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INTRODUCTION: The global cancer burden is increasing. Current global evidence indicates there will be a 47% rise of cancer cases for the period 2020-2040. The cancer rate differential also is evident within countries and regions. Efforts have been used to reduce the health disparities; however, the inequity prevails. One potential way to help reduce the disparity is through advocacy by physicians. METHODS: Two recent systematic review articles on advocacy among physicians note that physicians are unlikely to be taught advocacy in medical education, and also note there are no advocacy competencies or skill sets that are either taught or valued in medical education. We explore literature and develop a model to understand the components of advocacy in medical education, specifically in resident training. We follow the model's main components by examining principles of advocacy, relevant domains of advocacy, and competencies and values for advocacy education. RESULTS: Four ethical principles of advocacy education are identified: beneficence, non-maleficence, autonomy, and justice. These principles must be applied in meaningful, culturally sensitive, respectful, and promotion of the well-being ways. Three domains are identified: the practice domain (provider-patient interaction), the community domain (provider-community collaboration), and the health policy domain (the larger social environment). Advocacy occurs differently within each domain. Finally, competencies in the form of knowledge, skills, and values are described. We present a table noting where each competency occurs (by domain) as well as the value of each knowledge and skill. POLICY SUMMARY: The significance of including advocacy instruction in medical education requires a change in the current medical education field. Besides valuing the concept of including advocacy, principles, domains, and competencies of inclusion are critical. In summary, we encourage the inclusion of advocacy education in resident medical programs so physicians become competent medical providers at diverse levels of society.
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Internado y Residencia , Defensa del Paciente , Humanos , Competencia Clínica , Neoplasias , Defensa del Paciente/educaciónRESUMEN
Introducción: La pseudotrombocitopenia dependiente del ácido etilendiaminotetraacético (PTCP-EDTA) es un fenómeno de laboratorio con una prevalencia estimada del 0,1-2% entre los pacientes hospitalizados y entre el 15-17% en los pacientes ambulatorios evaluados por trombocitopenia aislada. Se produce por cambios conformacionales a nivel de las glicoproteínas de la superficie plaquetaria que inducen la agregación de plaquetas tras la exposición al EDTA. Esta agregación da lugar a una falsa disminución del conteo de unidades totales de plaquetas al utilizar analizadores automatizados. Presentación del caso: Presentamos el caso de un paciente de 5 años que presentaba niveles bajos de plaquetas sin signos de hemorragia activa. El paciente fue ingresado en el hospital mientras se estudiaba la causa de su bajo conteo plaquetario. Para el diagnóstico de PTCP-EDTA, se realizó un frotis de sangre periférica y se compararon los niveles plaquetarios utilizando el tubo con anticoagulante de citrato. Conclusión: La PTCP-EDTA suele ser un diagnóstico que se pasa por alto y que puede dar lugar a procedimientos innecesarios y gastos adicionales para los pacientes que presentan este fenómeno in vitro. (provisto por Infomedic International)
Introduction: Ethylenediaminetetraacetic acid-dependent pseudothrombocytopenia (PTCP-EDTA) is a laboratory phenomenon with an estimated prevalence of 0.1-2% among hospitalized patients and between 15-17% in outpatients evaluated for isolated thrombocytopenia. It is caused by conformational changes at the level of platelet surface glycoproteins that induce platelet aggregation following EDTA exposure. This aggregation results in a false decrease in total platelet unit count when using automated analyzers. Case presentation: We present the case of a 5-year-old patient who presented with low platelet levels without signs of active bleeding. The patient was admitted to the hospital while the cause of his low platelet count was being studied. For the diagnosis of PTCP-EDTA, a peripheral blood smear was performed and platelet levels were compared using the tube with citrate anticoagulant. Conclusion: PTCP-EDTA is often an overlooked diagnosis that may result in unnecessary procedures and additional expense for patients presenting with this phenomenon in vitro. (provided by Infomedic International)
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Pancreatic metastases of papillary thyroid carcinoma (PTC) are exceptional. We report a 80-year-old man consulting for obstructive jaundice and dysphonia. Abdominal ultrasonography showed biliary dilation and abdominal magnetic resonance imaging (MRI) showed a pancreatic head mass of 36 mm. A left vocal cord paralysis was confirmed and cervical computed tomography (CT) showed multiple thyroid nodules of up to 35 mm associated with bilateral cervical lymph nodes (LN). Positron emission tomography ( 18 F-FDG PET/CT) evidenced hyper-metabolic activity in bilateral cervical LN, lungs, pancreas and left intercostal soft tissue, as well as left gluteus. Thyroid biopsy reported a tall-cell variant of PTC, and endoscopic ultrasound guided fine needle aspiration (EUS-FNA) of pancreatic mass confirmed PTC metastasis. The molecular study was positive for BRAFV600E. Pancreatic metastasis from PTC can be accurately diagnosed with 18 F-FDG PET/CT and EUS-FNA, which is consistent with a predominant expression of BRAFV600E mutation and, thus, an aggressive presentation with poor short-term survival.
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Humanos , Neoplasias Pancreáticas/secundario , Neoplasias de la Tiroides/patología , Cáncer Papilar Tiroideo/patología , Pancreatectomía , Neoplasias Pancreáticas/cirugía , Tiroidectomía , Neoplasias de la Tiroides/cirugía , Resultado del Tratamiento , Cáncer Papilar Tiroideo/cirugía , Escisión del Ganglio Linfático , Metástasis LinfáticaRESUMEN
ABSTRACT Objective We aimed to describe the presentation of papillary microcarcinoma (PTMC) and identify the clinical and histological features associated with persistence/recurrence in a Latin American cohort. Subjects and methods Retrospective study of PTMC patients who underwent total thyroidectomy, with or without radioactive iodine (RAI), and who were followed for at least 2 years. Risk of recurrence was estimated with ATA 2009 and 2015 classifications, and risk of mortality with 7th and 8th AJCC/TNM systems. Clinical data obtained during follow-up were used to detect structural and biochemical persistence/recurrence. Results We included 209 patients, predominantly female (90%), 44.5 ± 12.6 years old, 183 (88%) received RAI (90.4 ± 44.2 mCi), followed-up for a median of 4.4 years (range 2.0-7.8). The 7th and 8th AJCC/TNM system classified 89% and 95.2% of the patients as stage I, respectively. ATA 2009 and ATA 2015 classified 70.8% and 78.5% of the patients as low risk, respectively. Fifteen (7%) patients had persistence/recurrence during follow-up. In multivariate analysis, only lymph node metastasis was associated with persistence/recurrence (coefficient beta 4.0, p = 0.016; 95% CI 1.3-12.9). There were no PTMC related deaths. Conclusions Our series found no mortality and low rate of persistence/recurrence associated with PTMC. Lymph node metastasis was the only feature associated with recurrence in multivariate analysis. The updated ATA 2015 and 8th AJCC/TNM systems classified more PTMCs than previous classifications as low risk of recurrence and mortality, respectively.
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Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Neoplasias de la Tiroides/cirugía , Carcinoma Papilar/cirugía , Recurrencia Local de Neoplasia , Pronóstico , Tiroidectomía , Neoplasias de la Tiroides/radioterapia , Carcinoma Papilar/radioterapia , Estudios Retrospectivos , Factores de Riesgo , Estudios de Cohortes , Terapia CombinadaRESUMEN
Background: The aim of the surgical treatment of primary hyperparathyroidism (PHPT) is to achieve its complete cure, evidenced by normal serum calcium in the postoperative period. Measurement of intraoperative serum parathormone (PTH) can be useful to predict complete cure of the disease. Aim: To assess the usefulness of intraoperative PTH measurement to predict complete cure of PHPT Material and methods: Serum PTH was measured to all patients operated for PHPT between 2003 and 2008, before and five and ten minutes after the excision of the parathyroid gland causing the disease. The criteria for complete cure were normal serum calcium at 24 hours and 6 months after surgery and the pathological confirmation of parathyroid gland excision. Results: Eighty-eight operated patients, aged 58±15 years (72 females) were studied. Sixty four percent were asymptomatic and their preoperative serum calcium was 11.6± 1.2 mg/dl. A normal serum calcium was achieved in 86 patients (98 percent) at 24 hours and 50 of 52 patients followed for six months (96 percent). The pathological study disclosed an adenoma in 69 (78 percent), and multiglandular disease in 16 (18 percent), a parathyroid cancer in one and a normal gland in one patient. Intraoperative PTH predicted early and definitive cure in 97 percent and 100 percent of patients with a single adenoma, respectively. Among patients with multiglandular disease, the predictive figures were 94 percent and 100 percent, respectively. Conclusions: Intraoperative PTH measurement efficiently predicts early and definitive surgical cure of PHPT.
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Femenino , Humanos , Masculino , Persona de Mediana Edad , Adenoma/cirugía , Calcio/sangre , Hiperparatiroidismo/cirugía , Hormona Paratiroidea/sangre , Neoplasias de las Paratiroides/cirugía , Adenoma/complicaciones , Biomarcadores/sangre , Hiperparatiroidismo/sangre , Hiperparatiroidismo/etiología , Cuidados Intraoperatorios , Neoplasias de las Paratiroides/complicaciones , Paratiroidectomía , Valor Predictivo de las Pruebas , Resultado del TratamientoRESUMEN
Purpose. To correlate axillary Technetium-99m-sestamibi uptake with the axillary histology in patients with proven breast cancer. Secondly, to correlate the breast scintimammography results with the tumor histology. Materials and methods. Fifty-one patients with operable breast cancer T1, T2 or T3 and N0 or N1 had a scintimammography before surgery. Images were interpreted directly from the computer screen by two specialists who did not have knowledge about clinical or radiological information concerning the patients. Surgical treatment included conservative surgery or mastectomy, both followed by axillary dissection for malignant tumors (45 patients) and only excision for benign lesions (6 patients). Statistical analysis correlated scintimammography and histologic results. Results. The sensitivity and specificity of Tc99m-sestamibi to assess histologic lymph node involvement in patients with operable breast cancer was 35 percent (95 percent CI:14-61 percent) and 57 percent (95 percent CI:37-75 percent) respectively. The positive predictive value was 33 percent (95 percent CI:13-58 percent) and the negative predictive value was 59 percent ( 95 percent CI: 38-77 percent). The sensitivity and specificity of Tc99-sestamibi to assess breast tumor malignancy was 97 percent (95 percent CI:88-99 percent) and 33 percent (95 percent CI: 4-77 percent) respectively, calculated in only six patients. The positive predictive value was 91 percent (95 percent CI: 80-97 percent) and the negative predictive value was 66 percent (95 percent CI:9-99 percent). Conclusion. Our findings regarding the preoperative axillary assessment with Tc99m-sestamibi do not support the use of this imaging modality for this purpose
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Humanos , Femenino , Neoplasias de la Mama , Metástasis Linfática/patología , Axila , Mamografía , Cintigrafía , Tecnecio Tc 99m Sestamibi , Ganglios Linfáticos/patologíaRESUMEN
Corresponde a la bioética el estudio sistemático de la conduta humana en el área de las ciencias de la vida y del cuidado de la salud, en cuanto dicha conducta es examinada a la luz de los valores y principios morales. Se describe la emergencia de la bioética como un fenómeno contemporáneo, su desarrollo inicial, las diferencias entre ética tradicional y la bioética y el papel de este último ante el uso indiscriminado y en ocaciones abusivos de los nuevos avances de la tecnología médica. Se hace énfasis en la enseñanza de la bioética, en el establecimiento de los cómites de bioética y en el papel de estos últimos en las labores de la investigación de seres humanos en las instituciones docentes asistenciales. Finalmente se emiten consideraciones acerca del futuro de la bioética en nuestro país
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Bioética/historia , Ética/clasificación , MoralRESUMEN
Se analiza la importancia de la historia médica, suselementos cosntitutivos, las regulaciones éticas y legales aplicables al manejo de las mismas y se concluye con el análisis de algunas incertidumbres, las cuales ponen a prueba el buen juicio y la capacidad de la enfermera para la toma de decisiones que no vulneren los intereses vitales del enfermo
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Humanos , Anamnesis , Enfermeras y EnfermerosRESUMEN
Se analizan, sucesivamente, las disposiciones legales y éticas vigentes en Venezuela relativas a la atención de los pacientes críticamente enfermos; el proceso de comunicación y de toma de decisiones en lo concerniente a la supresión y al no inicio de las medidas terapéuticas; la práctica de la eutanasia activa y el testamento biológico. Cada uno de estos aspectos justifica, dada su importancia, la discusión ulterior con carácter de controversia en Foros y Mesas Redondas, en diversas regiones del país, patrocinados por la Sociedad Venezolana de Medicina Crítica
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Humanos , Ética Médica , Unidades de Cuidados Intensivos , Legislación Médica , EutanasiaRESUMEN
Se hace un recuento de la huelga de médicos en Venezuela y de las razones que conducen a la utilización de tal procedimiento para derimir los conflictos del gremio médico con el Estado. El análisis del problema se efectúa desde las perspectivas éticas y legales. Especial consideración se dedica a la posición doctrinaria de la Academia Nacional de Medicina y de la Federación Médica Venezolana. Se concluye con una recomendación destinada a la búsqueda de un procedimiento idóneo para resolver los conflictos gremiales sin exponer la salud de la población de escasos recursos
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Humanos , Masculino , Femenino , Ética Médica , Médicos , Huelga de Empleados , VenezuelaRESUMEN
Se trataron 23 pacientes (Grupo A) con una mediana de 59 años, con 5-FU 600 mg/m cuadrado día 1, 8,29 y 36, ADX 30 mg/m cuadrado día 1 y 29 MTX 50 mg/m cuadrado día 1 y 8 vs 20 pacientes (Grupo B) con una mediana de 51 años con 5-FU 600 mg/m cuadrado día 1 y 8, ADX 40 mg/m cuadrado día 1 CTX 400 mg/m cuadrado día 1 y 8. Cada 4 semanas por 12 ciclos. Todos con cáncer gástrico avanzado. Grupo A: R.P. 10/23 (43,4%) con promedio de 7,1 meses y mediana de sobrevida 10,7 meses. Grupo B: R.P. 6/20 (30%) con promedio de 4,7 meses y mediana de sobrevida 11,4 meses. no hubo R.C. en ambos grupos. La toxicidad fue similar