RESUMEN
BACKGROUND: In clinically node-negative (cN0) early stage breast cancer (EBC) undergoing primary systemic treatment (PST), post-treatment positive sentinel lymph node (SLN+) directs axillary lymph node dissection (ALND), with uncertain impacts on outcomes and increased morbidities. PATIENTS AND METHODS: We conducted an observational study on imaging-confirmed cN0 EBC, who underwent PST and breast surgery that resulted in SLN+ and underwent ALND. The association among baseline/postsurgical clinic-pathological factors and positive nonsentinel additional axillary lymph nodes (non-SLN+) was analyzed with logistic regression. LASSO regression (LR) identified variables to include in a predictive score of non-SLN+ (ALND-predict). The accuracy and calibration were assessed, an optimal cut-point was then identified, and in silico validation with bootstrap was undertaken. RESULTS: Non-SLN+ were detected in 22.2% cases after ALND. Only progesterone receptor (PR) levels and macrometastatic SLN+ were independently associated to non-SLN+. LR identified PR, Ki67, and type and number of SLN+ as the most efficient covariates. The ALND-predict score was built based on their LR coefficients, showing an area under the curve (AUC) of 0.83 and an optimal cut-off of 63, with a negative predictive value (NPV) of 0.925. Continuous and dichotomic scores had a good fit (p = 0.876 and p = 1.00, respectively) and were independently associated to non-SLN+ [adjusted odds ratio (aOR): 1.06, p = 0.002 and aOR: 23.77, p < 0.001, respectively]. After 5000 bootstrap-adjusted retesting, the estimated bias-corrected and accelerated 95%CI included the aOR. CONCLUSIONS: In cN0 EBC with post-PST SLN+, non-SLN+ at ALND are infrequent (~22%) and independently associated to PR levels and macrometastatic SLN. ALND-predict multiparametric score accurately predicted absence of non-SLN involvement, identifying most patients who could be safely spared unnecessary ALND. Prospective validation is required.
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Neoplasias de la Mama , Linfadenopatía , Ganglio Linfático Centinela , Humanos , Femenino , Neoplasias de la Mama/patología , Ganglio Linfático Centinela/cirugía , Ganglio Linfático Centinela/patología , Biopsia del Ganglio Linfático Centinela , Metástasis Linfática/patología , Ganglios Linfáticos/cirugía , Ganglios Linfáticos/patología , Escisión del Ganglio Linfático/efectos adversos , Linfadenopatía/cirugía , Axila/patologíaRESUMEN
INTRODUCTION: It has been proposed that primary care diagnose and treat hepatitis C virus (HCV) infection. However, a care circuit between primary and specialized care based on electronic consultation (EC) can be just as efficient in the micro-elimination of HCV. It is proposed to study characteristics and predictive factors of continuity of care in a circuit between primary and specialized care. METHODS: From February/2018 to December/2019, all EC between primary and specialized care were evaluated and those due to HCV were identified. Variables for regression analysis and to identify predictors of completing the care cascade were recorded. RESULTS: From 8098 EC, 138 were performed by 89 (29%) general practitioners over 118 patients (median 50.8 years; 74.6% men) and were related to HCV (1.9%). Ninety-two patients (78%) were diagnosed>6 months ago, and 26.3% met criteria for late presentation. Overall, 105 patients required assessment by the hepatologist, 82% (n=86) presented for the appointment, of which 67.6% (n=71) were viraemic, 98.6% of known. Finally, 61.9% (n=65) started treatment. Late-presenting status was identified as an independent predictor to complete the care cascade (OR 1.93, CI 1.71-1.99, p<0.001). CONCLUSION: Communication pathway between Primary and Specialized Care based on EC is effective in avoiding significant losses of viraemic patients. However, the referral rate is very low, high in late-stage diagnoses, heterogeneous, and low in new diagnoses. Therefore, early detection strategies for HCV infection in primary care are urgently needed.
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Hepatitis C Crónica , Hepatitis C , Consulta Remota , Masculino , Humanos , Femenino , Hepacivirus , Hepatitis C Crónica/terapia , Hepatitis C Crónica/tratamiento farmacológico , Hepatitis C/terapia , Hepatitis C/tratamiento farmacológico , Viremia/tratamiento farmacológico , Antivirales/uso terapéutico , Continuidad de la Atención al Paciente , Atención Primaria de SaludRESUMEN
BACKGROUND: Recent evidence suggests that the number of low residue diet (LRD) days does not influence the bowel cleansing quality in non-selected patients. However, there are not data in the subgroup of patients with risk factors of inadequate bowel cleansing. OBJECTIVE: The aim of this study was to assess whether a 3-day LRD improved the bowel cleansing quality in patients with risk factors of poor bowel cleansing. PATIENTS AND METHODS: Post hoc analysis of a randomized controlled trial carried out between December 2017 and March 2018 in a tertiary care hospital. Patients with high risk of poor bowel cleansing were selected following a validated score. The patients were randomized to the 1-day LRD or 3-day LRD groups. All patients received a 2-L split-dose of polyethylene glycol plus ascorbic acid. Intention-to-treat (ITT) and per-protocol (PP) analyses were conducted for the main outcome. RESULTS: 135 patients (1-day LRD group=67, 3-day LRD=68) were included. The rate of adequate cleansing quality was not significantly different between the groups in the ITT analysis: 76.1%, 95% CI: [64.6-84.8] vs. 79.4%, 95% CI: [68.2-87.4]; odds ratio (OR) 1.2, 95% CI [0.54-2.73]) or in the PP analysis: 77.3%, 95% CI: [65.7-85.8] vs. 80.3%, 95% CI: [69.0-88.3]; OR 1.2, 95% CI [0.52-2.77]). Compliance with the diet or cleansing solution, satisfaction or difficulties with the LRD and the polyp/adenoma detection rates were not significantly different. CONCLUSION: Our results suggest that 1-day LRD is not inferior to 3-day LRD in patients with risk factors of inadequate bowel cleansing.
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Ácido Ascórbico/administración & dosificación , Catárticos/administración & dosificación , Colonoscopía , Dieta/métodos , Fibras de la Dieta , Polietilenglicoles/administración & dosificación , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cooperación del Paciente/estadística & datos numéricos , Periodo Preoperatorio , Estudios Prospectivos , Método Simple Ciego , Factores de TiempoRESUMEN
BACKGROUND: The aim of this study was to assess whether a 3-day low-residue diet (LRD) improved bowel cleansing quality compared with a 1-day LRD regimen. METHODS: Consecutive patients scheduled for outpatient colonoscopy were randomized to the 1-day LRD or 3-day LRD groups. All patients received a 2-L split-dose of polyethylene glycol plus ascorbic acid. The primary outcome was bowel cleansing quality as evaluated using the Boston Bowel Preparation Scale (BBPS) (adequate cleansingâ≥â2 points per segment). Secondary outcomes were adherence to and level of satisfaction with the LRD, difficulty following the dietary recommendations, and willingness to repeat the same LRD in the future. Intention-to-treat (ITT) and per-protocol (PP) analyses were conducted for the primary outcome. A superiority analysis was performed to demonstrate that a 3-day LRD regimen was superior to a 1-day LRD regimen with a margin of 10â%. RESULTS: 390 patients (1-day LRD groupâ=â196, 3-day LRDâ=â194) were included. The cleansing quality was not significantly different between the groups: ITT analysis 82.7â% (95â% confidence interval [CI] 77.4 to 88.0) vs. 85.6â% (95â%CI 80.7 to 90.5), with odds ratio (OR) 1.2 (95â%CI 0.72 to 2.15); PP analysis 85.0â% (95â%CI 79.9 to 90.1) vs. 88.6â% (95â%CI 84.0 to 93.2), with OR 1.4 (95â%CI 0.88 to 2.52). No differences were found regarding adherence to the diet or cleansing solution, satisfaction or difficulty with the LRD, and the polyp/adenoma detection rates. CONCLUSION: 3-day LRD did not offer advantages over 1-day LRD in preparation for colonoscopy.
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Catárticos/farmacología , Colonoscopía/métodos , Neoplasias Colorrectales/diagnóstico , Dieta/métodos , Cooperación del Paciente , Polietilenglicoles/farmacología , Cuidados Preoperatorios/métodos , Colon , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Estudios Prospectivos , Tensoactivos/farmacologíaRESUMEN
OBJECTIVES: Inadequate bowel cleansing is a major burden for endoscopy units. The aim of this study was to compare two intensive bowel cleansing regimens in patients with previous colonoscopy with inadequate bowel preparation. METHODS: Patients with inadequate cleansing at index colonoscopy were randomized to 4-L split-dose polyethylene-glycol (PEG) regimen vs. 2-L split-dose PEG plus ascorbic acid (PEG+Asc) regimen. All individuals underwent a 3-day low-residue diet and received 10 mg of bisacodyl, the day before colonoscopy. Cleansing was considered to be adequate if the Boston Bowel Preparation Scale scored ≥2 at each colonic segment. A non-inferiority analysis was performed to demonstrate that colonic cleansing with 2-L PEG+Asc was not inferior to 4-l PEG, considering a non-inferiority margin of 10%. RESULTS: Adequate bowel cleansing was significantly higher in patients assigned to 4-L PEG regimen (n=127) vs. those randomized to 2-L PEG+Asc regimen (n=129) by intention-to-treat analysis (81.1 vs. 67.4%, odds ratio (OR) 2.07, 95% confidence interval (CI) (1.163-3.689)) and by per-protocol analysis (86.6 vs. 71.7%, OR: 2.55, 95% CI: (1.316-4.922)). The study was terminated for futility after the interim analysis, because the 95% CI of the difference of proportions was 3.13-24.27% in the intention-to-treat analysis and 3.33-26.47% in the per-protocol analysis, confirming the superiority of 4-L PEG preparation. CONCLUSIONS: After 3-day low-residue diet and oral bisacodyl before colonoscopy, colon cleansing with 4-L split-dose PEG was superior to 2-L split-dose PEG+Asc in patients with previous inadequate cleansing. (EUDRACT: 2013-002506-31, NCT02073552).
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Adenoma/diagnóstico , Catárticos/administración & dosificación , Pólipos del Colon/diagnóstico , Colonoscopía/métodos , Neoplasias Colorrectales/diagnóstico , Polietilenglicoles/administración & dosificación , Anciano , Ácido Ascórbico/administración & dosificación , Bisacodilo/administración & dosificación , Catárticos/efectos adversos , Ciego , Fibras de la Dieta/administración & dosificación , Terminación Anticipada de los Ensayos Clínicos , Femenino , Humanos , Análisis de Intención de Tratar , Intubación Gastrointestinal , Masculino , Persona de Mediana Edad , Náusea/inducido químicamente , Polietilenglicoles/efectos adversos , Vitaminas/administración & dosificaciónRESUMEN
Background and study aim Inadequate bowel cleansing negatively affects the efficiency of colonoscopy in routine clinical practice. The aim of this study was to design and validate a predictive model for inadequate bowel cleanliness. Patients and methods The model was built from 667 consecutive outpatients (development cohort) who were prospectively scheduled for colonoscopy between June and September 2014.âThe validation cohort included 409 outpatients who underwent colonoscopy between October and December 2014.âCleansing was evaluated using the Boston Bowel Preparation Scale (BBPS). Bowel preparation was administered on the same day as the examination. Results In the development cohort, BBPS was adequate in 541 patients (81.1â%). At multivariate analysis, antidepressants (odds ratio [OR] 4.25, 95â% confidence interval [CI] 1.91â-â9.47), co-morbidity (OR 3.35, 95â%CI 2.16â-â5.18), constipation (OR 2.09, 95â%CI 1.29â-â3.40), and abdominal/pelvic surgery (OR 1.60, 95â%CI 1.03â-â2.47) were independent predictors for inadequate cleansing. The model built with these variables showed an area under the curve of 0.72 in the development cohort and 0.70 in the validation cohort. A cutoff of 1.225 predicted inadequate bowel preparation with a sensitivity, specificity, positive predictive value, and negative predictive value of 60.3â% (95â%CI 51.6â-â68.4), 75.4â% (95â%CI 71.6â-â78.9), 36.4â% (95â%CI 30.1â-â43.1), and 89.1â% (95â%CI 85.9â-â91.6) in the development cohort, and 50.0â% (95â%CI 38.1â-â61.9), 80.0â% (95â%CI 75.3â-â84.2), 35.7â% (95â%CI 26.4â-â45.6), and 87.9â% (95â%CI 83.7â-â91.3) in the validation cohort. Conclusion A simple score may assist the clinician in predicting which patients are at high risk of inadequate bowel cleanliness. This may guide changes in bowel preparation strategy accordingly.
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Colonoscopía/normas , Neoplasias Colorrectales/diagnóstico por imagen , Abdomen/cirugía , Adulto , Anciano , Antidepresivos/uso terapéutico , Catárticos/uso terapéutico , Comorbilidad , Estreñimiento/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pelvis/cirugía , Valor Predictivo de las Pruebas , Curva ROC , Factores de RiesgoRESUMEN
INTRODUCTION: Matrix metalloproteinases (MMPs) are overexpressed at different stages of colorectal carcinogenesis and could serve as early surrogate biomarkers of colorectal neoplasia. OBJECTIVE: To assess the utility of plasma MMP2 and MMP9 levels in the detection of advanced colorectal neoplasia and their correlation with tissue levels. METHODS: We analysed blood and tissue samples from patients with non-advanced adenomas (n=25), advanced adenomas (n=25), colorectal cancer (n=25) and healthy controls (n=75). Plasma and tissue gelatinase levels were determined by Luminex XMAP technology and gelatin zymography. Receiver operating characteristic (ROC) curve analysis was used to calculate the optimum cut-off for the detection of advanced colorectal neoplasia. RESULTS: Plasma MMP2 levels were similar between groups whatever the type of lesion. Plasma MMP9 levels were significantly higher in patients with neoplastic lesions than in healthy controls (median 292.3ng/ml vs. 139.08ng/ml, P<0.001). MMP9 levels were also higher in colorectal cancer than in non-advanced adenomas (median 314.6ng/ml vs. 274.3ng/ml, P=0.03). There was a significant correlation between plasma and tissue levels of MMP9 (r=0.5, P<0.001). The plasma MMP9 cut-off range with the highest diagnostic accuracy was between 173ng/ml and 204ng/ml (AUC=0.80 [95% CI: 0.72-0.86], P<0.001; sensitivity, 80-86% and specificity, 57-67%). CONCLUSION: Plasma MMP9 could be a surrogate biomarker for the early detection of advanced colorectal neoplasia, although its diagnostic performance could be increased by combination with other biomarkers.
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Adenocarcinoma/sangre , Biomarcadores de Tumor/sangre , Neoplasias Colorrectales/sangre , Metaloproteinasa 9 de la Matriz/sangre , Adenocarcinoma/química , Adenocarcinoma/patología , Adenoma/sangre , Adenoma/química , Adenoma/patología , Pólipos Adenomatosos/sangre , Pólipos Adenomatosos/química , Pólipos Adenomatosos/patología , Anciano , Área Bajo la Curva , Biomarcadores de Tumor/análisis , Biomarcadores de Tumor/genética , Colonoscopía , Neoplasias Colorrectales/química , Neoplasias Colorrectales/patología , Progresión de la Enfermedad , Femenino , Humanos , Masculino , Metaloproteinasa 2 de la Matriz/análisis , Metaloproteinasa 2 de la Matriz/sangre , Metaloproteinasa 9 de la Matriz/análisis , Metaloproteinasa 9 de la Matriz/genética , Persona de Mediana Edad , Polimorfismo de Nucleótido Simple , Estudios Prospectivos , Curva ROC , Factores de Riesgo , Sensibilidad y EspecificidadRESUMEN
An initial assessment process, called navigation, has been introduced at Medway Maritime Hospital emergency department (ED) to address problems with the triage system and to meet the latest ED quality clinical indicators. This article explains the rationale for introducing the new assessment process, describes the system and discusses the change-management process needed to implement it. -
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Citas y Horarios , Eficiencia Organizacional , Navegación de Pacientes/métodos , Triaje/métodos , Algoritmos , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/normas , Inglaterra , Control de Formularios y Registros , Implementación de Plan de Salud , Humanos , Navegación de Pacientes/organización & administración , Indicadores de Calidad de la Atención de Salud , Diseño de Software , Factores de Tiempo , Triaje/organización & administraciónRESUMEN
Importance: Survivors of breast cancer present more severe symptoms of genitourinary syndrome of menopause (GSM) than patients without history of breast cancer. Recently, new treatments, such as vaginal laser therapy, have appeared, but evidence of their efficacy remains scarce. Objective: To assess the safety and efficacy of carbon dioxide (CO2) vs sham vaginal laser therapy after 6 months of follow-up in survivors of breast cancer with GSM receiving aromatase inhibitors. Design, Setting, and Participants: This prospective double-blind sham-controlled randomized clinical trial with two parallel study groups was performed during October 2020 to March 2022 in a tertiary referral hospital. Survivors of breast cancer using aromatase inhibitors were assessed for eligibility, and eligible patients were randomized into the 2 treatment groups. Follow-up was conducted at 6 months. Data were analyzed in July 2022. Interventions: All patients from both groups were instructed to use the first-line treatment (FLT) based on nonhormonal moisturizers and vaginal vibrator stimulation. Patients for each group were allocated to 5 monthly sessions of fractional CO2 laser therapy (CLT) or sham laser therapy (SLT). Main Outcomes and Measures: The primary outcome was sexual function, evaluated through Female Sexual Function Index (FSFI) score. Other subjective measures of efficacy included a visual analog scale of dyspareunia, vaginal pH, a Vaginal Health Index, quality of life (assessed via Short-Form 12), and body image (assessed with the Spanish Body Image Scale). Objective measures of efficacy included vaginal maturation index, vaginal epithelial elasticity (measured in Pascals) and vaginal epithelial thickness (measured in millimeters). Measures were assessed before and after the intervention. Tolerance (measured on a Likert scale), adverse effects, and estradiol levels were recorded. Results: Among 211 survivors of breast cancer assessed, 84 women were deemed eligible and 72 women (mean [SD] age, 52.6 [8.3] years) were randomized to CLT (35 participants) or SLT (37 participants) and analyzed. There were no statistically significant differences between groups at baseline. At 6 months, both groups showed improvement in FSFI (mean [SD] score at baseline vs 6 months: CLT, 14.8 [8.8] points vs 20.0 [9.5] points; SLT, 15.6 [7.0] points vs 23.5 [6.5] points), but there was no significant difference between CLT and SLT groups in the improvement of sexual function evaluated through the FSFI test overall (mean [SD] difference, 5.2 [1.5] points vs 7.9 [1.2] points; P = .15) or after excluding women who were not sexually active (mean [SD] difference, 2.9 [1.4] points vs 5.5 [1.1] points; P = .15). There were also no differences between improvement of the 2 groups at 6 months of follow-up in the other assessed subjective outcomes, including dyspareunia (mean [SD] difference, -4.3 [3.4] vs -4.5 [2.3]; P = .73), Vaginal Health Index (mean [SD] difference, 3.3 [4.1] vs 5.0 [4.5]; P = .17), body image (mean [SD] difference, -3.7 [4.5] vs -2.7 [4.8]; P = .35), and quality of life (mean [SD] difference, -0.3 [3.6] vs -0.7 [3.2]; P = .39). Similarly, there were no differences in improvements in objective outcomes, including vaginal pH (mean [SD] difference, -0.6 [0.9] vs -0.8 [1.2]; P = .29), vaginal maturation index (mean [SD] difference, 10.2 [17.4] vs 14.4 [17.1]; P = .15), vaginal epithelial thickness (mean [SD] difference, 0.021 [0.014] mm vs 0.013 [0.012] mm; P = .30), vaginal epithelial elasticity (mean [SD] difference, -1373 [3197] Pascals vs -2103 [3771] Pascals; P = .64). There were significant improvements in the overall analysis regardless of group in many outcomes. The 2 interventions were well tolerated, but tolerance was significantly lower in the CLT group than the SLT group (mean [SD] Likert scale score, 3.3 [1.3] vs 4.1 [1.0]; P = .007). No differences were observed in complications or serum estradiol levels. Conclusions and Relevance: In this randomized clinical trial, vaginal laser treatment was found to be safe after 6 months of follow-up, but no statistically significant differences in efficacy were observed between CLT and SLT. Trial Registration: ClinicalTrials.gov identifier: NCT04619485.
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Neoplasias de la Mama , Dispareunia , Femenino , Humanos , Persona de Mediana Edad , Neoplasias de la Mama/terapia , Neoplasias de la Mama/complicaciones , Dióxido de Carbono , Inhibidores de la Aromatasa/efectos adversos , Dispareunia/complicaciones , Calidad de Vida , Estudios Prospectivos , Menopausia , Rayos Láser , Sobrevivientes , Síndrome , EstradiolRESUMEN
BACKGROUND: Genitourinary syndrome of menopause (GSM) can have a great impact on the quality of life (QOL), and affects between 53.8% and 90% of postmenopausal women. The literature suggests that vaginal laser therapy could be an effective treatment for GSM symptoms, but its efficacy and safety have not been established and international societies do not endorse its use. Despite that, there has been an increase in the use of vaginal laser therapy globally over the last decade. OBJECTIVE: The objective of this review is to evaluate the literature which assesses the efficacy and safety of the vaginal laser therapy in the treatment of GSM. METHODS: A comprehensive literature search was conducted electronically using Embase and PubMed to retrieve studies assessing evidence for the efficacy and safety of vaginal laser therapy for GSM or vulvovaginal atrophy up to June 2021. RESULTS: A total of 64 studies were finally included in the review. There were 10 controlled intervention studies, 7 observational cohort and cross-sectional studies and 47 before-after studies without a control group. CONCLUSION: Vaginal laser seems to improve scores on the Visual Analogue Scale (VAS), Female Sexual Function Index (FSFI) and Vaginal Health Index (VHI) in GSM over the short term. Safety outcomes are underreported and short-term. Further well-designed clinical trials with sham-laser control groups and evaluating objective variables are needed to provide the best evidence on efficacy.
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Terapia por Láser , Láseres de Gas , Atrofia/patología , Estudios Transversales , Femenino , Humanos , Láseres de Gas/uso terapéutico , Menopausia , Calidad de Vida , Vagina/patologíaRESUMEN
Breast cancer survivors (BCS) usually receive treatments which lead to persistent oestrogen suppression, which may cause atrophic vaginitis in a large proportion of these women. The most effective treatments for vulvovaginal atrophy (VVA) are based on local oestrogen therapy. However, these treatments are restricted in BCS due to the controversy over their use in women who had hormone-dependent tumours. Therefore, it is common to find untreated symptoms that affect sexual function and quality of life in BCS, thereby leading to the discontinuation of anti-oestrogenic treatments. This systematic review aims to discuss the current treatment options available for the genitourinary syndrome of menopause (GSM) in BCS. A comprehensive literature search was conducted electronically using Embase and PubMed to retrieve studies assessing treatment options for GSM or VVA in BCS up to April 2020. Studies evaluating treatments in different BCS cohorts were excluded. A total of 29 studies were finally included in the review. Non-hormonal treatments are the first-line treatment for VVA, but when these are not effective for symptom relief, other options can be considered, such as local oestrogen, erbium laser or CO2 laser and local androgens. The present data suggest that these therapies are effective for VVA in BCS; however, safety remains controversial and a major concern with all of these treatments.
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Neoplasias de la Mama/terapia , Supervivientes de Cáncer , Menopausia , Femenino , Enfermedades Urogenitales Femeninas/terapia , Humanos , Estudios Observacionales como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , SíndromeRESUMEN
New therapeutic options are being considered to treat genitourinary syndrome of menopause (GSM), such as vaginal laser, ospemifene, or prasterone, but there is no explicit agreement in the scientific community for its use. Some concerns have arisen on how to evaluate the improvement of GSM symptoms. In 2003, the FDA suggested possible end points for this purpose: change in severity of symptoms, change in vaginal pH, and change in vaginal maturation index (VMI). Contrarily, the most common assessment tools used to quantify severity and improvement of GSM nowadays are the visual analog scale of GSM symptoms, the vaginal health index, and the female sexual function index. In our opinion, subjective and objective variables to evaluate GSM can be differentiated, and not many of the considered objective outcomes are used in the recent literature assessing GSM. There is the possibility that some therapies present only subjective improvement, giving place to a possible placebo effect that is not being evaluated. To conclude, there is a demand to evaluate whether vaginal pH and VMI are enough to assess objectively GSM changes or new objective approaches should be audited.
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Objective: We tested the hypothesis that an enhanced bowel preparation strategy (EBS) improves colonic cleansing in patients at high risk for inadequate bowel cleansing (HRI). Methods: This prospective randomized clinical trial included consecutive HRI patients referred for outpatient colonoscopy between February and October 2019. HRI was considered if patients scored >1.225 according to a previously validated bowel-cleansing predictive score. HRI patients were randomized (1:1) to a low-volume conventional bowel cleansing strategy (CBS) (1-day low residue diet (LRD) plus 2 L of polyethylene glycol (PEG) plus ascorbic acid) or to an EBS (3-day LRD plus 10 mg oral bisacodyl plus 4 L PEG). The Boston Bowel Preparation Scale (BBPS) was used to assess the quality of cleanliness. Intention-to-treat (ITT) and per protocol (PP) analyses were performed. A sample size of 130 patients per group was estimated to reach a 15% difference in favor of EBP. Results: A total of 253 HRI patients were included (mean age 69.8 ± 9.5 years, 51.8% women). No statistically significant differences were found in the BBPS scale between the two groups in the ITT analysis (CBS 76.8% vs. EBS 79.7%, P = 0.58) or PP analysis (CBS 78% vs. EBS 84.3%, P = 0.21), risk difference 2.9% (95% CI-7.26 to 39.16) in the ITT analysis, or risk difference 6.3% (95% CI-3.48 to 16.08) in PP analysis. No differences in preparation tolerance, compliance, adverse effects, or colonoscopy findings were found. Conclusion: EBS is not superior to CBS in hard-to-prepare patients. (EUDRACT: 2017-000787-15, NCT03830489). Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03830489.
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INTRODUCTION: The aim of this study was to compare the feasibility, safety, and survival outcomes of Coelio-Schauta (CS) procedure versus open Wertheim-Meigs (WM) as primary surgical treatment of early-stage cervical cancer. METHODS: Observational study on the consecutive cases of cervical cancer undergoing CS during the last 11 years at our institution was performed. Data on clinical characteristics of patients, surgical performance, long-term morbidity, and survival were prospectively analyzed and compared with a historical series of 23 consecutive WM performed at the same hospital in the immediate previous period. RESULTS: Sixty-seven patients were included in the study group (CS). Cases and controls were comparable in age, body mass index, stage, tumor size, and histological diagnosis. The number of pelvic nodes, disease-free margin, and complications rate were similar in both groups, but blood loss and blood transfusion rate were marginally less in the CS group. Operating time was longer in the first 20 CS patients, but it became comparable to WM once the learning curve was overcome. Hospital stay was significantly shorter in the CS group as well as the bladder function recovery time. However, no differences were seen regarding long-term urinary and bowel function between groups. Four patients (5.9%) from the CS group and 3 (13%) in the WM group had recurrence. Mortality rates were 3% and 8.7%, respectively (P = not significant). CONCLUSIONS: The CS procedure is a suitable alternative to WM for small-volume, early-stage cervical cancer, showing a good safety profile, shorter postoperative recovery time, and similar survival outcomes.
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Carcinoma de Células Escamosas/cirugía , Procedimientos Quirúrgicos Ginecológicos/métodos , Histerectomía Vaginal/métodos , Laparoscopía/métodos , Neoplasias del Cuello Uterino/cirugía , Adulto , Anciano , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , Femenino , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Humanos , Histerectomía Vaginal/efectos adversos , Complicaciones Intraoperatorias/epidemiología , Laparoscopía/efectos adversos , Persona de Mediana Edad , Estadificación de Neoplasias , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Análisis de Supervivencia , Factores de Tiempo , Neoplasias del Cuello Uterino/mortalidad , Neoplasias del Cuello Uterino/patologíaRESUMEN
Solitary fibrous tumor (SFT) is a rare neoplasm of mesenchymal origin. The most commonly reported locations are the pleura and meninges. Less frequently, SFT manifests as an asymptomatic mass in the pancreas, liver, peritoneum or kidney. Clinical and radiological findings have failed to provide any specific diagnostic pattern but allow malignant development to be suspected due to infiltration or metastasis. In addition, preoperative cytology often yields inconclusive or misleading results. Therefore the definitive diagnosis is achieved after both surgical resection and immunohistochemical analysis, with markers such as CD34, vimentin and desmin. We present a case of SFT, which was difficult to diagnose, even after an extensive battery of tests based on imaging techniques.
Asunto(s)
Neoplasias Peritoneales/diagnóstico , Tumores Fibrosos Solitarios/diagnóstico , Antígenos CD34/análisis , Biomarcadores de Tumor/análisis , Diagnóstico Diferencial , Endosonografía , Humanos , Hallazgos Incidentales , Laparoscopía , Masculino , Persona de Mediana Edad , Proteínas de Neoplasias/análisis , Neoplasias Peritoneales/química , Neoplasias Peritoneales/diagnóstico por imagen , Neoplasias Peritoneales/cirugía , Tumores Fibrosos Solitarios/química , Tumores Fibrosos Solitarios/diagnóstico por imagen , Tumores Fibrosos Solitarios/cirugía , Tomografía Computarizada por Rayos X , Vimentina/análisisRESUMEN
In this opinion piece, we argue the current pandemic is shining a light on caregiving as critical work that is under-valued and under-paid. We call upon national lawmakers to raise the value of care work. Doing so would also make progress in solving another national crisis: closing the gender wage gap. We explore how the gender wage gap is driven primarily by the fact that men and women sort into different work, with women being over-represented in work where they care for others and in work that allows them to care for their families.
RESUMEN
Louis Braille (1809-1852) was born in France. At the age of three, he wounded his right eye with a cobbler's tool while playing in his father's workshop. No medical knowledge could save his eyesight at that time. Louis's left eye became inflamed, apparently due to subsequent sympathetic ophthalmia, and he eventually lost the sight in that eye. At the age of five, Louis Braille was completely blind. He is considered to be the inventor of a writing system by touch that bears his name, the Braille system. This revolutionary system has allowed blind people to access written culture, and it can therefore be considered a major advance in the quality of life for the blind. The immediate precursor of the invention of the Braille system was the alphabet created by Charles Barbier de la Serre (1767-1841) who created a language by touch designed for military and secret use. Louis Braille modified this alphabet into the Braille alphabet, which is practically the same one that is currently used. It required time to be recognized and to be implemented as a reading and writing method for blind people throughout the world. In 1950, UNESCO effectively universalized the Braille alphabet, and in 2005 it recognized Braille system as a "vital language of communication, as legitimate as all other languages in the world."
Asunto(s)
Ceguera/historia , Lectura , Auxiliares Sensoriales/historia , Personajes , Francia , Historia del Siglo XIX , Humanos , EscrituraRESUMEN
BACKGROUND AND OBJECTIVE: Detection of asymptomatic peripheral arterial disease increases the risk of vascular morbibity and mortality. We aimed to estimate the prevalence of clinical and subclinical peripheral arterial disease using the ankle-arm index (AAI) as diagnostic tool in a working population. SUBJECTS AND METHOD: We included 450 workers, older than 50 years old, attending voluntary regular health check-up at Centro de Prevención de Riesgos Laborales de la Junta de Andalucía in Málaga (Spain). We recorded clinical and anthopometrical data. Blood samples were taken after an overnight fast. Vascular risk was calculated using Framinghan and SCORE scales. Every participant was asked for symptoms of intermittent claudicatio and AAI was measured. AAI was considered normal within 0.9-1.3 values. RESULTS: Most of our workers were at low- or moderate vascular risk. Only 48 (10.6%) of individuals had an abnormal AAI: 9 (2%) showed an AAI<0.9 and 39 (8.6%) showed an AAI>1.3. An AAI<0.9 was found in 19% of those with a SCORE risk > or = 5%, and in 11% of those having a Framinghan risk > or = 20%. Intermittent claudication was present in 4 out of 9 (44%) of those having an AAI<0.9 and in 7 out of 402 (1.7%) with a normal AAI. CONCLUSIONS: Systematic screening of peripheral arterial disease using the AAI is not recommended in active working population over 50 years-old of age. Thus, AAI measurement is indicated only for those individuals suffering from intermitent claudicatio and those who are at moderate- or high vascular risk.
Asunto(s)
Índice Tobillo Braquial , Enfermedades Vasculares Periféricas/diagnóstico , Enfermedades Vasculares Periféricas/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Salud Laboral , Prevalencia , EspañaRESUMEN
There is an important proportion of reproductive-age patients with early stage cervical cancer, low risk of parametrial or lymph node invasion and 95% overall survival rate at 5 years. Actually, there are two conservative techniques for fertility preservation for which long-term follow-up data consistently show acceptable overall and recurrence-free survival rates: conization and vaginal radical trachelectomy (VRT) (Dargent' s operation). Conization is optimal for women with stage IA1 disease without lymphvascular space invasion, and Dargent' s operation is optimal for women with stage IA2 and IB1 disease who have tumors