ABSTRACT The incidence of thyroid cancer is increasing globally, but mortality rates have remained steady. Many patients with thyroid cancer have low-risk, nonmetastatic intrathyroidal tumors smaller than 2 cm. Active surveillance has shown benefits in these patients, but the adoption of this approach remains below standard in Latin America. The purpose of this article is to identify ways to improve the incorporation of active surveillance into clinical practice for patients with low-risk thyroid carcinoma in Latin America, taking into consideration cultural and geographic factors. Current recommendations include three steps involving patient participation. The first step, which consists of the initial clinical examination, has eight factors requiring special attention. Anxiety must be managed while considering individual, disease-related, cognitive, and environmental aspects. Terms like "overdiagnosis", "incidentaloma," and "overtreatment" must be explained to the patient. Implementing precise terminology contributes to adequate disease perception, substantially reducing stress and anxiety. Clarifying the nonprogressive nature of thyroid cancer helps dispel myths surrounding the disease. The second step includes advice about procedures and guidelines for patients who choose active surveillance. Flexible monitoring techniques should be implemented, with regular check-ins scheduled based on patient needs. Reasons for adjusting treatment must be clearly communicated to the patient, and changes in preference regarding active surveillance should be considered in advance. The third step includes assistance during follow-up. Patients must be educated about ultrasound results and receive surgical indications from specialized physicians. The effectiveness of active surveillance can be reinforced by explaining to the patients the dynamics of changes in nodule size using clear and concise visual aids. globally steady lowrisk, lowrisk low risk, risk cm America participation examination attention individual diseaserelated, diseaserelated related, related disease-related cognitive aspects overdiagnosis, overdiagnosis , "overdiagnosis" incidentaloma, incidentaloma "incidentaloma, overtreatment "overtreatment perception anxiety implemented checkins check ins needs advance followup. followup follow up. up follow-up physicians aids "overdiagnosis "incidentaloma

RESUMEN El hipoparatiroidismo es definido como hipocalcemia en presencia de hormona paratiroidea baja (< 20 pg/mL) o indetectable. Es una enfermedad rara con una prevalencia estimada de 37 casos por 100.000 habitantes. Aunque la etiología es variada, la causa más frecuente, en 75 % de los casos, es el hipoparatiroidismo posoperatorio. Esta situación puede ocurrir en cualquier cirugía de cuello, pero es más frecuente en la resección de tiroides. Otras causas infrecuentes incluyen trastornos autoinmunes como el síndrome poliglandular tipo 1, desórdenes genéticos como la anomalía de DiGeorge o trastornos funcionales como la hipomagnesemia. Los síntomas agudos más importantes de la hipocalcemia son la irritación neuromuscular, como parestesias y convulsiones. Crónicamente se pueden presentar calcificaciones en varios sitios del cuerpo incluyendo los ganglios basales. El diagnóstico y enfoque de esta enfermedad parte de un valor disminuido de calcio combinado con PTH menor de 20 pg/mL, siempre excluyéndose hipomagnesemia. Además, debe solicitarse fósforo y calciuria de 24 horas. El tratamiento se realiza con reposición oral de calcio y vitamina D activa (calcitriol). En algunos casos con hipercalciuria se pueden usar diuréticos tipo tiazida. Recientemente se aprobó en Estados Unidos y Europa, el uso de hormona recombinante paratiroidea 1-84 en pacientes con hipoparatiroidismo que no estén controlados fácilmente con calcio y calcitriol o en aquellos que tengan complicaciones o deterioro en la calidad de vida.

SUMMARY Hypoparathyroidism is an infrequent disorder. The main characteristic is low calcium with low PTH. The estimate prevalence is 37 cases per 100.000 inhabitants. The most frequent cause (75 % of all cases) is removal of parathyroid gland during neck surgery. Other causes are polyglandular autoimmune syndrome type 1, genetic disorders such as DiGeorge anomaly, or functional disorders like hypomagnesemia. Hypocalcemia may produce neuromuscular symptoms and seizures. Chronic manifestations include ectopic calcifications. The diagnosis of hypoparathyroidism is made when calcium is below normal in presence of low or undetectable PTH (< 20 pg/mL). Magnesium, phosphorus and 24-hour urine calcium should be measured in all patients with hypoparathyroidism. The management of this disease is with calcium supplements plus active vitamin D (calcitriol). In some cases, with hypercalciuria, a thiazide diuretic may be used. Recently, the use of recombinant PTH 1-84 was approved in the United Stated and Europe. This treatment is indicated in patients with uncontrolled hypoparathyroidism despite increasing doses of calcium and calcitriol or in patients with complications of hypoparathyroidism or deceased quality of life.

Resumen Introducción: No existen guías establecidas para seleccionar los pacientes para traqueostomía precoz. El objetivo del estudio fue determinar los factores que pueden predecir la posibilidad de intubación mayor a 7 días en pacientes adultos en la UCI. Métodos: Este es un estudio de cohorte realizado en la UCI. Los pacientes en ventilación mecánica mayor a 48 horas fueron incluidos. Se recogieron los datos clínicos y fisiológicos de cada paciente al tercer día de intubación. Se realizaron análisis uní y multivariado para determinar las variables asociadas a intubación prolongada. Resultados: 163 (62%) fueron hombres y la edad media fue de 59±17 años. Aproximadamente un tercio de los pacientes (36%) requirieron ventilación mecánica mayor a 7 días. Las variables asociadas con ventilación mecánica prolongada fueron: edad (HR 0.97 (95% CI 0.96-0.99); diagnóstico de urgencia quirúrgica en un paciente con enfermedad médica (HR 3.68 (95% CI 1.62-8.35),diagnostico de necesidad de cirugía no urgente (HR 8.17 (95% CI 2.12-31.3); diagnóstico de enfermedad medica no quirúrgica (HR 5.26 (95% CI 1.85-14.9); APACHE II (HR 0.91 (95% CI 0.85-0.97) y puntaje SAPS II (HR 1.04 (95% CI 1.00-1.09). El área bajo la curva ROC para predicción fue de 0.52. 16% de los pacientes fueron extubados después de 8 días de intubación. Conclusiones: No fue posible predecir la extubation precoz en pacientes de la unidad de cuidado intensivo en ventilación mecánica con las variables comúnmente usadas. La probabilidad de destete de ventilación mecánica después de 8 días de intubación sin realizar traqueostomía es baja.

Abstract Introduction: There are no established guidelines for selecting patients for early tracheostomy. The aim was to determine the factors that could predict the possibility of intubation longer than 7 days in critically ill adult patients. Methods: This is cohort study made at a general intensive care unit. Patients who required at least 48 hours of mechanical ventilation were included. Data on the clinical and physiologic features were collected for every intubated patient on the third day. Uni- and multivariate statistical analyses were conducted to determine the variables associated with extubation. Results: 163 (62%) were male, and the median age was 59±17 years. Almost one-third (36%) of patients required mechanical ventilation longer than 7 days. The variables strongly associated with prolonged mechanical ventilation were: age (HR 0.97 (95% CI 0.96-0.99); diagnosis of surgical emergency in a patient with a medical condition (HR 3.68 (95% CI 1.62-8.35), diagnosis of surgical condition-non emergency (HR 8.17 (95% CI 2.12-31.3); diagnosis of non-surgical-medical condition (HR 5.26 (95% CI 1.85-14.9); APACHE II (HR 0.91 (95% CI 0.85-0.97) and SAPS II score (HR 1.04 (95% CI 1.00-1.09) The area under ROC curve used for prediction was 0.52. 16% of patients were extubated after day 8 of intubation. Conclusions: It was not possible to predict early extubation in critically ill adult patients with invasive mechanical ventilation with common clinical scales used at the ICU. However, the probability of successfully weaning patients from mechanical ventilation without a tracheostomy is low after the eighth day of intubation.

El estrés se acepta como un fenómeno necesario que hace parte de los procesos evolutivos. Un síndrome general adaptativo comprende tres fases: una reacción inicial de alarma, un estado de resistencia y una fase de agotamiento. El síndrome de desgaste profesional es una entidad patológica producto del estrés crónico de profesiones que prestan servicios de atención intensa y prolongada a personas que están en una situación de necesidad o dependencia. El término fue mencionado por primera vez en 1974 por Freudenberg y, en 1981, Maslach y Jackson describieron un modelo multidimensional caracterizado por agotamiento o cansancio emocional, despersonalización y reducida realización personal. Se han desarrollado varios instrumentos de medición de la entidad, el más aceptado es el Malash Burnout Inventory (MBI). Se considera que debe existir una susceptibilidad individual asociada a otros factores ambientales, dentro del marco de un modelo ecológico, que lo presenta como un proceso dinámico e interrelacionado en el que se establecen cuatro niveles de influencia: microsistema, organizativo, periorganizativo y extraorganizativo, que son susceptibles de intervenciones a nivel del individuo y del trabajo, o ambiente organizativo.

Stress is a natural phenomenon in the process of evolution. The general adaptation syndrome has three phases: initial alarm reaction, phase of resistance, and phase of exhaustion. The professional burnout syndrome is a pathological entity caused by chronic professional stress in persons that provide intensive and prolonged health care to people in conditions of necessity or dependence. This term was first coined by Freudenberg in 1974, and in 1981 Maslach and Jackson described a multidimensional model characterized by exhaustion and emotional fatigue, depersonalization and reduced personal accomplishment. Among the several instruments that have been developed for its measurement, the most accepted one is the Malash Burnout Inventory (MBI) It is believed that there must be an individual sensibility associated with varied environmental factors within an ecologic framework, that presents the syndrome as a dynamic and interrelated process, in which there are four levels of influence: microsystem, organizational, periorganizational and extraorganizational, all of which are susceptible of intervention at the level of the individual and the workplace or at the organizational level.