Metastasis pulmonares tardías de carcinoma adenoideo quístico de la glandula de bartolino / Late lung metastases of cystic adenoid carcinoma of the bartolino gland

El carcinoma adenoideo quístico de la glándula de Bartolino (GB) es una entidad infrecuente, de crecimiento lento y comportamiento agresivo con alta recurrencia local y metástasis. Presentamos el caso de una paciente de 48 años, con antecedente de tratamiento quirúrgico de un absceso Bartolino derecho. La biopsia demostró un carcinoma adenoideo quístico (CAQ) de la GB, por lo que se realizó hemivulvectomía radical derecha y linfadenectomía inguinofemoral. El resultado de la biopsia mostró 4 ganglios positivos de 12 y margen lateral positivo a menos de 2 mm. Por lo que se realizó adyuvancia con radioterapia. La paciente no se presenta a su control y acude luego de tres años por dolor urente desde cadera izquierda hacia rodilla y cara lateral de la pierna y pie. Se realiza cintigrama óseo que muestra lesión osteoblástica sacroilíaca izquierda de 2 cm, por lo que se completó estudio de diseminación con tomografía computada de tórax, abdomen y pelvis con contraste que evidenció múltiples lesiones nodulares pulmonares bilaterales de distribución generalizada en parénquima central, periférico y subpleurales. Se deriva al Instituto Nacional del Tórax, completando estudio preoperatorio y se realizó una biopsia quirúrgica por video toracoscopía resecando un nódulo subpleural, el informe histológico señaló una metástasis de CAQ concordante con primario en GB. La paciente fue presentada en el comité oncológico y se indicó radioterapia paliativa a lesión sacroilíaca y control clínico ambulatorio. Ha evolucionado estable desde el punto de vista funcional pulmonar.

Adenoid cystic carcinoma of Bartholin glands (BG) is a rare, slow-growing but a highly aggressive tumor with remarkable capacity for local recurrence and distant metastasis. We present the case of a 48 year-old female patient with a history of surgical treatment for right Bartholin abscess. The biopsy showed a cystic adenoid carcinoma of the BG, which led to radical hemivulvectomy and inguinofemoral lymphadenectomy. The biopsy show inguinal lymph node metastasis on 4 of 12 lymph nodes and positive surgical resection margin. Adjuvant radiotherapy was applied. The patient doesnt present to her clinical follow up, and consult three years later with radiological evidence of sacroiliac metástasis on bone scintigraphy. Study was completed with thorax, abdomen and pelvis tomography scan, and showed multiple bilateral lung nodules. The patient was transfered to National Thoracic Institute, and preoperative study was performed. We decide to obtain histologycal confirmation by a video thoracoscopy, it was performed without incidents. Histology show metastasis of adenoid cystic carcinoma pattern, concordant with primary tumor. The patient was submitted to the oncology committee and palliative radiotherapy was indicated for sacroiliac lesion. The patient evolve stable and asintomatic at ambulatory clinical control.

Electrocauterio y broncoscopia flexible como primera medida en la obstrucción central de la vía aérea y hemoptisis asociada / Electrocautery and bronchoscopy as a first step for the management of central airway obstruction and associated hemoptysis

Background: Central airway obstruction caused by malignant or benign lesions, associated in some cases with hemoptysis, is a condition with high morbidity and mortality. The use of electrocautery by flexible bronchoscopy is an initial treatment option with immediate improvement of obstruction symptoms. It is as effective as Nd: YAG laser. Aim: To describe the usefulness of electrocautery in the management of central obstruction of the airway and hemoptysis. Material and Methods: A retrospective, descriptive study of patients referred for management of central airway obstruction or associated hemoptysis. Diagnoses, symptoms (dyspnea, cough, and hemoptysis) and radiology before and after the procedures were analyzed. Results: Eighteen patients aged 59 ± 12 years (66% males) were evaluated, registering 25 endoscopic procedures. Three conditions were found: partial or complete airway obstruction, hemoptysis and post lung transplant bronchial stenosis. Seventy two percent presented with dyspnea, 61% with cough and 33% with hemoptysis. Sixty six percent of patients had airway obstruction caused by malignant metastatic lesions. After electrocautery, 17 patients (94.4%) improved their symptoms and achieved complete airway clearing. Three patients had significant bronchial stenosis after lung transplant achieving subsequent clearing after electrocautery. Conclusions: Electrocautery during flexible bronchoscopy is an effective and safe procedure for the management of central airway obstruction and associated hemoptysis.

Use of the ROSE risk score for predicting mortality and cardiovascular events in adult patients at 7 and 30 days of syncope / Aplicación del puntaje de riesgo de la escala ROSE para predicción de mortalidad y desenlaces cardiovasculares mayores en pacientes adultos con síncope a 7 y 30 días

Abstract Introduction: The use of the ROSE risk score after syncope provides the possibility of identifying patients at risk of death or other important adverse events after 30 days of admission to the emergency department. Objective: To evaluate the performance of ROSE score in terms of mortality prediction and major adverse events at 7 and 30 days in adult patients with syncope admitted to the emergency department. Materials and methods: A prospective cohort study in patients with syncope who were admitted to the emergency room was performed. An operational analysis of the predictive ability for detection of possible complications was done by calculating sensitivity, specificity, positive and negative predictive values and ROC curves. Results: 60 patients were evaluated. An area under the curve for prediction of mortality or major outcome at 7 and 30 days of 0.62 (95%CI: 0.45-0.78) was obtained, with sensitivity of 60%, specificity of 18.18%, PPV of 6.25% and NPV of 83%. Conclusion: ROSE score showed low sensitivity for predicting mortality or serious outcomes at 7 and 30 days. Its high negative predictive value makes it a useful prognostic tool in low risk patients.

Resumen Introducción. El puntaje de riesgo ROSE para síncope tiene la capacidad de identificar pacientes en riesgo de presentar mortalidad o cualquier otro desenlace adverso mayor a los 30 días de su ingreso a urgencias. Objetivo. Evaluar el rendimiento pronóstico del puntaje para predicción de mortalidad o desenlaces adversos mayores a 7 y 30 días en pacientes adultos con síncope en el servicio de urgencias. Materiales y métodos. Estudio de cohorte prospectivo en pacientes con síncope admitidos en urgencias. Se realizó un análisis operativo de la capacidad predictiva de detección de riesgo de complicaciones calculando sensibilidad, especificidad, valor predictivo positivo (VPP) y negativo (VPN) y curvas ROC. Resultados. Se evaluaron 60 pacientes en los que se obtuvo un área bajo la curva para predicción de mortalidad o desenlaces mayores, tanto a los 7 como a los 30 días, de 0.62 (IC95%: 0.45-0.78), con sensibilidad de 60%, especificidad de 18.18%, VPP de 6.25% y VPN de 83%. Conclusión. El puntaje ROSE mostró una sensibilidad baja para predicción de mortalidad o desenlaces serios mayores a 7 y 30 días. Su alto valor predictivo negativo la hace una herramienta de pronóstico con utilidad en los pacientes de bajo riesgo.

Histeroscopia de consultorio: evaluación del dolor / Office hysteroscopy: pain assessment

Objetivo: Evaluar el dolor durante la histeroscopia de consultorio, sin anestesia e investigar los factores relacionados. Métodos: Estudio prospectivo, descriptivo, analítico y de corte transversal en una población de 309 pacientes de la Maternidad “Concepción Palacios” que acudieron al Servicio de Ginecología entre agosto 2010 y agosto 2011, quienes tenían indicación para histeroscopia. Se registraron antecedentes y datos clínicos relacionados con la percepción del dolor, así como la intensidad de dolor percibida mediante una escala análoga de 0 al 10. Resultados: Se obtuvo una media de percepción de dolor de 2,9. La percepción de dolor fue leve en 56.%, dolor moderado: 36,2 %, dolor intenso: 4,9 %, dolor intolerable: 2,9 %, nada de dolor: 4,2 %. No se encontró relación entre la percepción de dolor y la edad, paridad, estado hormonal, indicación del estudio ni tipo de procedimiento. El 60,6 % de las pacientes con cuello permeable, presentaron dolor leve, mientras que las que tenían sinequias o estenosis lo presentaron en 25,5 % y 31, 3 % respectivamente. Con cuello permeable hubo 0,4 % de dolor intolerable y en presencia de sinequias la cifra fue 12,5 % (P<0,05). 88,8.% de las pacientes con dolor intolerable presentaban estenosis o sinequias. Conclusiones: La histeroscopia de consultorio es un procedimiento bien tolerado por la mayoría de las pacientes; es independiente de la paridad, condición hormonal, indicación del estudio, edad y tipo de procedimiento. La percepción de dolor fue mayor en pacientes con estenosis o sinequias cervicales.

Objective: Assess pain during no anesthesia office hysteroscopy and investigate related factors. Method: Prospective, descriptive, analytical and cross-section study in a population of 309 patients who attended the gynaecology service of Maternidad Concepción Palacios between August 2010 and August 2011, who had indication for hysteroscopy. Background and clinical data was collected, relating to the perception of pain, as well as the intensity of pain perceived by means of an analog scale of 0 to 10. Results: An average of 2.9 pain perception. The perception of pain was mild in 56 %, moderate pain: 36.2 %, severe pain: 4.9 %, intolerable pain: 2.9 %, none of pain: 4.2 per cent. No relationship was found between the perception of pain and age, parity, hormonal state, indication of the study or type of procedure. 60.6 % of patients with permeable cervix presented mild pain, while if they had adhesions or stenosis the mild pain was present in 25.5 % and 31, 3 % respectively. With permeable cervix there was 0.4 % of intolerable pain and in the presence of adhesions was only 12.5 % (P < 0,05), 88.8 % of patients with intolerable pain had cervical stenosis or adhesions. Conclusions: Office hysteroscopy is a procedure well tolerated by most patients; It is independent of parity, hormonal condition, indication of the study, age and type of procedure. The perception of pain was greater in patients with cervical stenosis or adhesions.

Supervivencia de pacientes con fibrosis pulmonar idiopática diagnosticados por biopsia quirúrgica de pulmón: experiencia del Instituto Nacional del Tórax / Survival of patients with biopsy-proven idiopathic pulmonary fibrosis: Chilean National Thorax Institute experience

Background: Idiopathic Pulmonary Fibrosis (IPF) is the most prevalent of all interstitial lung diseases. The usual underlying pathological picture is an interstitial pneumonia (UIP). Aim: To describe the evolution of a Chilean cohort of patients with IPF. Material and Methods: Patients with the disease were identified at the pathology registry of National Institute of Thoracic Diseases, Santiago, Chile. Patients were included if they had surgical biopsy of UIP and compatible clinical and radiological characteristics. The medical records of included patients were reviewed, recording clinical information and lung function test results. Survival was analyzed obtaining death records from the Chilean National Identification Service. Results: Data from 142 patients with a mean age of 58 years (42% men), were analyzed. Mean initial lung function showed a forced vital capacity (FVC) of 73%, carbon monoxide diffusing capacity (DLCO) of 57% and a distance covered in 6-minute walk (6MWT) of 95% of expected normal values. The median survival was 80 months. Predictors of survival were a DLCO of less than 40% and an oxygen saturation at the end of the 6MWT of less than 89%. Conclusions: Survival in this group of patients was higher than the figures reported elsewhere. DLCO and the fall of oxygen saturation after walking were predictors of mortality, as previously described in other populations.

Gastrectomía extendida en cáncer gástrico: Evaluación de la morbilidad y mortalidad postoperatoria / Complications and mortality of extended gastrectomy for gastric cancer

Background: Extended gastrectomy allows a complete tumor excision in patients with advanced gastric cancer. Aim: To compare the surgical results of extended (ER) and non-extended gastrectomy (NER) among patients with gastric cancer, and determine factors associated with complications and mortality. Material and Methods: Review of medical records of patients with gastric cancer who underwent complete resection between 2002 and 2008 in an oncological hospital. Demographics, patient-related and therapeutic features were compared between groups, and independent factors were established with multivariate analysis. Results: Seventy four patients, (44 men, median age 62 years) underwent an ER and 103 patients, (56 men, median age 61 years) a NER. Specifically, ER included splenectomy alone in 27 patients, splenectomy associated with other procedure in 24, partial esophagectomy in 18, distal pancreatectomy in 13, hemicolectomy in 8, total esophagectomy in 7, partial hepatectomy in 4, and adrenalectomy in 1. Postoperative complications were observed in 19 patients treated with an ER (26 percent) and in 11 patients treated with a NER (11 percent), p < 0.05. Serious complications were higher in patients who underwent an ER compared with NER (6 patients (8 percent) vs. 4 (4 percent), respectively) p < 0.05. In the same way, mortality was higher in patients treated with ER when it was compared with NER (4 patients (5 percent) vs two (2 percent), respectively), p < 0.05. ER and serum albumin levels were independent factors associated to a higher risk of mortality and rate of complications. Conclusions: ER was associated with a higher rate of general and severe complications, and mortality.

Cáncer de la unión gastroesofágica: Evaluación de los resultados quirúrgicos, sobrevida alejada y factores pronósticos en enfermos con terapia resectiva / Adenocarcinoma of the esophagogastric junction: Retrospective analysis of 39 patients

Background: The long-term survival of adenocarcinoma of the esophago-gastric junction is poor and depends on the possibility of performing a complete surgical excision and the absence of lymph node involvement. Aim: To report surgical results and survival of patients with adenocarcinoma of the esophago-gastric junction. Material and Methods: Retrospective review of medical records of patients with adenocarcinoma of the esophago-gastric junction, subjected to a curative surgical procedure between 2000 and 2008. Deaths that occurred within 60 days of the operation were considered operative mortality. Tumor stage was determined using TNM and Siewert pathological classifications. Results: Thirty-nine patients aged 40 to 80years (27 men), were operated. According to Siewert classification, seven patients had type I, six type II and 26 type III tumors. Twenty-two patients were subjected to a total gastrectomy with partial excision of distal esophagus and mediastinal reconstruction, 10patients were subjected to a trans-hiatal esophagectomy and seven to a total esophagogastrectomy. According to postoperative staging, five patients were in stage I, 12 in stage II, nine in stage III and 13 in stage IV. Median, three and five year's survival figures were 21.4 months, 33 and 25 percent, respectively. Lymph node and perineural involvement was associated with a lower survival. Well differentiated and stage I tumors had a better survival. Multivariate analysis showed that the presence of a type III tumor, N3 lymph node involvement and vascular permeation were independent predictors' ofa lower survival. Conclusions: Among patients with adenocarcinoma of the esophago-gastric junction, type III tumors, lymph node involvement and vascular permeations are associated with a lower survival.

Melanoma primario del esófago tratado con esofagectomía: Casos clínicos / Esophageal melanoma: Report of two cases

Esophageal melanomas correspond to 0.1 to 0.2 percent of esophageal tumors. We report two patients with the disease. The first patient is a 51 year-old woman pre-sentingwith dysphagia and weight loss. An upper gastrointestinal endoscopy showed a polypoid ulcerated lesion in the middle third of the esophagus. The pathological study ofthe biopsy disclosed a malignant melanoma. The patient was subjected to an esophagectomy with a satisfactory postoperative evolution. Four months later, liver metastases were detected and the patient died eleven months after the operation. The second patient is a 59 year-old mole that consulted by dysphagia. An endoscopy showed a pigmented esophageal lesion whose pathological diagnosis was a malignant melanoma. The patient was subjected to an esophagectomy and sixteen months after surgery there was no evidence of relapse.

Carcinoma hepatocelular variedad fibrolamelar metastásico en menores de 20 años: Reporte de 2 casos tratados con intención curativa y revisión de la literatura / Fibrolamellar liver carcinoma: Report of two cases

Fibrolamellar hepatocellular carcinoma (FLC) is a rare histologic variant of hepatocellular carcinoma that appears most commonly in teenagers and young adults. The diagnosis is often made incidentally and surgical resection is the only curative treatment. Here we report two cases of incidental FLC involving a 19 year-old male, initially diagnosed with screening abdominal ultrasound, and a 14 year-old female that presented with abdominal pain. Diagnostic workup consisted of abdominal PET/CT and MRI Imaging studies and tissue diagnosis was confirmed with percutaneous liver biopsy. Both patients were treated with radical liver resection/tumor excision. However, tumor recurrence was observed in both during short-term follow-up. The male patient was treated successfully with surgical treatment however the female patient succumbed top regression of disease.

Granulomatosis sarcoidea necrosante con compromiso sistémico / Necrotizing sarcoid granulomatosis with systemic involvement

A 70-year-old mapuche female presented with a 1 year history of weight loss, bilateral red painful eyes and corneal ulcer that evolved into perforation and uveal herniation with complete visual loss. Reddish and painful nodules appeared on the distal aspect of both lower extremities, that ulcerated after months. A thoracic CT scan showed multiple pulmonary nodules. Infectious diseases were ruled out. An open lung biopsy and a skin biopsy were performed and both showed non-caseating necrotizing granulomas and granulomatous arteritis. Steroids and cyclophosphamide were started with complete regression of skin and pulmonary lesions within a month. Corneal transplantation was done. After 6 months follow-up, the patient is on low-dose of steroids, free of disease with partial vision recovery.

Mujer mapuche de 70 años quien en el curso de 1 año presentó baja de peso, ojo rojo bilateral y úlcera corneal que evolucionó hacia la perforación con herniación uveal y pérdida de la visión. Posteriormente se agregaron lesiones nodulares, violáceas, sensibles, algunas ulceradas en las zonas distales de ambas extremidades inferiores. La TAC de tórax demostró múltiples nódulos pulmonares. Tras un estudio exhaustivo se descartaron la tuberculosis y otras infecciones. Tanto la biopsia de las lesiones cutáneas como la biopsia pulmonar obtenida mediante toracotomía confirmaron la presencia de granulomas necrotizantes no caseificantes y arteritis granulomatosa. Se trató con esteroides y ciclofosfamida con mejoría de su condición general y regresión de las lesiones cutáneas y pulmonares en menos de 1 mes. Se realizó un trasplante de cornea. A los seis meses de seguimiento continúa en tratamiento, no ha presentado recaídas y tiene recuperación parcial de la visión.

Nuevo método para impartir el curso de electrocardiografía al tercer año de la carrera de Medicina / A new method for teaching the course of electrocardiography to third year students of Medicine

Se desarrolló una investigación prospectiva, en el curso 2003 ­ 2004 con la totalidad de los estudiantes del tercer año de la carrera de medicina con el objetivo de comprobar la eficacia de un nuevo método para impartir el curso de electrocardiografía en el Hospital Universitario Camilo Cienfuegos de Sancti Spíritus. A través de la creación de dos grupos (estudio y control) se demostró, que con el método propuesto, se lograron mejores resultados en lo concerniente a: motivación, comprensión y aptitudes de los estudiantes, siendo fundamental la alta efectividad alcanzada en la demostración final de la competencia.AU[]

Correlación clínica, imagenológica y patológica de los papilomas mamarios / Clinical, imaging and pathological correlation of mammary papilomas

Existe vasta literatura referente a la asociación de los papilomas mamarios con la patología neoplásica de esta glándula, la sintomatología ocasionada por éstos, como así también respecto a los métodos diagnósticos empleados en su detección. El objetivo de nuestro trabajo en esta fase es analizar la correlación entre la clínica, imágenes y anatomía patológica de los papilomas en nuestro universo de pacientes. En el Servicio de Cirugía del Hospital Salvador se realizaron 656 cirugías mamarias entre el 1 de julio de 1997 y el 31 de julio de 2001. Del total de la muestra, hubo 460 cirugías benignas, de las cuales se analizó en forma descriptiva y retrospectiva los antecedentes de 29 pacientes, en las que se detectó la patología en cuestión. En el 44,8 por ciento de nuestro universo los papilomas se presentaron sintomáticos, en tanto en el 55,2 por ciento restante estos fueron hallazgos de la anatomía patológica. El estudio imagenológico fue fundamental en la detección del 37,9 por ciento de los casos, mientras que la galactografía más la citología sólo contribuyeron en un 6,9 por ciento de éstos

Trombolisis con estreptoquinasa recombinante en pacientes con infarto del miocardio agudo en la provincia de Sancti Spíritus / Thrombolysis with recombinant streptoquinase in patients with acute myocardial infarction in the province of Sancti Spiritus

Se realizó un estudio de 149 pacientes con diagnóstico de Infarto del Miocardio Agudo (IMA), procedentes del Hospital Universitario "Camilo Cienfuegos" de la provincia de Sancti Spíritus y que fueron sometidos a la terapia con Estreptoquinasa Recombinante de producción nacional, obtenida del centro de Ingeniería Genética y Biotecnología de La Habana, para la realización de un ensayo clínico fase IV. Se recogieron una serie de datos generales y clínicos de cada paciente con los objetivos de estudiar el número de casos aportados por cada municipio y las causas de los mismos, evaluar la relación del IMA con las edades y sexos, así como con el estado de egreso del hospital, conocer las reacciones adversas más frecuentes y los medicamentos asociados al trombolítico y determinar el tiempo de demora de administración del fármaco desde el inicio de los síntomas hasta su aplicación. Se concluye que los municipios de Sancti Spíritus y Cabaiguán fueron los que más pacientes incorporaron al estudio, hubo una mayor letalidad en el sexo femenino; la aspirina y los beta bloqueadores fueron los fármacos más utilizados. Los temblores y la hipotensión fueron las reacciones adversas más frecuentemente encontrados; el tiempo medio de aplicación del fármaco estuvo sobre las 4 horas tanto en pacientes vivos como en los fallecidos.

Embarazo gemelar monocoriónico: mola hidatidiforme parcial y feto normal / Homochorionic twin gestation: it is composed of portial hydatidiform mole and normal fetus

Se presenta un raro caso de embarazo gemelar monocoriónico por una mola hidatidiforme parcial y una placenta normal con feto sin malformaciones. Se hacen comentarios acerca de su origen y revisión de la literatura nacional e internacional

Malacoplaquia del tracto genital femenino / Malacoplakia of female genitale tract

La malacoplaquia es un proceso granulomatoso inflamatorio crónico, poco frecuente que en raras ocasiones afecta el tracto genital femenino. Esta enfermedad parece ser debida a un defecto adquirido en la función bactericida de los histiocitos, estando con frecuencia asociada a bacterias coliformes, particularmente a Escherichia coli. Presentamos el primer caso de malacoplaquia en el tracto genital femenino reportado en Venezuela