Evaluación de la experiencia de telemedicina en consulta de Cirugía de cabeza y cuello en un centro de referencia en Manizales / Evaluation of telemedicine experience in head and neck surgery consultation in a referral center in Manizales

Introducción. La infección por COVID-19 afectó drásticamente la atención en salud a nivel mundial, generando retos para la atención primaria. En orden de mitigar y manejar el contagio, la telemedicina se convirtió en una modalidad emergente y efectiva en varias especialidades médicas, incluida la cirugía de cabeza y cuello. Métodos. Estudio de corte transversal con análisis retrospectivo de pacientes atendidos en la consulta virtual durante 18 meses. Se estimaron frecuencias absolutas y relativas, y bivariado con regresión logística binaria. Se incluyeron las variables de diagnóstico primario, poder resolutivo de la consulta, necesidad de cita presencial, plataforma y dificultades de la misma. Resultados. Se incluyeron 2485 pacientes provenientes de 11 departamentos. La patología tiroidea fue la más frecuente (62,9 %), seguida de la aerodigestiva (10,9 %). La consulta fue eficiente en el 99 % de los casos, con una capacidad resolutiva del 96,4 %. El 1,4 % tuvo dificultades en la plataforma y el 8,3 % de los pacientes requirió cita presencial. Cuando hubo dificultad para la revisión de exámenes o una inadecuada inspección funcional, fue 30 veces más probable no poder resolver eficientemente la consulta. Conclusión. La telemedicina provee una alternativa eficiente de atención en cirugía de cabeza y cuello, especialmente en los controles de patología tiroidea, evitando desplazamientos innecesarios. En el tracto aerodigestivo, donde el examen físico es primordial, su utilidad está limitada a la posibilidad de realizar un examen endoscópico posterior que permita una adecuada estadificación y facilite la valoración presencial.

Introduction. The COVID-19 infection drastically affected health care worldwide, creating challenges for primary care. In order to mitigate and manage infection, telemedicine has become an emerging and effective modality in several medical specialties, including head and neck surgery. Methods. Retrospective cross-sectional analysis of patients seen in virtual consultation over 18 months. Absolute and relative frequencies were estimated, univariate analysis was done with chi-square, and bivariate analysis with binary logistic regression. Variables such as primary diagnosis, the resolution power of the consultation, the need for an in-person appointment, the platform, and its difficulties were included. Results. 2485 patients from 11 departments were included. Thyroid pathology was the most frequent (62.9%), followed by aerodigestive tract pathology (10.8%). The consultation was efficient in 99% of cases, with a resolution capacity of 96.4%. 1.4% had difficulties on the platform and 8.3% of patients required an in-person. When there was difficulty in reviewing exams or an inadequate functional inspection, it was 30 times more likely to not be able to efficiently be resolved. Conclusion. Telemedicine provides an efficient alternative for care in head and neck surgery, especially in thyroid pathology controls, avoiding unnecessary travel. In the aerodigestive tract, where the physical examination is essential, its usefulness is limited to the possibility of performing a subsequent endoscopic examination that allows adequate staging and facilitates in-person assessment.

Longer time to testosterone recovery impacts favorably on outcomes for prostate cancer following androgen deprivation and radiotherapy.

PURPOSE: To evaluate the impact of sustained hypogonadism after androgen deprivation therapy (ADT) associated with radiotherapy in prostate cancer (PCa) patients with biochemical relapse-free survival (bRFS). METHODS: A retrospective cohort analysis of 213 consecutive PCa patients referred for radiotherapy plus ADT was carried out. Follow-up times including time to testosterone recovery (TTR) and bRFS were calculated from the end of ADT. Univariate and multivariate Cox regression analyses predicting bRFS were used. The optimal cutoffs for TTR and duration of ADT were determined using the maximally selected rank statistics (MSRS). RESULTS: After a median follow-up of 104 months, 18 patients relapsed among those who had recovered testosterone levels and 9 among those who did not. Median ADT duration was 36 months. The optimal cutoff for TTR was determined using MSRS. TTR >48 months was significantly associated with better bRFS (logrank, p < 0.0027). Five-year bRFS was 100% for >48 months vs. 85% for <48 months. TTR was the only significant variable for bRFS in multivariate Cox analysis. CONCLUSION: Our data show an association between longer TTR and bRFS values among PCa patients treated with ADT.

Evaluación de la agudeza diagnóstica de la Ecografía Translaríngea Transcutánea (ETLTC) en la valoración de la movilidad de las cuerdas vocales en cirugía de tiroides y paratiroides / Evaluation of the diagnostic acuity of the Transcutaneous Translaryngeal Ultrasound (TCTLUS) in the assessment of the vocal cords mobility in thyroid and parathyroid surgery

Introducción. La evaluación de la movilidad de las cuerdas vocales en cirugía de tiroides y paratiroides hace parte de la adecuada valoración integral. Aunque la laringoscopia directa es prueba de referencia, su uso real no es rutinario por lo que se propone la ecografía translaríngea como alternativa de evaluación. Métodos. Estudio prospectivo de evaluación de una prueba diagnóstica de la movilidad de las cuerdas vocales pre y posoperatoria, comparando la ecografía translaríngea con la video laringoscopia, en pacientes con cirugía de tiroides y paratiroides, de febrero 1° a noviembre 30 de 2022. Se describieron las variables usando frecuencias absolutas y relativas. En el análisis univariado se calcularon Chi cuadrado y T de Student y en el bivariado, regresión logística binaria. La agudeza diagnóstica se determinó con sensibilidad, especificidad y valores predictivos; se consideró la significancia estadística con p < 0,05. Resultados. Se incluyeron 267 pacientes, 219 mujeres y 48 hombres; 196 pacientes (73,4%) tenían malignidad. Se encontró en el preoperatorio, sensibilidad 100 %, especificidad 99,6 %, VPP 83,3 %, VPN 100 %, odds de probabilidad positiva 83 % y Odds de probabilidad negativa 0,004 %. En el posoperatorio, sensibilidad 82,8 %, especificidad 99,2 %, VPP 92,3 % VPN 97,9 %, odds de probabilidad positiva 92 % y odds de probabilidad negativa 0,2 %. Conclusiones. La ecografía translaríngea en nuestro medio tiene alta agudeza diagnóstica. Podría ser usada en el abordaje inicial de la evaluación de la movilidad de las cuerdas vocales y reemplazar la laringoscopia directa, dejando ésta para cuando la visualización ecográfica no sea adecuada, o en casos de afectación o sospecha de invasión, para su confirmación.

Introduction. The evaluation of the mobility of the vocal cords in thyroid and parathyroid surgery is part of the adequate comprehensive assessment. Altough, direct laryngoscopy is the gold standard, its real use is not routine, so translaryngeal ultrasound approach is proposed as an alternative. Methods. A prospective diagnostic test study was carried out to evaluate the translaryngeal ultrasound compared with video laryngoscopy in visualizing vocal mobility in patients with thyroid and parathyroid surgery from February 1 to November 30, 2022. Patients were described using absolute and relative frequencies. Univariate statistical analysis with Chi-square and Student's t tests. T. Bivariate analysis using binary logistic regression. Diagnostic acuity was calculated with sensitivity, specificity, PPV, NPV. Statistical significance with p< 0.05, 95% confidence interval. Results. 267 patients undergoing thyroid or parathyroid surgery were included, 219 women and 48 men. Malignant: thyroid neoplasm 196 patients (73.4%). The findings were for the preoperative period, 100% sensitivity, 99.6% specificity, PPV 83.33%, NPV 100%, 83% positive probability odds, and 0.004% negative probability odds. For the postoperative period, 82.8% sensitivity, 99.2% specificity, 92.3% PPV, 97.9% NPV, 92% positive probability odds, and 0.2% negative probability odds were found.Conclusions. Translaryngeal ultrasound in our series has high diagnostic acuity. It could be used as the initial approach to evaluate vocal mobility and might replace direct laryngoscopy, leaving it when its visualization is not adequate or in cases of involvement or suspected invasion for confirmation.

P38 MAPK and Radiotherapy: Foes or Friends?

Over the last 30 years, the study of the cellular response to ionizing radiation (IR) has increased exponentially. Among the various signaling pathways affected by IR, p38 MAPK has been shown to be activated both in vitro and in vivo, with involvement in key processes triggered by IR-mediated genotoxic insult, such as the cell cycle, apoptosis or senescence. However, we do not yet have a definitive clue about the role of p38 MAPK in terms of radioresistance/sensitivity and its potential use to improve current radiotherapy. In this review, we summarize the current knowledge on this family of MAPKs in response to IR as well as in different aspects related to radiotherapy, such as their role in the control of REDOX, fibrosis, and in the radiosensitizing effect of several compounds.

Hipercolesterolemia familiar descripción de un caso en una familia de Armenia - Quindío (Colombia)

Introducción: La Hipercolesterolemia familiar (HF) es una enfermedad genética de carácter autosómico dominante, poco frecuente, generada por la mutación en el cromosoma 19. Es la primera causa de enfermedad cardiovascular prematura. Las mutaciones patogénicas que generan la HF se relacionan con el receptor de LDL (LDLr), la apolipoproteina B-100 (Apo- B100) y la proteína convertasa subtilisina / kexina tipo 9 (PCSK9), que produce elevación del colesterol y alteración de la vía del LDLr en el 80 % de los casos diagnosticados de HF (5). Presentamos un reporte de caso de cuatro pacientes que pertenecen a la misma familia, quienes presentan mutaciones patogénicas de diferente compromiso a nivel cardiovascular y sistémico que ha afectado de manera negativa su cotidianidad. El objetivo de este trabajo es realizar una correlación del hipercolesterolemia familiar de tipo genético a partir de la literatura, con respecto a la serie de casos presentada, y evaluar el impacto que este genera en los servicios de salud, en la vida del paciente y su familia. Discusión: El reporte de caso que presentamos se fundamenta en la sospecha de HF según los criterios de Holanda. En estos pacientes se reconoce mutación del gen LDLr que se relaciona con HF. Sin embargo, no ha sido ampliamente estudiada. Chmara realizó en Polonia por primera vez un estudio en el que reportó la variante ac 11G>T. En Colombia, el estudio de López encontró tres mutaciones, identificadas como variante a c.11G > A, n c.416A > G y c.1187G > A (8). Conclusión: La HF en nuestro medio es poco frecuente y con gran impacto social, en la mayoría de los casos genera síntomas clínicos y aumento del riesgo cardiovascular desde una edad temprana. Es importante resaltar el diagnóstico oportuno y el conocimiento por parte del personal de salud para generar una calidad de vida adecuada a los pacientes y evitar que aumente el riesgo cardiovascular.

Introduction: Familial hypercholesterolemia (FH) is a rare autosomal dominant genetic disease caused by a chromosome 19 mutation. It is the main cause of premature cardiovascular disease. Pathogenic mutations which cause FH are related to the LDL receptor (LDLr), B-100 apolipoprotein (Apo-B100) and type 9 subtilisin/kexin convertase protein (PCSK9), causing blood cholesterol increase and impairment of the LDLr pathway in up to 80% of patients diagnosed with FH. We present the case of 4 patients belonging to the same family and who present pathogenic mutations leading to diverse kinds of cardiovascular and systemic disease. Discussion: The case report we are presenting is based on the suspicion of FH according to the dutch criteria. These patients had the LDLr gene mutation related to FH. However, this mutation has not been thoroughly studied. The ac 11G>T variant was reported for the first time in Poland by Chmara. In Colombia, Lopez found 3 mutations identified as variant a c.11G > A, variant n c.416A > G and variant c.1187G > A. Conclusion: FH is rare in Colombia. Early diagnosis and healthcare worker awareness must be highlighted to improve the quality of life and decrease the cardiovascular risk of patients.

Localización intraoperatoria de las recurrencias en cáncer de tiroides mediante la inyección de azul de metileno guiada por ecografía / Intraoperative localization of recurrences in thyroid cancer by ultrasound-guided injection of methylene blue

Introducción. La cirugía para extirpación de metástasis en un cuello previamente intervenido afronta un reto para lograr una resección exitosa. El presente estudio pretende demostrar la utilidad de la técnica de inyección de azul de metileno, guiada por ecografía, para la localización intraoperatoria de lesiones recurrentes en cáncer de tiroides, para facilitar su resección. Métodos. Se realizó un estudio observacional, descriptivo y retrospectivo, en pacientes reintervenidos por recurrencia de carcinoma diferenciado de tiroides, durante un periodo de dos años y medio. Se utilizó la inyección intratumoral de azul de metileno guiada por ecografía para su identificación intraoperatoria de recurrencia. Se hizo análisis de variables demográficas y clínicas. Resultados. Este estudio incluyó 10 procedimientos en 9 pacientes, 77,8 % mujeres, con una media de edad de 54 años. Todos tenían un nivel de tiroglobulina detectable y elevado antes de la intervención; posteriormente, el 89 %presentó un descenso y el 33 % una adecuada respuesta bioquímica. La técnica agregó 10 minutos al tiempo quirúrgico. En el 100 % se identificaron de manera intraoperatoria los ganglios marcados; el promedio de ganglios resecados fue de 12, de los cuales, 6 fueron positivos, todos con carcinoma papilar de tiroides. Esta técnica se consideró de gran utilidad y de bajo costo en todos los casos. Discusión. Esta técnica se muestra como una estrategia efectiva para la identificación intraoperatoria de las recurrencias corregionales en carcinoma de tiroides, permitiendo una disección ganglionar exitosa, disminuyendo complicaciones, tiempo quirúrgico y, especialmente, costos frente a otras intervenciones

Introduction. The approach of a previously operated neck for metastasis resection faces a challenge to achieve a successful resection. The present study aims to demonstrate the usefulness of the ultrasound-guided injection of methylene blue technique for the intraoperative localization of recurrent lesions in thyroid cancer to facilitate their resection. Methods. An observational, descriptive and retrospective study was conducted in patients reoperated for recurrences of differentiated thyroid carcinoma over a period of two and a half years, using ultrasound-guided intratumoral injection of methylene blue for its intraoperative identification. An analysis of demographic and clinical variables was carried out and its advantages over other methods were identified. Results. This study included 10 procedures in nine patients, 77.8% women and 22.2% men, with a mean age of 54 years. All had a detectable and elevated thyroglobulin level before the intervention, 89% had a decrease in its level and 33% had an adequate biochemical response. The technique added 10 minutes to the surgical time. All marked lymph nodes were identified intraoperatively. The average number of lymph nodes resected was 12, of which six were positive, all with papillary thyroid carcinoma. It was considered of great utility and low cost in all cases. Discussion. This technique shows to be an effective strategy for the intraoperative identification of locoregional recurrences in thyroid carcinoma, allowing a successful lymph node dissection, reducing complications, surgical time and especially costs compared to other interventions

Quistectomía laparoscópica en quiste hidatídico hepático / Laparoscopic cystectomy in hidatidid cyst

Resumen Objetivo: Describir resultados en términos de morbilidad y mortalidad del tratamiento de quistes hidatídicos hepáticos (QHH) por vía laparoscópica en una serie de pacientes consecutivos. Comparar calidad de vida (CV) de pacientes sometidos a quistectomía laparoscópica (QL) con pacientes llevados a colecistectomía laparoscópica. Materiales y Método: Serie de casos con seguimiento de pacientes con QHH, sometidos a QL. Analizamos datos con Stata® 10.0, mediante medidas de tendencia central y dispersión. Describimos 4 variables, realizando seguimiento con tomografía computada (TC) abdominal. Aplicamos encuesta de calidad de vida SF-36. Resultados: Incluimos 12 pacientes, 58,3% de género femenino. Número de quistes 2,02 ± 1,56, volumen quístico mayor 809,16 ± 766,05 ml, diámetro de quiste mayor 11,77 ± 4,33 cm, predominando en lóbulo hepático derecho (58%). Tiempo operatorio promedio 234,1 ± 52,9 minutos. Estadía hospitalaria promedio 11,5 ± 14,5 días. Morbilidad en 16,6%, sin mortalidad posoperatoria. Seguimiento con imágenes promedio fue 7,9 ± 4,3 meses, encontrando cavidades residuales pequeñas y asintomáticas en 50% de pacientes. No reportamos recidivas. Al comparar CV con grupo de colecistectomía sólo encontramos diferencia respecto a vitalidad (p = 0,04). Discusión: Aunque nuestra serie es pequeña y presenta mayor tiempo quirúrgico (por selección de pacientes) y mayor estancia hospitalaria que en otras series de QL, presenta menor porcentaje de recidivas, de fístulas biliares y no presenta mortalidad, concordando con otras series de QL que la recomiendan como opción terapéutica. Conclusiones: La QL para el tratamiento de los QHH resulta una cirugía aceptable, con morbilidad y mortalidad comparable con reportes de cirugía abierta.

Aim: To describe results in morbidity and mortality terms of the hepatic hydatidosis (HHC) treatment by laparoscopic route in selected patients. In addition, compare the quality of life (QL) of cystomectized vs cholecystectomized patients, both laparoscopically. Materials and Method: Case series with follow-up of patients with HHC, undergoing laparoscopic cystectomy (LC). Data analysis, through measures of central tendency and dispersion, performed with Stata® 10.0. Analyzing 4 variables followed-up with abdominal computed tomography. A quality of life survey SF-36" was applied. Results: 12 patients were included, 58.3% female gender. Cysts number 2.02 ± 1.56, largest cystic volume 809.16 ± 766.05 ml, larger cyst diameter 11,77 ± 4,33 cm. Right hepatic lobe is predominantly 58%. Surgical time, 234.16 ± 52.95 minutes. Hospital stay, 11.58 ± 14.55 days. Morbidity 16.6%, with no postoperative mortality. Follow-up, performed at 7.9 ± 4.3 months, finding residual cavity in 50%, no recurrences were reported. At comparing QL with cholecystectomy group, we only found differences at the vitality item (p = 0,04). Discussion: Although our series is small and has a longer surgical time (by patient selection) and a longer hospital stay than in other LC series, it has a lower recurrences percentage, biliary fistulas, and no mortality, agreeing with other LC series that recommend it as a therapeutic option. Conclusions: The laparoscopic approach for the HHC treatment, is an acceptable surgery, with morbidity and mortality comparable to the reports of laparotomy surgery.

Colecistectomía extendida mínimamente invasiva en pacientes con cáncer de vesícula biliar / Minimal invasive extended cholecystectomy in gallbladder cancer patients

Resumen Objetivo: Describir resultados en términos de morbilidad y mortalidad de la colecistectomía extendida laparoscópica (CELap) en pacientes con cáncer de vesícula biliar (CVB) incidental. Materiales y Método Serie de casos de pacientes con CVB incidental sometidos a CELap en el Hospital Regional de Temuco entre diciembre de 2017 y marzo de 2019. Resultados: Incluimos 10 pacientes, con edad promedio de 59,2 ± 11 años, 90% de género femenino. Respecto a la invasión de pared de la vesícula biliar (TNM), 1 presentó invasión hasta mucosa (T1a) con invasión de senos de Rokitansky Aschoff y 9 hasta subserosa (T2). Dos tuvieron ganglio cístico positivo en biopsia inicial. Respecto a la CELap, el tiempo operatorio promedio fue 333 ± 40 minutos. El promedio de ganglios resecados fue 4 ± 2,78, presentando lecho hepático positivo en 1 paciente. La clasificación TNM obtenida: un paciente T1aN0M0, siete T2N0M0 y dos T2N1M0. La estancia hospitalaria promedio fue 5 ± 2,3 días. Siete pacientes recibieron, posteriormente, quimioterapia con gemcitabina + cisplatino. Hubo morbilidad en 2 pacientes, tipo I de Dindo-Clavien. No reportamos mortalidad. El seguimiento promedio fue 7,1 ±5,1 meses, no reportamos recurrencia. Discusión: Esta serie presenta menor número de ganglios resecados que otros estudios (posiblemente por ser nuestra serie inicial) y mayor morbilidad, pero sólo tipo I de Dindo-Clavien. Presentamos una estancia hospitalaria similar a series internacionales y menor presencia de metástasis según reportan análisis retrospectivos. Conclusión: La CELap es una opción terapéutica aceptable y presenta cifras de morbilidad y mortalidad comparables con series nacionales e internacionales.

Aim: Describe results in terms of morbidity and mortality of minimally invasive treatment in patients with gallbladder cancer until subserosal layer. Materials and Method: Case series of patients with gallbladder cancer undergoing CELap at Hospital Regional of Temuco between December 2017 and March 2019. Results: Ten patients were included, the average age was 59,2 ±11 years. Ninety percent female. According to the invasion in gallbladder layers (TNM Classification), 1 patient was T1a (mucosa) with invasion of Rokytansky-Aschoff sinus and 9 patients T2 (subserosa). Two patients had a positive cystic node. The average operating time of CELap was 333 ± 40 minutes. The average number of resected nodes was 4 ± 2,78 and a positive liver bed was found in 1 patient. The TNM classification was 1 patient T1aN0M0, 7 patients T2N0M0 and 2 patients T2N1M0. Mean hospitalization was 5 ± 2,3 days. Seven patients subsequently received chemotherapy with gemcitabine + cisplatin. There was 2 patients with morbidity, type I of Dindo-Clavien scale. No mortality is reported. The average follow-up was 7,1 ±5,11 months and no recurrence was reported. Discussion: This series has a lower number of resected nodes than other studies (possibly because it is our initial series) and higer morbidity, but only Dindo-Clavien type I. Furthermore, we present a hospital stay similar to international series and a lower presence of metastases as reported in retrospective analysis. Conclusion: CELap is an acceptable therapeutic option and presents morbidity and mortality comparable with the national and international series.

El estrés crónico como mediador de la relación entre la posición socioeconómica y el cumplimiento del tratamiento farmacológico de pacientes hipertensos / Chronic stress as a mediator of the relationship between socioeconomic status and pharmacological adherence in hypertensive patients

Introducción. La hipertensión arterial sistémica es un problema de salud pública en el mundo. En Colombia, su prevalencia es del 25 % y la mortalidad es alta. Los factores psicosociales que afectan el cumplimiento del tratamiento farmacológico no han sido estudiados suficientemente. En otros países, se ha estudiado el papel del estrés crónico en la relación entre la posición socioeconómica y el cumplimiento del tratamiento farmacológico antihipertensivo. Objetivo. Examinar el papel del estrés crónico como mediador de la relación entre la posición socioeconómica y el cumplimiento del tratamiento farmacológico, en pacientes hipertensos de 45 a 70 años en el 2015 y el 2016. Materiales y métodos. Se hizo un estudio transversal de una población de pacientes hipertensos. Los datos provienen de la muestra seleccionada para el programa "De todo corazón" en Bogotá, Medellín y Quibdó. El análisis estadístico de los datos se hizo mediante análisis factorial y regresiones multivariadas. Resultados. Los resultados confirmaron una asociación positiva entre la posición socioeconómica y el grado de cumplimiento del tratamiento farmacológico, y una relación negativa entre la primera y el estrés crónico. Además, se evidenció que el estrés tiene una asociación negativa con el grado de cumplimiento. Conclusiones. Los resultados sugieren que el estrés no es un mediador entre la posición socioeconómica y el cumplimiento del tratamiento farmacológico antihipertensivo en Colombia. Se requieren estudios adicionales para confirmar estas relaciones con una muestra más amplia.

Introduction: High blood pressure is a public health problem worldwide. In Colombia, its prevalence is 25% with a high mortality rate. The psychosocial factors affecting pharmacological adherence among patients have not been sufficiently studied and despite international evidence on their impact, in Colombia, there is a paucity of research on the role of chronic stress in the relationship between socioeconomic status and pharmacological adherence. Objective: To examine the role of chronic stress in the relationship between socioeconomic status and pharmacological adherence in hypertensive patients aged 45 to 70 years old in three Colombian cities between 2015 and 2016. Materials and methods: We conducted a cross-sectional study in a population of hypertensive patients. Data for this study came from the first wave of longitudinal study aimed at examining social factors associated with the control of hypertension in Bogotá, Medellín, and Quibdó. Patients with hypertension were selected randomly from a sample of those participating in the hypertension control program De todo corazón. For the statistical analysis of the data, we used factorial analysis and multivariate regressions. Results: We found a positive association between socioeconomic status and the degree of pharmacological adherence and a negative one with chronic stress. Besides, evidence was found that stress has a negative association with the degree of adherence. Conclusions: The results suggest that stress is not a likely mediator between socioeconomic status and the pharmacological adherence of hypertensive patients in Colombia. Additional studies are required to confirm these relationships with a larger sample.

Oropharyngeal Squamous Cell Carcinoma: Human Papilloma Virus Coinfection with Streptococcus anginosus.

INTRODUCTION: Human papilloma virus (HPV) and oral bacteria capable of acetaldehyde production from ethanol, such as Streptococcus anginosus, Prevotella melaninogenica, and Fusobacterium naviforme are among oropharyngeal squamous cell carcinoma (OSCC) infectious risk factors. OBJECTIVE: Determine associations with HPV and S. anginosus, P. melaninogenica, and F. naviforme in patients with and without OSCC. METHODS: Presence of HPV and HPV-16 was determined in 26 patients with OSCC and 26 without OSCC by conventional PCR and simultaneous presence of S. anginosus, P. melaninogenica, and F. naviforme quantification through q-PCR. Statistical analysis was carried out using Pearson's X² and Student's-t test. RESULTS: Patients with OSCC had HPV and HPV-16 frequencies of 84% and 61.5%, respectively, in contrast for patients without OSCC frequencies were 34.6 and 30.7%. P. melaninogenica, and F. naviforme microorganisms were not present in any participant in this study. S. anginosus frequency in patients with OSC was 38.4% and in patients without OSCC was 30.7%. Patients with OSCC had S. anginosus + HPV co-infection at a 38.4% frequency and S. anginosus + HPV-16 at a 23.1% frequency. For individuals without OSCC S. anginosus + HPV co-infection was 3.8% and S. anginosus + HPV-16 3.8%. A greater frequency of S. anginosus + HPV co-infection and S. anginosus + HPV-16 was observed in patients with OSCC in comparison with individuals without OSCC, suggesting the importance of detecting HPV/HPV-16 and S. anginosus simultaneously in individuals at risk of developing OSCC.

Oropharyngeal squamous cell carcinoma: human papilloma virus coinfection with streptococcus anginosus

Abstract Introduction: Human papilloma virus (HPV) and oral bacteria capable of acetaldehyde production from ethanol, such as Streptococcus anginosus, Prevotella melaninogenica, and Fusobacterium naviforme are among oropharyngeal squamous cell carcinoma (OSCC) infectious risk factors. Objective: Determine associations with HPV and S. anginosus, P. melaninogenica, and F. naviforme in patients with and without OSCC. Methods: Presence of HPV and HPV-16 was determined in 26 patients with OSCC and 26 without OSCC by conventional PCR and simultaneous presence of S. anginosus, P. melaninogenica, and F. naviforme quantification through q-PCR. Statistical analysis was carried out using Pearson's X² and Student's-t test. Results: Patients with OSCC had HPV and HPV-16 frequencies of 84% and 61.5%, respectively, in contrast for patients without OSCC frequencies were 34.6 and 30.7%. P. melaninogenica, and F. naviforme microorganisms were not present in any participant in this study. S. anginosus frequency in patients with OSC was 38.4% and in patients without OSCC was 30.7%. Patients with OSCC had S. anginosus + HPV co-infection at a 38.4% frequency and S. anginosus + HPV-16 at a 23.1% frequency. For individuals without OSCC S. anginosus + HPV co-infection was 3.8% and S. anginosus + HPV-16 3.8%. A greater frequency of S. anginosus + HPV co-infection and S. anginosus + HPV-16 was observed in patients with OSCC in comparison with individuals without OSCC, suggesting the importance of detecting HPV/HPV-16 and S. anginosus simultaneously in individuals at risk of developing OSCC

Resumo O vírus do papiloma humano (VPH) e bactérias orais capacidade de produção acetaldeído a partir do etanol, tais como Streptococcus anginosus, Prevotella melaninogenica e Fusobacterium naviforme, estão entre os fatores de risco infecciosos do carcinoma de células escamosas de orofaringe (CCEO). Determinar associações o VPH e S. anginosus, P. melaninogenica, e F. naviforme em pacientes com e sem o CCEO. A presença de VPH e VPH-16 foi determinada em 26 pacientes com CCEO e 26 sem CCEO por PCR convencional e presença simultânea de quantificação de S. anginosus, P. melaninogenica e F. naviforme por meio de q-PCR. Uma análise estatística foi realizada por meio do t-Student e χ² de Pearson. Os pacientes com CCEO apresentaram frequências de VPH e VPH-16 de 84% e 61,5%, respectivamente, em contraste, para os pacientes sem CCEO frequências de 34,6 e 30,7%. Os microorganismos P. melaninogenica e F. naviforme não estavam presentes em nenhum dos participantes deste estudo. A freqüência de S. anginosus em pacientes com CCEO foi de 38,4% e em pacientes sem CCEO foi de 30,7%. Os pacientes com CECO apresentaram coinfecção com S. anginosus + VPH em uma freqüência de 38,4% e S. anginosus + VPH-16 com freqüência de 23,1%. Para os indivíduos sem CCEO, co-infecção com S. anginosus + VPH foi de 3,8% e S. anginosus + VPH-16 foi de 3,8%. A Maior frequência de co-infecção com S. anginosus + VPH e S. anginosus + VPH-16 foi observada em pacientes com CCEO em comparação com indivíduos sem CCEO, sugerindo a importância da detecção de VPH / VPH-16 e S. anginosus simultaneamente em indivíduos em risco de desenvolver CCEO.

Does postoperative irradiation improve survival in early-stage endometrial cancer?

Endometrial cancer is the most common gynecological cancer in developed countries. Postoperative irradiation has been shown to lower locoregional relapses among high-intermediate risk endometrial cancer patients. In addition, vaginal cuff brachytherapy has demonstrated similar control to external beam radiotherapy but with lower toxicity. Although randomized trials have failed to translate that into better overall survival, reports from large databases, such as the National Cancer Database and the Surveillance, Epidemiology, and End Results database, have shown evidence of a statistical relationship between postoperative irradiation and survival in the intermediate- and high-risk groups. This review will address the risk groups that have led the therapeutic decisions and then we will review the clinical results accordingly. Special attention will be paid to the survival results based on the data presented through an analysis of the large databases that suggest a possible survival benefit.

Experiencia con paratiroidectomía quirúrgica en pacientes con enfermedad renal crónica e hiperparatiroidismo terciario / Experience with surgical parathyroidectomy in patients with chronic kidney disease and tertiary hyperparathyroidism

Resumen Introducción: el hiperparatiroidismo terciario es la consecuencia final de las alteraciones del metabolismo calcio-fósforo en pacientes con enfermedad renal crónica. Aquellos pacientes que no logran controlarlo con el tratamiento médico, requieren paratiroidectomía. Objetivo: describir la evolución clínica y paraclínica en pacientes con enfermedad renal crónica y diagnóstico de hiperparatiroidismo terciario, que fueron llevados a paratiroidectomía. Metodología: estudio prospectivo, que incluyó pacientes con hiperparatiroidismo terciario llevados a paratiroidectomía entre los años 2006 y 2015. Se realizaron estudios bioquímicos pre y post quirúrgicos y se evaluó la presencia y progresión de síntomas. Resultados: se incluyeron 32 pacientes, 68.8% mujeres, con media de edad de 46.2 años. Se identificaron diferencias estadísticamente significativas en el cambio en los valores de calcio, fósforo y PTH pre y post quirúrgicos. El 81.5% de los pacientes reportaron presencia de síntomas. El 34.6, 26.9, y 23% presentaron mejoría total de dolor óseo, dolor articular y prurito, respectivamente. El 28% presentaron hipocalcemia sintomática post operatoria. No hubo casos de muerte durante el seguimiento. Conclusiones: la paratiroidectomía se constituye en un alternativa segura y confiable para los pacientes con hiperparatiroidismo terciario, mejorando significativamente los síntomas y las alteraciones en el metabolismo óseo y mineral. Vigilar los niveles de calcio en el post operatorio es importante para evitar las complicaciones del síndrome de hueso hambriento.

Abstract Introduction: tertiary hyperparathyroidism is the final consequence of alterations in calcium-phosphorus metabolism in patients with chronic kidney disease. Those patients who fail to control it with medical treatment require parathyroidectomy. Objective: go describe the clinical and paraclinical evolution in patients with chronic kidney disease and diagnosis of tertiary hyperparathyroidism, who underwent parathyroidectomy. Methodology: prospective study, which included patients with tertiary hyperparathyroidism taken to parathyroidectomy between 2006 and 2015. Pre and post-surgical biochemical studies were performed and the presence and progression of symptoms was evaluated. Results: 32 patients were included. 68.8 (%) were women with an average age of 46.2 years. Statistically significant differences were identified in the change in calcium, phosphorus and PTH values before and after surgery. 81.5% of patients reported the presence of symptoms. 34.6, 26.9, and 23% presented total improvement of bone pain, joint pain and pruritus, respectively. 28% presented postoperative symptomatic hypocalcemia. There were no deaths during follow-up. Conclusions: parathyroidectomy is a safe and reliable alternative for patients with tertiary hyper-parathyroidism, significantly improving symptoms and alterations in bone and mineral metabolism. Monitoring calcium levels in the postoperative period is important to avoid the complications of the hungry bone syndrome.

Vaginal cuff brachytherapy in endometrial cancer - a technically easy treatment?

Endometrial cancer (EC) is one of the most common gynecological cancers among women in the developed countries. Vaginal cuff is the main location of relapses after a curative surgical procedure and postoperative radiation therapy have proven to diminish it. Nevertheless, these results have not translated into better survival results. The preeminent place of vaginal cuff brachytherapy (VCB) in the postoperative treatment of high- to intermediate-risk EC was given by the PORTEC-2 trial, which demonstrated a similar reduction in relapses with VCB than with external beam radiotherapy (EBRT), but VCB induced less late toxicity. As a result of this trial, the use of VCB has increased in clinical practice at the expense of EBRT. A majority of the clinical reviews of VCB usually address the risk categories and patient selection but pay little attention to technical aspects of the VCB procedure. Our review aimed to address both aspects. First of all, we described the risk groups, which guide patient selection for VCB in clinical practice. Then, we depicted several technical aspects that might influence dose deposition and toxicity. Bladder distension and rectal distension as well as applicator position or patient position are some of those variables that we reviewed.

The usefulness of fleet rectal enemas on high-dose-rate intracavitary cervical cancer brachytherapy. A prospective trial.

PURPOSE: To evaluate the effects of rectal enemas on rectal doses during radical high-dose-rate (HDR) intracavitary cervical brachytherapy (BT). MATERIAL AND METHODS: Twenty patients suffering from cervical cancer and treated with external beam radiotherapy and HDR-BT were included in a prospective trial. The first brachytherapy fraction was considered the basal status, and patients were instructed to self-administer two rectal cleansing enemas before the second fraction. Dose-volume histogram (DVH) values were generated for the rectum and correlated with rectal volume variation. Brachytherapy was carried out with a Fletcher or Utrecht applicator. RESULTS: No significant rectal volume differences were observed between fractions with or without rectal enemas (without, 52.64 ± 15.92 cc; with, 53.16 ± 19.28 cc). There was a significant correlation between both rectal volumes (r = 0.722, p = 0.001). No significant differences were observed in analyzed DVH parameters (median values: ΔD0.1cc, 4.17 vs. 3.61 Gy; ΔD1cc, 3.23 vs. 2.87 Gy; ΔD2cc, 2.9 vs. 2.54 Gy; ΔD5cc, 2.35 vs. 2.05 Gy, for no enema and enema fraction, respectively). No significant rectal volume differences nor DVH parameter differences were observed according the applicator type. CONCLUSIONS: Our rectal enemas protocol prior to HDR-BT was ineffective in significantly modifying rectal DVH parameters. No differences were observed according to the type of applicator used.

Safety, long-term outcomes and predictors of recurrence after first-line combined endoepicardial ventricular tachycardia substrate ablation in arrhythmogenic cardiomyopathy. Impact of arrhythmic substrate distribution pattern. A prospective multicentre study.

BACKGROUND: First-line endoepicardial ventricular tachycardia (VT) ablation has been proposed for patients with arrhythmogenic cardiomyopathy (AC). This study reports procedural safety, outcomes, and predictors of recurrence. METHODS AND RESULTS: Forty-one consecutive patients [12 with left ventricle (LV) involvement, 7 left-dominant] underwent first-line endoepicardial VT substrate ablation. Standard bipolar and unipolar thresholds were used to define low-voltage areas (LVA). Arrhythmogenic substrate area (ASA) was defined as the area containing electrograms with delayed components. Implantable cardioverter defibrillator interrogations were evaluated for VT recurrence. Epicardial LVA was larger in all cases (102.5 ± 78.6 vs. 19.3 ± 24.4 cm2; P< 0.001). Consistent with an epicardium-to-endocardium arrhythmogenic substrate progression pattern, epicardial ASA (epi-ASA) was negatively correlated with bipolar endocardial LVA (r = -0.368; P= 0.035) and with endocardial bipolar/unipolar-LVA (Bi/Uni-LVA) ratio (r= -0.38; P= 0.037). A Bi/Uni-LVA ratio >0.23 predicted an epi-ASA ≤10 cm2 (100% sensitivity, 84% specificity). Patients showing an epi-ASA < 10 cm2 required less epicardial (8.4 ± 5.8 vs. 25.3 ± 16; P= 0.045) and more endocardial (16.5 ± 8.6 vs. 7.5 ± 8.2; P= 0.047) radiofrequency applications. One patient with epi-ASA < 10 cm2 died of cardiac tamponade after epicardial puncture. Acute success (no VT inducibility after procedure) was achieved in 36 patients (90%). After 32.2 ± 21.8 months, 11 (26.8%) patients had VT recurrences. Left-dominant AC was associated with an increased risk of recurrence (HR = 3.41 [1.1-11.2], P= 0.044; log-rank P= 0.021). CONCLUSION: First-line endoepicardial VT substrate ablation achieves good long-term results in AC. Left-dominant AC is associated with an increased risk of recurrence. The Bi/Uni-LVA ratio identifies patients with limited epicardial arrhythmogenic substrate in whom the indication of epicardial approach should be more cautiously assessed.

Analysing the integration of MR images acquired in a non-radiotherapy treatment position into the radiotherapy workflow using deformable and rigid registration.

AIM: Our aim was to analyse the feasibility of integrating an MRI acquired in a non-radiotherapy set-up into the prostate cancer radiotherapy workflow. MATERIAL AND METHODS: The MRIs of 15 prostate cancer patients, acquired with a flat table-top (MRI-flat), and with a curved tabletop (MRI-curve) were analysed. MRIs were rigidly (RIR) and non-rigidly registered (DIR) with CT images. The prostate and rectum were contoured in each image set and translated to the CT, and IMRT plans were computed taking into account structural changes after RIR and DIR (P-flatRIR, P-curveRIR and P-curveDIR). In addition the P-curveDIR was overlaid with RIR structures. Spatial overlap parameters and dose-volume histogram metrics were generated. RESULTS: No significant differences were observed among P-flatRIR and P-curveRIR or P-flatRIR and P-curveDIR. Median gamma-values: P-curveRIR, 95.3%; P-curveDIR, 96%, translated-P-curveDIR, 95%. DVH metrics for translated-P-curveDIR were: Dmin, 64.5Gy; Dmean, 70.06Gy; V95%, 100%. No statistically significant differences were found in the dosimetric MRI-flatDIR values. CONCLUSIONS: The dosimetric reproduction of treatment position image following image registration of non-radiotherapy set-up images suggests that it is feasible to integrate these images into the radiotherapy workflow.

Effect of rectal enemas on rectal dosimetric parameters during high-dose-rate vaginal cuff brachytherapy: A prospective trial.

PURPOSE: To evaluate the effects of rectal enemas on rectal doses during postoperative high-dose-rate (HDR) vaginal cuff brachytherapy (VCB). PATIENTS AND METHODS: This prospective trial included 59 patients. Two rectal cleansing enemas were self-administered before the second fraction, and fraction 1 was considered the basal status. Dose-volume histogram (DVH) values were generated for the rectum and correlated with rectal volume variation. Statistical analyses used paired and unpaired t-tests. RESULTS: Despite a significant 15 % reduction in mean rectal volume (44.07 vs. 52.15 cc, p = 0.0018), 35.6 % of patients had larger rectums after rectal enemas. No significant rectal enema-related DVH differences were observed compared to the basal data. Although not statistically significant, rectal cleansing-associated increases in mean rectal DVH values were observed: D0.1 cc: 6.6 vs. 7.21 Gy; D1 cc: 5.35 vs. 5.52 Gy; D2 cc: 4.67 vs. 4.72 Gy, before and after rectal cleaning, respectively (where Dx cc is the dose to the most exposed x cm(3)). No differences were observed in DVH parameters according to rectal volume increase or decrease after the enema. Patients whose rectal volume increased also had significantly larger DVH parameters, except for D5 %, D25 %, and D50 %. In contrast, in patients whose rectal volume decreased, significance was only seen for D25 % and D50 % (Dx % dose covering x % of the volume). In the latter patients, nonsignificant reductions in D2 cc, D5 cc and V5 Gy (volume receiving at least 5 Gy) were observed. CONCLUSION: The current rectal enemas protocol was ineffective in significantly modifying rectal DVH parameters for HDR-VCB.

Rectal contrast increases rectal dose during vaginal cuff brachytherapy.

PURPOSE: To evaluate the impact of rectal dose on rectal contrast use during vaginal cuff brachytherapy (VCB). METHODS AND MATERIALS: A retrospective review of gynecology patients who received some brachytherapy fractions with and without rectal contrast was carried out. Rectal contrast was instilled at the clinician's discretion to increase rectal visibility. Thirty-six pairs of CT scans in preparation for brachytherapy were analyzed. Pairs of CTs were segmented and planned using the same parameters. The rectum was always defined from 1 cm above the cylinder tip up to 1.5 cm below the last activated dwell source position. An individual plan was computed at every VCB fraction. A set of values (Dmax, D(0.1cc), D(1cc), and D(2cc)) derived from dose-volume histograms were extracted and compared according to the rectal status. RESULTS: Rectal volume was 26.7% larger in the fractions with rectal contrast. Such an increase in volume represented a significant increase from 7.7% to 10.4% in all parameters analyzed except Dmax dose-volume histogram. CONCLUSIONS: Avoiding rectal contrast is a simple way of decreasing the rectal dose parameters of VCB, which would mean a better therapeutic ratio. Results also suggest that action directed at maintaining the rectum empty might have the same effect.