além das lesões vasculares características da nefropatia desta síndrome, várias outras alterações renais têm sido relatadas. As glomerulopatias primárias podem sobrepor-se ao quadro clínico característico desta nefropatia e apresentar-se como síndrome nefrótica com ou sem disfunção renal. O caso descrito corresponde a uma mulher de 45 anos com síndrome do anticorpo antifosfolipídico, que recorreu ao Serviço de Urgência por quadro de edemas generalizados. Após a avaliação inicial, perante o diagnóstico de síndrome nefrótica realizou-se biópsia renal. Não se visualizaram alterações glomerulares além da esclerose associada a isquémia subcapsular. A imunofluorescência foi negativa para depósitos glomerulares. A escassez de lesões nos glomérulos não esclerosados sugeriu a podocitopatia primária como a causa mais provável da síndrome nefrótica, pelo que iniciou corticoterapia com resultante remissão completa ao fim de 8 semanas. No entanto, durante a redução progressiva da terapêutica verificou-se recaída desta síndrome com necessidade de aumentar a dose de prednisolona. Porém, constatou-se que a manutenção da regressão da síndrome nefrótica só foi possível com a toma permanente de corticoterapia em baixas doses. O início súbito do quadro, juntamente com as características histológicas e a boa resposta à corticoterapia, apontou a doença de lesões mínimas como o diagnóstico mais provável. Todavia, permanece ainda por esclarecer se esta glomerulopatia está relacionada com a síndrome anticorpo antifosfolípido ou se resultou apenas de um acaso infeliz.

The antiphospholipid syndrome is a clinical entity that presents as arterial or venous thrombotic events in association with circulating phospholipid autoantibodies. Patients may display a constellation of neurologic, cardiovascular, obstetric and renal complications as a result of antibody-induced vessel injury. Kidneys are one of the most affected organs and its involvement often reflects the extension of the thrombotic process in its vasculature. However, in addition to the characteristic vascular findings of antiphospholipid nephropathy, an expanding spectrum of renal lesions has been reported. Primary glo- merulopathies may often overcome the clinical picture and present themselves as nephrotic syndrome with or without renal dysfunction. Here, we report a case of a 45-year old woman with antiphospholipid syndrome that presented to the emergency department with generalized oedema. After the initial workup nephrotic syndrome was assumed and a renal biopsy was performed. No detectable glomerular abnormalities other than sclerosis as a result of subcapsular ischaemia were seen. Immunofluorescence was negative for glomeruli deposits. The paucity of lesions in the non-sclerosed glomeruli pointed a primary podocytopathy as the most probable cause. The patient was started on corticosteroids with resultant complete remission in about 8 weeks. Nonetheless, during steroid tapering, the nephrotic syndrome relapsed and a higher dose was again needed for remission. However, the patient had to remain on low-dose corticosteroids for maintenance of nephrotic syndrome regression. Its sudden onset, together with the histological features and the good steroid response, made minimal change disease the most probable diagnosis. Yet, it remains unclear whether minimal change disease was related with antiphospholipid syndrome or was an unfortunate event.

Background and objectives: Hypervolemia is a major concern in dialysis patients, and is associated with increased cardiovascular risk and death. Cross sectional analysis have previously demonstrated that peritoneal dialysis (PD) patients are not more overhydrated when compared to haemodialysis' ones. This study was designed to evaluate longitudinal trends in hydration status and corporal composition in a PD population. Methods: We conducted a 2 year prospective observational study of 58 PD patients from a single centre. Incident and prevalent patients were included. Yearly measurements were performed using multifrequency electric bioimpedance. Overhydration (OH) was defined as an extra-cellular water (ECW)/total body water (TBW) over 15%. Clinical and biochemical variables were also explored. Results: A total of 30 patients completed evaluation (female 63.3%, mean age 56.9 years, BMI 25.0 kg/m², diabetes 10.0%, APD-50.0%). Median PD vintage was 21.9 months, and 36.7% were anuric. At baseline 6.7% were overhydrated. On longitudinal analysis no significant changes were found in hydration status, systolic blood pressure, pro-BNP, nor albumin levels. Similar results were found among incident (n=11; APD- 45.5%; anuric- 9.1%) and prevalent (n=19; APD- 52.6%; anuric- 52.6%) patients (p>.05). However, at the second year, prevalent patients were moderately overhydrated compared to incident ones (median 10.2% vs 3.5%; p=.009). Nonetheless, no statistical difference was observed considering adequacy, TBW, or ECW. Moreover, nutritional parameters remained stable. Conclusions: Peritoneal dialysis maintenance without increasing volume status, nor major deleterious corporal composition trends, is feasible under careful therapy strategies. Longitudinal application of BIA may be a useful clinical tool to evaluate adequacy beyond Kt/V.

Antecedentes y objetivos: La hipervolemia constituye un gran problema en los pacientes de diálisis, y se asocia a un incremento del riesgo cardiovascular y muerte. Los análisis transversales han demostrado previamente que los pacientes de diálisis peritoneal (DP) no sufren de sobrehidratación, en comparación a los pacientes de hemodiálisis. Este estudio fue diseñado para evaluar las tendencias longitudinales de composición corporal e hidratación en una población de pacientes de DP. Métodos: Realizamos un estudio observacional prospectivo de dos años a 58 pacientes de DP de un único centro. Se incluyó pacientes incidentales y prevalentes. Se realizaron mediciones anuales utilizando bioimpedancia eléctrica de multi-frecuencia. La sobrehidratación se definió como el ratio agua extra-celular (ECW)/agua corporal total (ACT) superior al 15%. También se exploraron variables clínicas y bioquímicas. Resultados: Un total de 30 pacientes completarán el estudio (mujeres: 63,3%, edad media 56,9 años, IMC 25,0 kg/m², diabetes 10,0%, DPA-50,0%). La antigüedad media de DP fue de 21,9 meses, y el 36,7% padecía anuria. Al inicio, el 6,7% padecía sobrehidratación. En los análisis longitudinales no se hallaron cambios en cuanto a hidratación, presión sanguínea sistólica, pro-BNP, o niveles de albúmina. Se hallaron resultados similares entre los pacientes incidentales (n = 11; APD- 45,5%; anuria- 9,1%) y prevalentes (n = 19; DPA- 52,6%; anuria- 52,6%) (p > 0,05). Sin embargo, al segundo año, los pacientes prevalentes estaban moderadamente sobrehidratados en comparación con los incidentales (media 10,2% frente a 3,5%; p = 0,009). En cambio, no se observó una diferencia estadística en cuanto a adecuación, ACT, o ECW. Además, los parámetros nutricionales permanecieron estables. Conclusiones: La prevalencia de la diálisis peritoneal sin incremento de volumen ni alteración de los índices de composición corporal es factible si se aplican estrategias terapéuticas prudentes. La aplicación longitudinal de BIA puede constituir una herramienta clínica para evaluar la adecuación por encima de Kt/V.