Cross-sectional clinical cancer genomics community of practice survey analysis of provider attitudes and beliefs regarding the use of deceased family member tissue to guide living family member genetic cancer risk assessment.

Next-generation tumor tissue sequencing techniques may result in the detection of putative germline pathogenic variants (PVs), raising the possibility that germline cancer predisposition could be identified from archival medical tissue samples of deceased relatives. The approach, termed traceback, is designed to inform risk management recommendations for living family members. Provider perspectives regarding traceback testing have not yet been explored, so we conducted a cross-sectional survey of Clinical Cancer Genomics Community of Practice providers regarding their attitudes and beliefs toward traceback testing. Self-reported demographics, provider characteristics, attitudes and perceived barriers were collected. We evaluated responses in the context of whether providers had previous experience with traceback testing. Data were analyzed using chi-square and Fisher's exact testing. Among 207 respondents (of 816 eligible), most were women (89.4%), white (85.5%), and not Hispanic or Latino (89.7%). US-based providers represented the majority of respondents (87.4%). Relatively, few providers 32 of 207 (15.5%) had previous experience with traceback. Among the individuals without experience in traceback, 84.0% thought there would be barriers to implementation; however, only 68.8% of individuals with previous traceback experience agreed (p = .04). Respondents in both groups thought that traceback would be valuable in their practice (82.6%, p = .22) and that they would feel comfortable discussing the concept (83.6%, p = .83), interpreting the results (72.2%, p = .24), and discussing the results with their patients (80.7%, p = .38). Patient interest and cost were seen as less of a barrier by those with experience with traceback testing. Recurrent themes obtained in open-ended responses are also presented. Overall, providers believe that traceback would be a valuable tool in their practice. Individuals with previous experience identified less barriers with implementation of this testing, highlighting an area for future research and education.

Alimentação oral e gástrica na pancreatite aguda grave / Gastric and oral feeding in severe acute pancreatitis

ABSTRACT BACKGROUND: There is controversy about the initiation of gastric or oral feeding in patients with severe acute pancreatitis (SAP) because they could increase pancreatic stimulation and exacerbate symptoms and complications. OBJECTIVE: To describe the clinical characteristics and results of patients with SAP who underwent gastric tube or oral feeding versus parenteral or jejunal feeding. METHODS: A retrospective study was carried out on patients over 18 years old with SAP diagnostic, who had been treated in critical care units. We excluded patients coming from other hospitals and those with incomplete medical records. RESULTS: Thirty patients with SAP were included, fifty three percent of them tolerated the gastric tube or oral feeding, and most of them were females and older than patients who received parenteral or jejunal feeding. Other clinical characteristics and outcomes were similar in both groups. Conclusion: Gastric tube or oral feeding is no absolute contraindication for SAP.

RESUMO CONTEXTO Há controvérsias sobre o início da alimentação gástrica ou oral em pacientes com pancreatite aguda grave (PAG), pois elas podem aumentar a estimulação pancreática e exacerbar os sintomas e complicações. OBJETIVO Descrever as características clínicas e os resultados de pacientes com PAG submetidos à alimentação por sonda gástrica ou via oral versus alimentação parenteral ou jejunal. MÉTODOS Foi realizado um estudo retrospectivo em pacientes maiores de 18 anos com diagnóstico de PAG, atendidos em unidades de terapia intensiva. Excluímos pacientes procedentes de outros hospitais e aqueles com prontuário incompleto. RESULTADOS Trinta pacientes com PAG foram incluídos, 53% deles toleravam a sonda gástrica ou alimentação via oral, e a maioria era do sexo feminino e tinha mais idade do que os pacientes que receberam alimentação parenteral ou jejunal. Outras características clínicas e resultados foram semelhantes em ambos os grupos. CONCLUSÃO A sonda gástrica ou alimentação oral não é contra-indicação absoluta para PAG.

Genetic epidemiology of BRCA1- and BRCA2-associated cancer across Latin America.

The prevalence and contribution of BRCA1/2 (BRCA) pathogenic variants (PVs) to the cancer burden in Latin America are not well understood. This study aims to address this disparity. BRCA analyses were performed on prospectively enrolled Latin American Clinical Cancer Genomics Community Research Network participants via a combination of methods: a Hispanic Mutation Panel (HISPANEL) on MassARRAY; semiconductor sequencing; and copy number variant (CNV) detection. BRCA PV probability was calculated using BRCAPRO. Among 1,627 participants (95.2% with cancer), we detected 236 (14.5%) BRCA PVs; 160 BRCA1 (31% CNVs); 76 BRCA2 PV frequency varied by country: 26% Brazil, 9% Colombia, 13% Peru, and 17% Mexico. Recurrent PVs (seen ≥3 times), some region-specific, represented 42.8% (101/236) of PVs. There was no ClinVar entry for 14% (17/125) of unique PVs, and 57% (111/196) of unique VUS. The area under the ROC curve for BRCAPRO was 0.76. In summary, we implemented a low-cost BRCA testing strategy and documented a significant burden of non-ClinVar reported BRCA PVs among Latin Americans. There are recurrent, population-specific PVs and CNVs, and we note that the BRCAPRO mutation probability model performs adequately. This study helps address the gap in our understanding of BRCA-associated cancer in Latin America.

Development and Pilot Implementation of the Genomic Risk Assessment for Cancer Implementation and Sustainment (GRACIAS) Intervention in Mexico.

PURPOSE: Genomic cancer risk assessment (GCRA) is standard-of-care practice that uses genomic tools to identify individuals with increased cancer risk, enabling screening for early detection and cancer prevention interventions. GCRA is not available in most of Mexico, where breast cancer (BC) is the leading cause of cancer death and ovarian cancer has a high mortality rate. METHODS: Guided by an implementation science framework, we piloted the Genomic Risk Assessment for Cancer Implementation and Sustainment (GRACIAS) intervention, combining GCRA training, practice support, and low-cost BRCA1/2 (BRCA) gene testing at four centers in Mexico. The RE-AIM model was adapted to evaluate GRACIAS intervention outcomes, including reach, the proportion of new patients meeting adapted National Comprehensive Cancer Network criteria who participated in GCRA. Barriers to GCRA were identified through roundtable sessions and semistructured interviews. RESULTS: Eleven clinicians were trained across four sites. Mean pre-post knowledge score increased from 60% to 67.2% (range 53%-86%). GCRA self-efficacy scores increased by 31% (95% CI, 6.47 to 55.54; P = .02). Participant feedback recommended Spanish content to improve learning. GRACIAS promoted reach at all sites: 77% in Universidad de Guadalajara, 86% in Instituto Nacional de Cancerología, 90% in Tecnológico de Monterrey, and 77% in Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Overall, a pathogenic BRCA variant was identified in 15.6% (195 of 1,253) of patients. All trainees continue to provide GCRA and address barriers to care. CONCLUSION: We describe the first project to use implementation science methods to develop and deliver an innovative multicomponent implementation intervention, combining low-cost BRCA testing, comprehensive GCRA training, and practice support in Mexico. Scale-up of the GRACIAS intervention will promote risk-appropriate care, cancer prevention, and reduction in related mortality.

Germline mutations and age at onset of lung adenocarcinoma.

BACKGROUND: To identify additional at-risk groups for lung cancer screening, which targets persons with a long history of smoking and thereby misses younger or nonsmoking cases, the authors evaluated germline pathogenic variants (PVs) in patients with lung adenocarcinoma for an association with an accelerated onset. METHODS: The authors assembled a retrospective cohort (1999-2018) of oncogenetic clinic patients with lung adenocarcinoma. Eligibility required a family history of cancer, data on smoking, and a germline biospecimen to screen via a multigene panel. Germline PVs (TP53/EGFR, BRCA2, other Fanconi anemia [FA] pathway genes, and non-FA DNA repair genes) were interrogated for associations with the age at diagnosis via an accelerated failure time model. RESULTS: Subjects (n = 187; age, 28-89 years; female, 72.7%; Hispanic, 11.8%) included smokers (minimum of 5 pack-years; n = 65) and nonsmokers (lighter ever smokers [n = 18] and never smokers [n = 104]). Overall, 26.7% of the subjects carried 1 to 2 germline PVs: TP53 (n = 5), EGFR (n = 2), BRCA2 (n = 6), another FA gene (n = 11), or another DNA repair gene (n = 28). After adjustment for smoking, sex, and ethnicity, the diagnosis of lung adenocarcinoma was accelerated 12.2 years (95% confidence interval [CI], 2.5-20.6 years) by BRCA2 PVs, 9.0 years (95% CI, 0.5-16.5 years) by TP53/EGFR PVs, and 6.1 years (95% CI, -1.0 to 12.6 years) by PVs in other FA genes. PVs in other DNA repair genes showed no association. Germline associations did not vary by smoking. CONCLUSIONS: Among lung adenocarcinoma cases, germline PVs (TP53, EGFR, BRCA2, and possibly other FA genes) may be associated with an earlier onset. With further study, the criteria for lung cancer screening may need to include carriers of high-risk PVs, and findings could influence precision therapy and reduce lung cancer mortality by earlier stage diagnosis.

[Clinical profile and results of acute pancreatitis in the Intensive and Intermediate Care Unit of a general hospital]. / Perfil clínico y resultados de la pancreatitis aguda en la Unidad de Cuidados Intensivos e Intermedios de un hospital general.

INTRODUCTION: Intraductal papillary mucinous neoplasms (IPMN) are diagnosed more frequently because the higher use of radiologic exams, in that sense they are a great challenge to define its management and treatment in relation to its potential malignant transformation. OBJECTIVE: To describe IPMN clinical profile, endoscopic ultrasound (EUS) characteristics and survival in all patients diagnosed with IPMN by EUS at HNERM. MATERIALS AND METHODS: Retrospective cohort of patients with IPMN diagnosed at HNERM by EUS from 2013 to 2018. Descriptive statistics was used for clinical profile and EUS characteristics. Kaplan Meir Method and Cox regression analysis was applied for survival analysis. RESULTS: 133 patients with IPMN were included. Medium age was 68.6 years, 80 (60.2%) were female. According to IPMN subtypes, 89 (66.9%) originated from secondary branch, 23 (17.3%) from main duct (MD) and 21 (15.8%) were mixed type (MT). Head of pancreas was the main localization (41.4%). In follow-up, 22 (16.5%) were derived to surgery. Mortality occurred in 16.5% (22 cases) after a median follow-up of 522 days. Malignant transformation was diagnosed in 6% (8 cases). Survival was 86.8% (IC 95%, 79.6-91.6) at 1 year and 81.9% (IC95%, 73.3-88.0) at 3 years. Univariate analysis demonstrated that factors associated to survival were MD-IPMN (p=0.02) y MT-IPMN (p=0.005), male gender (p=004), nodule size ≥30 mm (p=0.000), presence of nodules (p=0.014) and Wirsung ≥10 mm (p=0.01). Multivariate analysis showed that predictive factors for survival were MD-IPMN (HR=6.3, p=0.005), MT-IPMN (HR=4.9, p=0.008) and nodule size ≥30 mm (HR=7.1, p=0.000). CONCLUSIONS: Diagnosis of MD-IPMN and MT-IPMN are predictive factors for survival as well as nodule size ≥ 30mm.

Perfil clínico y resultados de la pancreatitis aguda en la Unidad de Cuidados Intensivos e Intermedios de un hospital general / Clinical profile and results of acute pancreatitis in the Intensive and Intermediate Care Unit of a general hospital

RESUMEN La pancreatitis aguda (PA) es un proceso inflamatorio agudo del páncreas que, de acuerdo con la clasificación de Atlanta del 2012, puede ser leve, moderada o grave. Objetivo: Describir las características epidemiológicas, clínicas, terapéuticas y los resultados de pacientes con PA ingresados a la unidad de cuidados intensivos e intermedios de un hospital general y compararlos con los descritos en la literatura nacional e internacional. Materiales y métodos: Estudio observacional de pacientes con PA atendidos en un periodo de 3 años. Resultados: Se incluyeron 59 casos; predominó el sexo femenino (54,2%), la edad media fue de 59,3 años, la etiología más frecuente fue biliar (84,7%). Los puntajes de severidad promedio al ingreso fueron APACHE II de 12,4 puntos, SOFA de 4,9 puntos y Marshall modificado de 2,8 puntos; la falla orgánica más frecuente fue la respiratoria (47,5%). La estancia media en cuidados fue 13,9 días y en el hospital fue de 23,3 días. Ningún paciente con PA leve o moderada falleció durante su estancia hospitalaria, 6 pacientes con PA grave fallecieron durante su estancia hospitalaria (20% de los casos de PA grave). Conclusión: Los casos de nuestro hospital tuvieron un perfil clínico y terapéutico semejante al descrito en la literatura mundial y latinoamericano. Se evidenció una estancia hospitalaria mayor a la descrita en trabajos recientes, pero nuestra mortalidad fue menor.

ABSTRACT Acute pancreatitis (AP) is an acute inflammatory process of the pancreas that, according to the 2012 Atlanta classification, can be mild, moderate or severe. Objective: Describe the epidemiological, clinical, therapeutic and outcomes of patients with AP admitted to the intensive care and intermediate care unit of a general hospital and compare them with those described in the national and international literature. Materials and methods: Observational study of patients with AP treated over a period of 3 years. Results: 59 cases were included; the female sex prevailed (54.2%), the average age was 59.3 years, the most frequent etiology was biliary (84.7%). Average entry severity scores were APACHE II of 12.4 points, SOFA of 4.9 points and Marshall modified of 2.8 points; The most frequent organ failure was respiratory (47.5%). The average stay in care was 13.9 days and in the hospital it was 23.3 days. No patients with mild or moderate AP died during their hospital stay, 6 patients with severe AP died during their hospital stay (20% of cases of severe AP). Conclusion: The cases of our hospital had a clinical and therapeutic profile similar to that described in the world and Latin American literature. A hospital staying was greater than that described in recent works, but our mortality was lower.

Personalized circulating tumor DNA analysis to detect residual disease after neoadjuvant therapy in breast cancer.

Longitudinal analysis of circulating tumor DNA (ctDNA) has shown promise for monitoring treatment response. However, most current methods lack adequate sensitivity for residual disease detection during or after completion of treatment in patients with nonmetastatic cancer. To address this gap and to improve sensitivity for minute quantities of residual tumor DNA in plasma, we have developed targeted digital sequencing (TARDIS) for multiplexed analysis of patient-specific cancer mutations. In reference samples, by simultaneously analyzing 8 to 16 known mutations, TARDIS achieved 91 and 53% sensitivity at mutant allele fractions (AFs) of 3 in 104 and 3 in 105, respectively, with 96% specificity, using input DNA equivalent to a single tube of blood. We successfully analyzed up to 115 mutations per patient in 80 plasma samples from 33 women with stage I to III breast cancer. Before treatment, TARDIS detected ctDNA in all patients with 0.11% median AF. After completion of neoadjuvant therapy, ctDNA concentrations were lower in patients who achieved pathological complete response (pathCR) compared to patients with residual disease (median AFs, 0.003 and 0.017%, respectively, P = 0.0057, AUC = 0.83). In addition, patients with pathCR showed a larger decrease in ctDNA concentrations during neoadjuvant therapy. These results demonstrate high accuracy for assessment of molecular response and residual disease during neoadjuvant therapy using ctDNA analysis. TARDIS has achieved up to 100-fold improvement beyond the current limit of ctDNA detection using clinically relevant blood volumes, demonstrating that personalized ctDNA tracking could enable individualized clinical management of patients with cancer treated with curative intent.

Síndrome de embolismo graso postraumático: reporte de un caso / Post-traumatic fat embolism syndrome: a case report

El síndrome de embolismo graso (SEG) post traumático es una complicación potencialmente letal y poco sospechada. Se presenta un caso de SEG diagnosticado clínicamente y confirmado por los criterios diagnósticos vigentes; cuyas características epidemiológicas, factores de riesgo, cuadro clínico y evolución favorable después del tratamiento recibido, fueron de acuerdo a lo publicado. Se realiza una revisión de la literatura y se proponen medidas para disminuir el riesgo de su presentación y mejorar el diagnóstico oportuno

Post-traumatic fat embolism syndrome (FES) is a potentially lethal and poorly suspected complication. We present a case of FES diagnosed clinically and confirmed by current diagnostic criteria. The epidemiological characteristics, risk factors, clinical features and favorable evolution after treatment were as reported. We review the literature and propose measures to reduce the risk of its presentation and improve early diagnosis

Two-stage classifiers that minimize PCA3 and the PSA proteolytic activity testing in the prediction of prostate cancer recurrence after radical prostatectomy.

INTRODUCTION: Early biochemical recurrence after prostate cancer surgery is associated with higher risk of aggressive disease and cancer specific death. Many new tests are being developed that will predict the presence of indicators of aggressive disease like early biochemical recurrence. Since recurrence occurs in less than 10% of patients treated for prostate cancer, validation of such tests will require expensive testing on large patient groups. Moreover, clinical application of the validated test requires that each new patient be tested. In this report we introduce a two-stage classifier system that minimizes the number of patients that must be tested in both the validation and clinical application of any new test for recurrence. MATERIALS AND METHODS: Expressed prostatic secretion specimens were prospectively collected from 450 patients prior to robot-assisted radical prostatectomy for prostate cancer. Patients were followed for 2.5 years for evidence of biochemical recurrence. Standard clinical parameters, the levels proteolytic activity of prostate specific antigen (PSA) and the levels of PCA3 RNA, PSA RNA and TMPRSS2:ERG fusion RNA were determined in each prospective patient specimen for subsequent correlation with biochemical recurrence. RESULTS: While levels of PCA3 and PSA proteolytic activity (PPA) in prostatic secretions provided an effective pre-surgical predictor of early biochemical recurrence in prostate cancer, application of the two-stage classifier shows that only 60% of the patients need these tests. CONCLUSION: Two-stage classifiers can provide a parsimonious approach to both the validation and clinical application of biomarker-based tests. Adoption of the two-stage neutral zone classifier can reduce unnecessary testing in prostate cancer treatment.

Significado cultural de la menstruación en mujeres españolas / Cultural meaning of menstruation among spanish women

RESUMEN Objetivo: Conocer qué significados culturales existen en nuestra sociedad respecto de la menstruación, desde la perspectiva de la enfermería transcultural y analizar si se han superado creencias falsas del pasado. Material y método: Estudio cualitativo con diseño basado en la Teoría Fundamentada y cuyas técnicas de investigación fueron la entrevista semiestructurada y los grupos de discusión. Participaron 47 mujeres de diferentes regiones de España. Como criterios de segmentación se establecieron la edad y el lugar de residencia. Como criterios de variabilidad el nivel educativo, madres o mujeres sin hijos/as y la profesión. Las categorías de análisis fueron la menarquia, menstruación, conocimientos sobre sus propios cuerpos y el género. Resultados: La menarquia es vivida de diferente forma según el grado de conocimiento previo; existencia de tabú en diferentes grados según la edad de la mujer, asociado a desconocimiento e ideas falsas; el traspaso de creencias populares erróneas, por transmisión oral, sigue presente. Conclusión: Los cuidados de enfermería transcultural deben ir encaminados a desterrar creencias falsas, utilizando talleres grupales que permitan erradicar creencias erróneas y ayuden a las mujeres a aclarar dudas que al respecto puedan tener.

ABSTRACT The objective of the research was to know what cultural meanings exist in our society regarding menstruation, from the perspective of transcultural nursing, and to analyze whether past false beliefs have been overcome. Method : Qualitative study with a design based on Grounded Theory and whose research techniques were semi-structured interviews and discussion groups. 47 women from different regions of Spain participated. Age and place of residence were established as segmentation criteria and educational level, mothers or women without children and the profession were established as the variability criteria. The categories of analysis were menarche, menstruation, knowledge about their own bodies and gender. Results: The menarche is lived in a different way depending on the degree of prior knowledge; presence of taboo in different degrees depending on the age of the woman, associated to ignorance and false ideas; the transfer of erroneous popular beliefs, by oral transmission, is still present. Conclusion: Transcultural nursing care should be aimed at banishing false beliefs, using group workshops to eradicate erroneous beliefs and help women to clarify any doubts they may have.

Factors influencing family care by immigrant women in Spain: a qualitative study / Fatores que influem no cuidado familiar prestado por mulheres imigrantes na Espanha: um estudo qualitativo / Factores que influyen en el cuidado familiar prestado por mujeres inmigrantes en España: un estudio cualitativo

Abstract Objective. To identify and understand factors that influence the relationships in the environment of family care provided by live-in immigrant caregivers. Methods. Interpretive qualitative study from a phenomenological perspective, using in-depth interviews, discussion groups and participant observation. The observation unit was the Sevillian families (Spain) with elderly dependents and a live-in female immigrant caregiver. Analysis units considered were health, care, dependence, gender, ethnicity and social class. Categories were analysed using QSR-NUD*ISTVivo9. After saturation, we triangulated between researchers, disciplines, sources and techniques to validate the results. Results. Factors of cultural discovery or clash were: language, religion, food, concept of space and time, caregiver's name and the attitudes held by both the hiring family, related to its social class, and by caregivers. Conclusion. Interpersonal relationships are the most important factor: an egalitarian relationship based on good treatment is beneficial to all involved. Knowing these codes will improve the quality of professional care in the family.

Resumo Objetivo. Identificar e compreender os fatores que influem nas relações no contexto do cuidado familiar prestado por mulheres imigrantes internas contratadas. Métodos. Estudo qualitativo interpretativo desde uma perspectiva fenomenológica, se utilizaram entrevistas em profundidade, grupos de discussão e observação participante. A unidade de observação a constituem famílias sevilhanas (Espanha) com adultos maiores dependentes a seu cargo e cuidadora imigrante interna contratada. Como unidades de análise se contemplaram: saúde, cuidados, dependência, gênero, etnia, classe social. As categorias se analisaram com o programa informático QSR NUD*ISTVivo9. Após chegar à saturação, se triangularam investigadoras, disciplinas, fontes e técnicas, para validar os resultados. Resultados. Como elementos de encontro/choque cultural se encontraram: a linguagem, a religião, a alimentação, a noção espaço-tempo, o nome da cuidadora e as atitudes, tanto da família que contratadora, relacionada com sua classe social, como das cuidadoras. Conclusão. As relações interpessoais é o fator mais importante: uma relação baseada no bom trato beneficia a todas as pessoas implicadas. Conhecer estas chaves pode favorecer a qualidade do cuidado profissional enfermeiro prestado à família.

Resumen Objetivo. Identificar y comprender los factores que influyen en las relaciones en el contexto del cuidado familiar prestado por mujeres inmigrantes internas contratadas. Métodos . Estudio cualitativo interpretativo desde una perspectiva fenomenológica. Para el efecto, se utilizaron entrevistas en profundidad, grupos de discusión y observación participante. La unidad de observación la constituyen familias sevillanas (España) con adultos mayores dependientes a su cargo y con una cuidadora inmigrante interna contratada. Como unidades de análisis se contemplaron: salud, cuidados, dependencia, género, etnicidad, clase social. Las categorías se analizaron con el programa informático QSR NUD*ISTVivo9. Tras llegar a la saturación, se triangularon investigadoras, disciplinas, fuentes y técnicas para validar los resultados. Resultados . Como elementos de encuentro/choque cultural se han encontrado: el lenguaje, la religión, la alimentación, la noción espacio-tiempo, el nombre de la cuidadora y las actitudes, tanto de la familia que contrata -relacionada con su clase social-, así como de las cuidadoras. Conclusión. Las relaciones interpersonales son el factor más importante: una relación basada en el buen trato beneficia a todas las personas implicadas. Conocer estas claves puede favorecer la calidad del cuidado profesional enfermero prestado a la familia.

Características clínicas, epidemiológicas y evolución de la neumonía nosocomial severa en la unidad de cuidados intensivos / Clinical, epidemiological evolución y de la severe nosocomial neumonía en la unidad intensive care

Describir las características clínicas, epidemiológicas, evolución e identificar factores asociados a la mortalidad en pacientes con NNS. Material y Métodos: Estudio descriptivo de una serie de casos de la Unidad de Cuidados Intensivos (UCI) de un hospital general. Se revisaron las historias clínicas de los pacientes atendidos y que cumplieran los criterios de selección. Resultados: Cuarenta y un historias clínicas fueron evaluadas. La edad promedio fue de 69.6 años, predominando el género masculino (68.3%), la NNS fue el motivo de ingreso en 60.9% y el 95.1% requirió ventilación mecánica. La estancia hospitalaria previa al diagnóstico fue de 10.0 días, 65.9% de los pacientes tuvo algún factor de riesgo para organismosmultirresistentes, el Clinical Pulmonary Infection Score (CPIS) de ingreso fue 9.3 puntos, los cultivos fueron positivos en 39% de los casos y de estos el 48.8% recibieron antibiótico adecuado al cultivo. Los días de estancia en UCI fueron 20.6 días y 20 de las 41 historias correspondieron a pacientes que habían fallecido. Las características clínico epidemiológicas de los fallecidos y sobrevivientes al alta, fueron semejantes. Se realizó un análisis de factores que pudieron estar asociados a mortalidad por NNS encontrando que la edad ≥ 70 años, la presencia de algún factor de riesgo para microorganismos multidrogorresistente y el CPIS control ≥ 6 puntos estuvieron asociados a mayor mortalidad; mientras que la adquisición de la NNS en la UCI estuvo asociada a menor mortalidad. Conclusión: Las características clínicas, epidemiológicas y la evolución de los pacientes con NNS de nuestra UCI fueron semejantes a los descritos en la literatura. Se identificaron tres factores asociados a mortalidad por NNS en la UCI...

To describe the clinical and epidemiological characteristics, evolution and to identify mortality factors associated in patients with SNP. Material and Methods: Descriptive study of a serie of cases of the Intensive Care Unit (ICU) of a General Hospital. Medical records of patients which received medical attention and who meet the selection criteria were reviewed Results: Forty-one clinical records were evaluated. The average age was 69 old, predominantly male (68,3%). SNP was the reason of admission in 60.9% and 95.1% required mechanical ventilation. Hospital stay prior to diagnosis was 10 days, 65% of patients had some risk factor for multi resistence organisms, CPIS of entry was 9.3, cultures were positive in 39% of the cases and of these, 48.8% received proper antibiotic according to culture results. The days of stay in ICU were 20.6 days and 20 of the 41 medical records were for death patients. The clinical and epidemiological characteristics were similar between death and alive patients. An analysis of factors that could be associated with mortality SNP was made and it was found that for an age ≥ 70 years, the presence of any risk factor for multidrug resistence organism and control CPIS ≥ 6 were associated with higher mortality; while acquisition of the ICU was associated to lower mortality. Conclusions: The clinical, epidemiological characteristics and evolution of patients with SNP in our ICU were similar to those describe in the literature. Three factors associated with mortality in the ICU were identified...

Fears and concerns related to menstruation: a qualitative study from the perspective of gender / Medos e receios relacionados com a menstruação: estudo qualitativo a partir da a perspectiva de género / Miedos y temores relacionados con la menstruación: estudio cualitativo desde la perspectiva de género

The aim of this article is to analyze the fears about menstruation and health that have been passed down to us by oral transmission from a gender perspective. A qualitative study, whose design was the Grounded Theory, performed in Seville, Spain, with 24 rural and urban women from different generations, young (18-25, 26-35 years), middle aged (36-45, 46-55, 56-65 years) and elderly (> 65 years). The semi-structured interview was used as a data collection technique. The discourses were subjected to content analysis, following the steps of Grounded Theory. The results highlight the abundant fears related to use of water during menstruation, with very harmful effects to health. As a conclusion to highlight the lack of women's knowledge about reproductive health and that despite Health Education campaigns there are still ancient misconceptions present about menstruation.

O objetivo do artigo foi analisar os medos sobre a menstruaçao e a saúde que chegaram até aos nossos dias através da comunicação oral, numa perspectiva do género. Um estudo qualitativo, cujo desenho se baseou na Teoria Fundamentada nos Dados, realizado em Sevilha, Espanha, tendo como base 24 mulheres de meio rural e urbano de diferentes gerações, jovens (18-25, 26-35 anos), de meia idade (36-45, 46-55, 56-65 anos) e idosos (>65 anos). Utilizou-se como técnica de obtenção de dados a entrevista semiestruturada. Os dados foram submetidos a uma análise de conteúdo, seguindo os passos da Teoria Fundamentada. Dentro dos resultados, destacamos os abundantes medos relacionados com o uso de água durante a menstruação, com efeitos muito prejudiciais para a saúde. Destacamos a falta de conhecimento por parte das mulheres na saúde reproductiva ja que, apesar das campanhas no âmbito da Educação para a Saúde, continuam presentes crenças milenares erradas sobre a menstruação.

El objetivo del artículo es analizar los miedos sobre la menstruación y la salud que han llegado hasta nuestros días mediante transmisión oral desde la perspectiva de género. Estudio cualitativo, cuyo diseño fue la Teoría Fundamentada realizado en Sevilla, España, con 24 mujeres de medio rural y urbano de diferentes generaciones jóvenes (18-25, 26-35 años), mediana edad (36-45, 46-55, 56-65 años) y mayores (>65 años). Se utilizó como técnica de obtención de datos la entrevista semi-estructurada. Los discursos fueron sometidos al análisis de contenido, siguiendo los pasos de la Teoría Fundamentada. Como resultados destacar abundantes miedos relacionados con el uso del agua durante la menstruación, con efectos muy perjudiciales para la salud. Como conclusiones destacar la falta de conocimientos de las mujeres en la salud reproductiva ya que a pesar de las campañas en Educación para la Salud todavía siguen presente creencias erróneas milenarias sobre la menstruación.

Menopausia y estereotipos de género: importancia del abordaje desde laeducación para la salud / Menopausa e estereótipos de gênero: a importância da abordagem da educação para a saúde / Menopause and gender stereotypes: the importance of the health education approach

El objetivo de esta investigación fue conocer y analizar los estereotipos de género que existen actualmente sobre la menopausia. Estudio cualitativo, cuyo diseño fue la Teoría Fundamentada, realizado en Sevilla (España), con 43 mujeres de medio rural y urbano de diferentes generaciones jóvenes (18-25 años, 26-35 años), mediana edad (36-45 años, 46-55 años, 56-65 años) y ancianas (> 65 años). Se utilizaron como técnica obtención de datos la entrevista semiestructurada y 3 grupos de discusión. Se realizaron entre marzo de 2008 y diciembre de 2011. Los discursos fueron sometidos al análisis de contenido hallándose diferencias importantes entre los discursos de las diferentes generaciones, siendo las más ancianas las que tienen una visión más fisiológica y las más jóvenes una idea más patológica del mismo proceso. Estos resultados reflejan el prejuicio cultural existente y refuerzan la importancia dela educación para la salud para erradicarlo.

O objetivo desta pesquisa foi compreender e analisar os estereótipos de gênero que existem sobre a menopausa. Trata-se de um estudo qualitativo apoiado na Teoria Fundamentada. O estudo foi realizado em Sevilha (Espanha), com 43 mulheres de população rural e urbana de diferentes faixas etárias, jovens (18-25 anos, 26-35 anos), meia-idade (36-45 anos, 46-55 anos, 56-65 anos) e idosas (> 65 anos). Como técnica para coleta de dados utilizou-se entrevistas semi-estruturadas individuais e 3 grupos focais, realizadas entre março de 2008 e dezembro de 2011. Os discursos foram submetidos à análise de conteúdo. Foram encontradas diferenças significativas entre os discursos de diferentes gerações: as mulheres mais velhas apresentaram um ponto de vista fisiológico enquanto as mais jovens uma idéia patológica do mesmo processo. Estes resultados refletem o viés cultural existente e reforçam a importância da Educação em Saúde para erradicá-la.

This research aimed at assessing and analyzing gender stereotypes on menopause. It holds a qualitative nature on the basis of the Grounded Theory. The research was held in Seville (Spain), with 43 women of both rural and urban areas, from different age groups, namely, the young ones (18-25 years, 26-35 years), the middle aged (36-45 years, 46-55 years, 56-65 years), and the elderly (> 65 years). Data collection took place from March, 2008 to December, 2011, and made use of techniques such as semi-structured interviews and 3 focus groups. Speeches were treated on the basis of content analysis. Significant differences between the discourses in different generations stood out. Older women held a physiological stand whereas the younger sustained a pathological idea of same process. Results highlight existing cultural bias and reinforce the importance of health education to eradicate it.

Pancreatitis aguda grave asociada a gangrena vesicular / Severe acute pancreatitis associated with gallbladder gangrene

Se presenta el caso un paciente diabético que desarrolló un cuadro de pancreatitis aguda grave asociada a gangrena vesicular, en el que se evaluó la aplicabilidad de los criterios de clasificación y manejo de la hoja de ruta para pancreatitis aguda, así mismo se proponen algunos tópicos que pudieran ser investigados a futuro.

We present a diabetic patient who developed severe acute pancreatitis associated to gallbladder gangrene, in this case we assessed the applicability of classification criteria and management of the pathways for acute pancreatitis and also we suggest some topics that could be investigated in the future.

Complications and outcomes of salvage robot-assisted radical prostatectomy: a single-institution experience.

OBJECTIVE: To determine the peri-operative outcomes of men undergoing salvage robot-assisted prostatectomy (RARP) and to examine the complications, functional consequences and need for additional treatments after salvage RARP. PATIENTS AND METHODS: At total of 51 consecutive patients underwent salvage RARP after previous failed local therapy. Biochemical recurrence (BCR) was defined as two postoperative PSA measurements ≥0.2 ng/mL. Complications at any time postoperatively were recorded prospectively using a modified Clavien system. The Kaplan-Meier method was used for survival estimation, and regression models were used to identify the predictors of BCR or progression-free survival (PFS) and complications. RESULTS: The median age at salvage RARP was 68 years and a median of 68 months had elapsed from the time of primary treatment. The median follow-up was 36 months. The median operation duration was 179 min with a median estimated blood loss of 175 mL. In all, 50% of patients had pathological stage 3 disease and positive surgical margins were found in 31% of patients. The estimated 3-year BCR-free or PFS was 57%. The overall complication rate was 47%, with a 35% major complication rate (Grade III-V). Potency was maintained in 23% of preoperatively potent patients and 45% of all patients regained urinary control. No clinical variables were predictive of major complications, but all patients with postoperative bladder neck contracture were incontinent. A higher PSA level and extracapsular extension were significantly associated with BCR or progression (P < 0.01). CONCLUSIONS: Salvage RARP provides oncological control with potential avoidance of systemic non-curative therapy. Complication, incontinence and erectile dysfunction rates are significant but frequently correctable. This reinforces the need for proper patient counselling and selection.

Expressed prostatic secretion biomarkers improve stratification of NCCN active surveillance candidates: performance of secretion capacity and TMPRSS2:ERG models.

PURPOSE: Active surveillance is a viable patient option for prostate cancer provided that a clinical determination of low risk and presumably organ confined disease can be made. To standardize risk stratification schemes the NCCN (National Comprehensive Cancer Network®) provides guidelines for the active surveillance option. We determined the effectiveness of expressed prostatic secretion biomarkers for detecting occult risk factors in NCCN active surveillance candidates. MATERIALS AND METHODS: Expressed prostatic secretion specimens were obtained before robot-assisted radical prostatectomy. Secretion capacity biomarkers, including total RNA and expressed prostatic secretion specimen volume, were measured by standard techniques. RNA expression biomarkers, including TXNRD1 mRNA, prostate specific antigen mRNA, TMPRSS2:ERG fusion mRNA and PCA3 mRNA, were measured by quantitative reverse-transcription polymerase chain reaction. RESULTS: Of the 528 patients from whom expressed prostatic secretions were collected 216 were eligible for active surveillance under NCCN guidelines. Variable selection on logistic regression identified 2 models, including one featuring types III and VI TMPRSS2:ERG variants, and one featuring 2 secretion capacity biomarkers. Of the 2 high performing models the secretion capacity model was most effective for detecting cases in this group that were up-staged or up-staged plus upgraded. It decreased the risk of up-staging in patients with a negative test almost eightfold and decreased the risk of up-staging plus upgrading about fivefold while doubling the prevalence of up-staging in the positive test group. CONCLUSIONS: Noninvasive expressed prostatic secretion testing may improve patient acceptance of active surveillance by dramatically reducing the presence of occult risk factors among those eligible for active surveillance under NCCN guidelines.

Standardized comparison of robot-assisted limited and extended pelvic lymphadenectomy for prostate cancer.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Extended pelvic lymphadenectomy is the present standard of care according to European Association of Urology guidelines. Extended dissection improves staging, removes more metastatic lymph nodes, and potentially has therapeutic benefits. Previous reports have examined the morbidity of extended dissection compared with a more limited dissection in the open and laparoscopic setting. While some have suggested an increased complication rate with extended node dissection, others have not. This represents the first study focused on comparing the complications associated with the extent of node dissection using the modified Clavien system and Martin criteria in the literature on robot-assisted surgery. In a single surgeon series, we found no statistically significant differences in complications. With careful anatomic dissection, robot-assisted extended lymph node dissection can be performed safely and effectively, although operating time and length of hospital of stay are slightly increased. OBJECTIVES: To compare the perioperative course of patients undergoing robot-assisted limited lymph node dissection (LLND) or extended lymph node dissection (ELND) for prostate cancer. To examine the differential lymph node counts and rates of detection of lymph node metastases. PATIENTS AND METHODS: Between 2008 and 2012, 406 consecutive patients with D'Amico intermediate- or high-risk prostate cancer underwent either bilateral LLND (n = 204) or ELND (n = 202) and robot-assisted laparoscopic radical prostatectomy by a single surgeon. The region of dissection was the obturator fossa for LLND, while ELND included, in addition, the common iliac, external iliac and internal iliac lymph nodes. All complications within 90 days of surgery were recorded according to a modified Clavien system. Clinical variables were summarized and compared. Logistic regression was used to identify predictors of complications. RESULTS: There were no differences in demographics when comparing patients who underwent ELND with those who underwent LLND. The median operating time was 3.0 h for the ELND cohort and 2.8 h in the LLND cohort (P < 0.001). Intraoperative blood loss was 200 mL in both cohorts. Hospital stay was longer for a small percentage of patients in the ELND cohort, with 75% of ELND patients and 85% of LLND patients staying 1 day (P = 0.004). No significant difference was found in the overall or major complication rates between LLND (21.6% overall; 6.9% major) and ELND (22.8% overall; 4.5% major). No difference was seen in the symptomatic lymphocele rate between LLND and ELND, 2.9 vs 2.5%, respectively. Overall, the lymph-node-positive rate was 12% compared with 4% for the ELND and LLND groups, respectively (P = 0.002). A higher Charlson comorbidity index score was associated with the development of major complications. CONCLUSIONS: ELND at the time of robot-assisted radical prostatectomy can be performed safely with minimal additional morbidity. Long-term oncological and functional outcomes require further study.

Robotic extended pelvic lymphadenectomy for intermediate- and high-risk prostate cancer.

BACKGROUND: Accurate staging of prostate cancer is enhanced by a thorough evaluation of the pelvic lymph nodes. Limited data are available regarding robotic extended pelvic lymphadenectomy (PLA) in this setting. OBJECTIVE: Analyze our experience performing robotic extended PLA. DESIGN, SETTING, AND PARTICIPANTS: A total of 143 consecutive men with intermediate- or high-risk clinically localized adenocarcinoma of the prostate underwent robotic extended PLA and radical prostatectomy between September 2010 and November 2011 by a single surgeon. SURGICAL PROCEDURE: Lymph node packets were sent separately from bilateral common, external, and internal iliacs, obturators, node of Cloquet, and anterior prostatic fat. MEASUREMENTS: Descriptive statistics were used to summarize lymph node yields and positive nodes. Clinical variables were examined in logistic regression models to predict lymph node positivity. RESULTS AND LIMITATIONS: Median lymph node yield was 20 (range: 9-65, interquartile range: 15-25). Eighteen patients (13%) were found to have metastatic prostate cancer in the lymph nodes. The mean number of positive nodes found was 2.9 (range: 1-11). In 14 of 18 node-positive patients (78%), the extent of nodal invasion was outside the boundaries of a limited PLA. For four patients with positive nodes (22%), prostate biopsy predicted unilateral disease but PLA revealed contralateral positive lymph nodes. A total of 82% of patients experienced no complications, and most Clavien grade 1-2 complications consisted of anastomotic leakage, urinary retention, ileus, and lymphocele. Only 4% of patients experienced a grade 3 complication. Under multivariate regression analysis, prostate-specific antigen (PSA), clinical stage, and maximum biopsy core tumor volume were identified as significant predictors of finding positive pelvic lymph nodes (area under the curve: 91%). The main limitations include short follow-up and lack of randomization. CONCLUSIONS: Robotic extended bilateral PLA for prostate cancer up to the common iliac bifurcation increases nodal yield and positive nodal rate and can be performed safely. PSA, clinical stage, and maximum biopsy core volume are predictors for lymph node invasion. Long-term follow-up is needed to evaluate for therapeutic benefit.