Factors Associated with Time to Progression and Overall Survival in Patients with De Novo Metastatic Breast Cancer: A Colombian Cohort.

PURPOSE: About 10% of breast cancer (BC) is diagnosed in stage IV. This study sought to identify factors associated with time to progression (TTP) and overall survival (OS) in a cohort of patients diagnosed with de novo metastatic breast cancer (MBC), from a single cancer center in Colombia, given that information on this aspect is limited. METHODOLOGY: An observational, analytical, and retrospective cohort study was carried out. Time to progression and OS rates were estimated using the Kaplan-Meier survival functions. Cox models were developed to assess association between time to progression and time to death, using a group of fixed variables. RESULTS: Overall, 175 patients were included in the study; 33.7% of patients had luminal B HER2-negative tumors, 49.7% had bone involvement, and 83.4% had multiple metastatic sites. Tumor biology and primary tumor surgery were the variables associated with TTP and OS. Patients with luminal A tumors had the lowest progression and mortality rates (10 per 100 patients/year (95% CI: 5.0-20.0) and 12.6 per 100 patients/year (95% CI: 6.9-22.7), respectively), and patients with triple-negative tumors had the highest progression and mortality rates (40 per 100 patients/year (95% CI: 23.2-68.8) and 44.1 per 100 patients/year (95% CI: 28.1-69.1), respectively). Across the cohort, the median TTP was 2.1 years (95% CI: 1.6; the upper limit cannot be reached) and the median OS was 2.4 years (95% CI: 2-4.3). CONCLUSIONS: In this cohort, patients with luminal A tumors and those who underwent tumor surgery given that they presented clinical benefit (CB) after initial systemic treatment, had the lowest progression and mortality rates. Overall, OS was inferior to other series due to high tumor burden and difficulties in accessing and continuing oncological treatments.

Development and validation of a scoring system for predicting cancer patients at risk of extended-spectrum b-lactamase-producing Enterobacteriaceae infections.

BACKGROUND: Extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBL-PE) infections are frequent and highly impact cancer patients. We developed and validated a scoring system to identify cancer patients harboring ESBL-PE at the National Institute of Cancer of Colombia. METHODS: We retrospectively analyzed medical records of 1695 cancer patients. Derivation phase included 710 patients admitted between 2013 to 2015, ESBL-PE positive culture (n = 265) paired by month and hospitalization ward with Non-ESBL-PE (n = 445). A crude and weighted score was developed by conditional logistic regression. The model was evaluated in a Validation cohort (n = 985) with the same eligibility criteria between 2016 to 2017. RESULTS: The score was based on eight variables (reported with Odds Ratio and 95% confidence interval): Hospitalization ≥7 days (5.39 [2.46-11.80]), Hospitalization during the previous year (4, 87 [2.99-7.93]), immunosuppressive therapy during the previous 3 months (2.97 [1.44-6.08]), Neutropenia (1.90 [1.12-3.24]), Exposure to Betalactams during previous month (1.61 [1.06-2.42]), Invasive devices (1.51 [1.012-2.25]), Neoplasia in remission (2.78 [1.25-1.17]), No chemotherapy during the previous 3 months (1.90 [1.22-2.97]). The model demonstrated an acceptable discriminatory capacity in the Derivation phase, but poor in the Validation phase (Recipient Operating Characteristic Curve: 0.68 and 0.55 respectively). CONCLUSIONS: Cancer patients have a high prevalence of risk factors for ESBL-PE infection. The scoring system did not adequately discriminate patients with ESBL-PE. In a high-risk population, other strategies should be sought to identify patients at risk of resistant ESBL-PE infection.

Validation of a Spanish version of the health-related quality of life (HRQoL) measure for Chronic Otitis Media (COMQ-12).

BACKGROUND: Evaluation of health-related quality of life (HRQoL) is considered an important aspect of clinical assessment and health research. Chronic Otitis Media (COM) is related to the quality of life deterioration subsequent to COM symptoms, social communication impairments, and lower work performance. However, there is no reliable information regarding the impact of this disease on health and quality of life in many resource-poor countries. Therefore, we translated into Spanish the Chronic Otitis Media Questionnaire-12 (COMQ-12) for the evaluation of HRQoL of Chronic Otitis Media (COM) in adult patients. Also, we assessed the psychometric properties of the Spanish version of the questionnaire. METHODS: Two otology referral centers in Bogotá, Colombia were included. The Spanish version of COMQ-12 was applied twice to 200 adult patients with confirmed COM diagnosis and 31 healthy controls to perform the validation process and assess the internal consistency of this questionnaire. Psychometric characteristics (internal consistency, test-retest reliability, and construct validity) of the COMQ-12 were assessed. Exploratory Factor Analysis and Confirmatory Factor Analysis were conducted via structural equation modeling to test the questionnaire's structure. RESULTS: The Spanish version of the COMQ-12 showed good internal consistency (Cronbach's Alpha: 0.86, McDonald's Omega: 0.89). Coefficients corresponding to Lin's Concordance test and test-retest reliability were 0.95 and 0.83 respectively. Correlation between the Visual Analogue Scale (VAS) and the COMQ-12 was 0.68 (95% CI 0.59-0.75, p value < 0.001). Factor analysis of the Spanish version of the COMQ-12 indicated a questionnaire structure with three domains: smelly discharge related symptoms; hearing loss related symptoms; and impact on work, lifestyle, and health services. CONCLUSION: This Spanish version of the COMQ-12 showed high reliability and high internal consistency. This questionnaire can be used as an objective clinical tool to assess the HRQoL of patients who have a COM diagnosis. TRIAL REGISTRATION: Hospital Universitario Fundación Santa Fe, Ethical Committee Registration ID: CCEI-8807-2018. Hospital de San José, Ethical Committee: Record number 500, DI-I-0632-18.

Validation of an instrument for measuring satisfaction of patients undergoing hemodialysis.

BACKGROUND: Patients' satisfaction is an indicator of the quality of healthcare services. Its measurement involves developing and validating complex instruments. The purpose of this study was to validate a scale for measuring hemodialysis patients' satisfaction with the provided care, the Scale for Evaluation of Hemodialysis Patient's Satisfaction with Service provided at a Chronic Kidney Disease Unit (or ESUR-HD, its acronym in Spanish). METHODS: The instrument was applied to 370 patients undergoing hemodialysis for undertaking exploratory and confirmatory analyses, internal consistency assessment, and Rasch analysis. In order to assure test-retest reliability, the instrument was applied once again to 54 patients after 2 days. Convergent validity was assessed by estimating correlation coefficients based on the results of 2 instruments (ESUR-HD and SDIALOR) simultaneously applied in 70 patients. Sensitivity to change was assessed in 40 patients by comparing the scale scores before and after an intervention consisting of improved care conditions. RESULTS: In the 44 items of the scale a 9-factor structure was found (1: Facilities and organization of the service. 2: Care provided by the attending nurses and/or nursing assistants. 3: Attention to psychological and administrative issues. 4: Contact and social work personnel. 5: Medical attention and care. 6: Nutritional attention and care. 7: Medications supply and quality. 8: Features of the admission process. 9: Attention and care provided by head nurses). Chronbach alpha for the scale was 0.96. Lin's concordance correlation for the whole scale was 0.85. Although statistically different from 0, low correlation values with dimensions from another scale measuring the same attribute were found. The scale could detect construct changes through increased scores in specific dimensions following an intervention aimed at enhancing satisfaction. Rasch analysis located improperly fit items and suggested reducing items measurement levels. Despite the effect encountered, Rasch analysis showed the scale might not capture variability in upper attribute levels. CONCLUSION: The ESUR-HD scale measures hemodialysis patients' satisfaction in one dimension with 9 domains. Validity and reliability are adequate. The instrument may detect changes in the construct. Subsequent versions of the scale should include new items allowing improved discrimination amongst high satisfaction levels. TRIAL REGISTRATION: ISRCTN45318400 . April 05, 2017.

Health-related quality of life in stroke patients questionnaire, short version (HRQOLISP-40): validation for its use in Colombia.

BACKGROUND: The health-related quality of life in stroke patients (HRQOLISP-40, short version) survey was developed in Nigeria and constitutes a 40-item, multidimensional, self-administrated questionnaire. We assessed the validity and reliability of the HRQOLISP-40 Spanish version for stroke patients in Colombia. METHODS: The analysis included factor analysis, confirmatory factor analysis, Rasch analysis, convergent validity, internal consistency (261 stroke patients), test-retest reliability (73 patients assessed at two different times) and sensitivity to change (46 patients assessed before and after a rehabilitation intervention). RESULTS: We found an 8-domain structure. None of the items had a significant impact on the global alpha value in order to be removed. Lin's concordance correlation coefficient indicated test-retest reliability (Rho IC: 0.76 to 0.95), suggesting an adequate stability of the instrument. Regarding sensitivity to change differences, they were only significant in the psychological and eco-social domains (p <0.05). When comparing SF-36 with HRQOLISP-40, all the correlation coefficients values were significantly different from zero, except those related to vitality. The highest scores were found in the physical and physical functioning domains, with a value of 0.722. CONCLUSIONS: The HRQOLISP-40 scale is valid and reliable for assessing patients' quality of life after a stroke. Validating quality of life assessment instruments is necessary in order to improve the effectiveness of rehabilitation programs for Colombian stroke patients.

The frequency of rehospitalization and associated factors in Colombian psychiatric patients: a cohort study.

BACKGROUND: The rehospitalization of patients with mental disorders is common, with rehospitalization rates of up to 80% observed in these patients. This phenomenon negatively impacts families, patients, and the health care system. Several factors have been associated with an increased likelihood of rehospitalization. This study was aimed at determining the frequency and the factors associated with rehospitalization in a psychiatric clinic. METHODS: We performed a prospective cohort study with 361 patients who were hospitalized at the Clinic of Our Lady of Peace in Bogota, Colombia from August-December 2009. We calculated the incidence rates of rehospitalization and the risk factors using Cox regression. RESULTS: Overall, 60% of the patients in this cohort were rehospitalized during the year that followed the index event. The variables associated with rehospitalization were separated, divorced, or single status; higher socio-economic strata; a longer duration of index hospitalization; and a diagnosis of substance abuse, schizophrenia, bipolar disorder, or depression. CONCLUSIONS: The rehospitalization rate in our study was as high as reported in other studies. The associated factors with it in this group, may contribute to the design of programs that will reduce the frequency of rehospitalization among patients with mental disorders, in countries like Colombia. Additionally, these results may be useful in interventions, such as coping skills training, psycho-education, and community care strategies, which have been demonstrated to reduce the frequency of rehospitalization.

Prognostic Factors Associated with Tumor Recurrence and Overall Survival in Soft Tissue Sarcomas of the Extremities in a Colombian Reference Cancer Center.

Introduction: Soft tissue sarcomas (STS) are low-incidence tumors whose clinical and histopathological factors are associated with adverse oncological outcomes. This study evaluated prognostic factors (PF) associated with tumor recurrence and overall survival (OS) in patients diagnosed with STS of the extremities, treated at the Instituto Nacional de Cancerología (INC), Bogotá, Colombia. Materials and Methods: An analytical observational study of a historical cohort was carried out, including patients diagnosed with STS and managed surgically in the Functional Unit for Breast and Soft Tissue Tumors of the INC from January 2008 to December 2018. Results: A total of 227 patients were included; 74.5% had tumors greater than 5 cm. Most patients (29.1%) were in stage IIIB at diagnosis. Age was associated with higher mortality (HR = 1.01; CI95%: 1-1.02; p = 0.048). Tumor persistence at admission to the INC (HR = 2.34; CI95%: 1.25-4.35; p = 0.007) and histologic grade III (HR = 5.36; CI95%: 2.29-12.56; p = <0.001) showed statistical significance in the multivariate analysis for recurrence of any type, as did the PFs associated with a higher risk of local recurrence (HR = 2.85; CI95%: 1.23-6.57; p = 0.014 and HR = 6.09; CI95%: 2.03-18.2; p = 0.001), respectively. Tumor size (HR = 1.03; CI95%: 1-1.06; p = 0.015) and histologic grade III (HR = 4.53; CI95%: 1.42-14.49; p = 0.011) were associated with a higher risk of distant recurrence. Conclusions: This cohort showed that in addition to histologic grade and tumor size, tumor persistence at the time of admission has an impact on disease recurrence, so STS should be managed by a multidisciplinary team with experience in this pathology in high-volume reference centers.

Association of Healthcare Fragmentation and the Survival of Patients With Colorectal Cancer in Colombia.

OBJECTIVES: The objective of this study was to identify the association between healthcare fragmentation and survival for patients with colorectal cancer in Colombia. METHODS: A retrospective cohort study was performed using administrative databases, with an electronic algorithm to identify patients with colorectal cancer based on codes. The patients were enrolled between January 1, 2013, and December 31, 2016. The exposure variable was fragmentation, which was measured based on the number of different healthcare institutions that treated a patient during the first year after diagnosis. Matching was performed using propensity scores to control for confounding, and the hazard ratio for exposure to higher fragmentation was calculated for the matched sample. RESULTS: A total of 5036 patients with colorectal cancer were identified, 2525 (49.88%) of whom were women. The mean number of network healthcare institutions for the total sample was 5.71 (SD 1.98). The patients in the quartile with higher fragmentation had the highest mortality rate, 35.67 (95% CI 33.63-38.06) per 100 patients. The comparison of higher and lower quartiles of fragmentation resulted in an incidence rate ratio of 1.23 (95% CI 1.04-1.45; P = .02). Of the 5036 patients, 422 (8.38%) were classified as the exposed cohort (higher fragmentation). The total matched sample consisted of 844 subjects, and an HR of 1.26 (95%CI; 1.05-1.51) was estimated. CONCLUSIONS: Exposure to more highly fragmented healthcare networks decreases overall 4-year survival for patients with colorectal cancer in Colombia.

Algorithm for the evaluation of therapeutic failure reports--proposal and pilot analysis.

PURPOSE: To propose and validate an algorithm to analyze the reports of suspected therapeutic failure (TF) received in pharmacovigilance programs. METHODS: A Delphi consensus method with a group of 12 international experts was used to identify the different causes that prompt TF and to propose an algorithm to analyze reports of suspected lack of efficacy of medicines. A pilot analysis of 50 reports was the basis to evaluate the interrater and intrarater validity of the algorithm. RESULTS: A 10-question algorithm was proposed. The evaluation of 50 reports of suspected TF showed that only 8% could be actually attributed to a manufacturing quality problem, whereas the real reason underlying the alleged TF was the inappropriate use of the prescribed drug in 28%. Minimum information to attribute the cause to a TF was lacking in 31% of these reports. The interrater reliability was "moderate" (kappa coefficient = 0.55), and the intrarater reliability ranged from 0.732 to 0.908 ("substantial" to "almost perfect"). CONCLUSIONS: The proposed TF algorithm is a valid, reliable, and reproducible analysis tool that can help to disentangle the frequent and complex reports of suspected TF.

Soluble HLA-G (sHLA-G) measurement might be useful as an early diagnostic biomarker and screening test for gastric cancer.

Gastric cancer (GC) is the fifth most frequent malignancy worldwide and has a high mortality rate related to late diagnosis. Although the gold standard for the GC diagnosis is endoscopy with biopsy, nonetheless, it is not cost-effective and is invasive for the patient. The Human leukocyte antigen G (HLA-G) molecule is a checkpoint of the immune response. Its overexpression in cancer is associated with immune evasion, metastasis, poor prognosis, and lower overall survival. We evaluate the plasma levels of soluble HLA-G, (sHLA-G) in patients with GC and benign gastric pathologies using an ELISA test. A higher concentration of sHLA-G in patients with GC than in those with benign pathologies, higher levels of plasma sHLA-G in women with GC compared with men and significant differences in the sHLA-G levels between the benign gastric pathologies evaluated, was our main findings. As no significant differences were found between the GC assessed stages in our study population, we suggest that sHLA-G is not an adequate marker for staging GC, but it does have diagnostic potential. In addition to providing information on the potential of sHLA-G as a diagnostic marker for GC, our study demonstrate that HLA-G molecules can be found in the membrane of exosomes, which highlights the need to perform studies with a larger number of samples to explore the functional implications of HLA-G positive exosomes in the context of gastric cancer, and to determine the clinical significance and possible applications of these findings in the development of non-invasive diagnostic methods.

Fungemia in Hospitalized Adult Patients with Hematological Malignancies: Epidemiology and Risk Factors.

Fungemia in hematologic malignancies (HM) has high mortality. This is a retrospective cohort of adult patients with HM and fungemia between 2012 and 2019 in institutions of Bogotá, Colombia. The epidemiological, clinical, and microbiological characteristics are described, and risk factors related to mortality are analyzed. One hundred five patients with a mean age of 48 years (SD 19.0) were identified, 45% with acute leukemia and 37% with lymphomas. In 42%, the HM was relapsed/refractory, 82% ECOG > 3, and 35% received antifungal prophylaxis; 57% were in neutropenia, with an average duration of 21.8 days. In 86 (82%) patients, Candida spp. was identified, and other yeasts in 18%. The most frequent of the isolates were non-albicans Candida (61%), C. tropicalis (28%), C. parapsilosis (17%), and C. krusei (12%). The overall 30-day mortality was 50%. The survival probability at day 30 in patients with leukemia vs. lymphoma/multiple myeloma (MM0 group was 59% (95% CI 46-76) and 41% (95% CI 29-58), p = 0.03, respectively. Patients with lymphoma or MM (HR 1.72; 95% CI 0.58-2.03) and ICU admission (HR 3.08; 95% CI 1.12-3.74) were associated with mortality. In conclusion, in patients with HM, non-albicans Candida species are the most frequent, and high mortality was identified; moreover, lymphoma or MM and ICU admission were predictors of mortality.

Clinical Outcomes of Adjuvant Hormone Therapy in a Cohort of Patients With Infiltrating Non-metastatic Breast Cancer in a Latin American Cancer Center.

INTRODUCTION: Breast cancer (BC) is the most commonly diagnosed cancer in women. This study evaluated the clinical outcomes and prognostic factors associated with disease-free survival (DFS) and overall survival (OS) in a cohort of patients diagnosed with hormone receptor-positive non-metastatic BC managed with adjuvant hormone therapy. METHODS: An observational, analytical, historical cohort study was conducted. DFS and OS rates were estimated, Kaplan-Meier survival functions were calculated, and Cox models were developed to assess the association between time to event (all-cause mortality or relapse) and hormone therapy exposure with a set of established variables. RESULTS: Inclusion criteria were met by 685 patients; the mean age at diagnosis was 58 years (SD=11.9 years). The most commonly used drug was tamoxifen for five years in 241 (35.7%) patients; 470 (69.6%) patients received initial therapy, 112 (16.5%) underwent switch therapy, and 93 (13.8%) had extended therapy. The factors associated with better rates of DFS and OS were early clinical stage (p=0.00), luminal A and luminal B Her2-positive biological subtypes (p=0.00), and adherence to adjuvant hormone therapy (p=0.001). Mortality rate was 0.77 deaths per 100 patients/year (95% CI, 0.51-1.2). CONCLUSION: This cohort demonstrated that adjuvant hormone therapy improves DFS and OS rates in locally advanced tumors. The main factor for reducing disease progression in this cohort was adequate adherence to treatment.

When is Sentinel Lymph Node Biopsy Useful in Ductal Carcinoma In Situ? The Experience at a Latin American Cancer Center.

Introduction Ductal carcinoma in situ (DCIS) accounts for 15% of breast cancers. Surgery is the main treatment, and the use of sentinel node biopsy (SLNB) is restricted to patients at risk of infiltration, which is estimated to be around 26%. Materials and methods Aimed at evaluating the benefit of SLNB in patients with DCIS at the Breast and Soft Tissue Functional Unit of the National Cancer Institute (INC for its initials in Spanish), a descriptive observational study of a retrospective cases series was conducted between August 1, 2013, and September 30, 2018. Results A total of 40 patients with a median age of 57 years were included in the study; 62.5% of them underwent mastectomy with SLNB, and the remaining 37.5% underwent conservative surgery with SLNB. 100% of sentinel nodes were identified, by using lymphoscintigraphy in 95%. Sentinel node was positive in four patients (10%), three of whom had infiltration in the surgical specimen reported. With a follow-up of 49 months, only one patient had a local relapse. None of the patients had axillary or distant recurrence. Conclusions SLNB in DCIS should be limited to patients with risk factors for infiltration (tumor size greater than 3 cm, comedo-type histology, and high-grade DCIS), and patients with an indication for mastectomy. Its percentage of complications is low, and a high identification percentage in surgical groups with adequate training.

Spatio-temporal dynamics of Plasmodium falciparum transmission within a spatial unit on the Colombian Pacific Coast.

As malaria control programmes concentrate their efforts towards malaria elimination a better understanding of malaria transmission patterns at fine spatial resolution units becomes necessary. Defining spatial units that consider transmission heterogeneity, human movement and migration will help to set up achievable malaria elimination milestones and guide the creation of efficient operational administrative control units. Using a combination of genetic and epidemiological data we defined a malaria transmission unit as the area contributing 95% of malaria cases diagnosed at the catchment facility located in the town of Guapi in the South Pacific Coast of Colombia. We provide data showing that P. falciparum malaria transmission is heterogeneous in time and space and analysed, using topological data analysis, the spatial connectivity, at the micro epidemiological level, between parasite populations circulating within the unit. To illustrate the necessity to evaluate the efficacy of malaria control measures within the transmission unit in order to increase the efficiency of the malaria control effort, we provide information on the size of the asymptomatic reservoir, the nature of parasite genotypes associated with drug resistance as well as the frequency of the Pfhrp2/3 deletion associated with false negatives when using Rapid Diagnostic Tests.

Clinical Behavior of Triple Negative Breast Cancer in a Cohort of Latin American Women.

INTRODUCTION: Breast cancer is a worldwide public health problem. In Colombia, there are 13,000 new cases, having the highest incidence and mortality among cancers. This article describes the clinical behavior of patients with triple negative breast cancer (TNBC) treated at the National Cancer Institute (NCI) in Bogota, Colombia. METHODS: A historical cohort and analytical study that included elderly patients diagnosed with TNBC treated at the National Cancer Institute Functional Breast Cancer Unit (NCI-FBCU) was conducted. RESULTS: Of the 1,066 patients registered in the unit from September 1st 2013 to December 31st 2016: 146 (13.7 %) had triple negative tumors. The average age was 57.3 years; 61% of patients had locally advanced tumors. The majority of patients received neoadjuvant chemotherapy as their first treatment (69.1%), and in 41.2% of the cases platinum was added to the chemotherapy regimen. The most common surgery conducted was modified radical mastectomy in 57.8% of cases. The pathological complete response (pCR) (Chevallier 1 and 2) was reached in 22.6% and, in this group of patients, a greater overall survival (OS) was found [hazard ratio (HR) 0.08, 95% CI 0.01-0.63; p = 0.016]. Progression of the disease occurred in 36.5% of cases, being lungs the most frequent location (44.4%). The death incidence rate was 1.21 deaths per 100 patients/month. The median event-free survival (EFS) was 18.2 months. CONCLUSION: TNBC occurs in Latin American women at advanced clinical stages with aggressive clinical behavior, with lower OS rates, and higher risk of metastasis compared to other molecular subtypes.

[Models used for decision-making in health care]. / Modelos empleados para la Toma de Decisiones en el Cuidado de la Salud.

Decision analysis consists of a set of tools supporting and handling structured evaluation. Such methodology is widely used for the economic evaluation of health care planning and programmes. This article outlines some characteristics regarding complex decision-making and shows the fundamental issues and stages considered when making decisions in an uncertain scenario (problem definition, choosing an appropriate time-frame, structuring the problem, developing a model for analysing it, selecting the best alternative and analysing sensitivity). Some criticism of this decision-making method is then made.

Anxiety and Depression Disorders in Relation to the Quality of Life of Breast Cancer Patients with Locally Advanced or Disseminated Stage. / Trastornos de ansiedad y depresión en relación con la calidad de vida de pacientes con cáncer de mama en estadio localmente avanzado o diseminado.

OBJECTIVE: To evaluate patterns of association between anxiety and depression and the different elements of the construct of quality of life, in patients with locally advanced breast cancer or disseminated stages METHODS: With a single measure over time, HADS and FACIT-B scales were applied in 107 women histologically confirmed to have breast cancer, in stages IIB, IIIA, IIIB, IIIC and IV. Factor analysis and multidimensional scaling methods were used to analyze patterns of association RESULTS: In 84.1% of the patients clinical anxiety was found (95%CI, 75.8-90.5%) and clinical depression in 25.2% (95%CI, 17.3-34.6%). Factor analysis groups items of the two scales in 4 domains which accounted for 59% of the total variance, where 2 items (H11 and B8) showed high values of uniqueness and low factor loadings. Multidimensional scaling suggests five groups, showing proximity between depressive symptoms and physical symptoms, as well as between anxious symptoms and related to functionality and social and family environment CONCLUSIONS: The HADS in patients with neoplastic disease detects a high frequency of depressive and especially anxious symptoms, which makes it advisable to reevaluate their psychometric properties in patients with cancer. The association between depressive symptoms of HADS and physical symptoms of quality of life construct is in favor of the difficulty of diagnosing depressive disorder in patients with cancer, so it may be necessary to develop instruments that allow locating symptoms or clinical characteristics that facilitate this diagnosis.

Toma de decisiones para la adecuación del esfuerzo terapéutico al final de la vida en pacientes oncológicos del instituto Nacional de Cancerología de Colombia

Propósito: la adecuación del esfuerzo terapéutico es una decisión clínica basada en la evidencia que pretende evitar la futilidad médica. Se han señalado diferentes factores que pueden influir en esta toma de decisiones los cuales se relacionan con el paciente, el profesional médico que toma de las decisiones, barreras del sistema, cultura y economía, entre otros. El presente estudio pretende identificar aquellos factores que influyen en los médicos especialistas que laboran en la institución referente del cáncer en Colombia, a fin de planear acciones que mejoren el abordaje de la toma de decisiones con respecto a la adecuación del esfuerzo terapéutico en pacientes con cáncer. Metodología: diseño cualitativo basado en 13 entrevistas en profundidad a médicos especialistas del Instituto Nacional de Cancerología de Colombia. Resultados: participaron 3 mujeres y 10 hombres, con un promedio de edad de 36 años, 7 pertenecientes a la especialidad de oncología de adultos, 2 a oncohematología pediátrica, 1 a cuidados intensivos de adultos y 3 a cuidados intensivos pediátricos. Los factores hallados se agruparon en cuatro categorías: 1) conocimiento, 2) aspectos relacionados con la toma de decisiones, 3) quién decide, 4) tipo de decisión que se toma; a su vez, estas categorías se agruparon en temas que hacen alusión a los factores que influyen en la toma de decisiones de los especialistas para adecuar los esfuerzos terapéuticos. Conclusión: la adecuación de los esfuerzos terapéuticos es importante para evitar procedimientos médicos fútiles que prolonguen el sufrimiento. Se evidenciaron algunos factores que influyen en la toma de decisiones de los especialistas: falta de preparación de los profesionales de salud en el tema de toma de decisiones al final de la vida, uso reducido de escalas que permitan mejorar la información del pronóstico y desconocimiento sobre voluntades anticipadas; estos son algunos de aquellos factores que deben fortalecerse para generar acciones que mejoren el abordaje de esta temática.

Purpose: Adjusting therapeutic efforts is an evidence-based clinical decision that aims to avoid medical futility. Varied factors that can influence this decision-making have been pointed out, related to the patient, the medical professional who makes the decisions, system barriers, culture, and the economy, among others. The present study aims to identify those factors that help the specialists working in a cancer referral institution in Colombia to plan actions that improve the approach to decision-making regarding the adequacy of therapeutic efforts in cancer patients. Methodology: This qualitative design is based on 13 in-depth interviews with Colombia's National Cancer Institute specialists. Results: Three women and ten men participated, with an average age of 36 years; seven belonged to the specialty of adult oncology, two to pediatric oncohematology, one to adult intensive care, and three to pediatric intensive care. The factors found were grouped into four categories: 1) knowledge, 2) aspects related to decision-making, 3) the decision-maker, and 4) the type of decision made. These categories were clustered into themes that allude to the factors swaying specialists' decision-making to adjust therapeutic efforts. Conclusion: Adjusting therapeutic actions is vital to avoid futile medical procedures that prolong suffering. Some factors that influence the specialists' decision-making were noted: lack of preparation of health professionals on end-of-life decision-making, reduced use of scales to improve prognostic information, and ignorance about advance directives. These factors must be strengthened to improve the approach to this issue.

Introdução: a adequação do esforço terapêutico é uma decisão clínica baseada em evidências que pretende evitar a futilidade médica. Diferentes fatores que podem influenciar nessa tomada de decisão vêm sendo identificados e estão relacionados com o paciente, com o profissional médico que toma as decisões, com as barreiras do sistema, com a cultura e a economia, entre outros. Objetivo: este estudo pretende identificar aqueles fatores que influenciam os médicos especialistas que trabalham na instituição referente do câncer na Colômbia, a fim de propor ações que melhorem a abordagem da tomada de decisões a respeito da adequação do esforço terapêutico em pacientes com câncer. Metodologia: desenho qualitativo baseado em 13 entrevistas em profundidade com médicos especialistas do Instituto Nacional de Cancerologia da Colômbia. Resultados: participaram 3 mulheres e 10 homens, com média de idade de 36 anos - 7 pertencentes à especialidade de oncologia de adultos; 2, onco-hematologia pediátrica; 1, terapia intensiva de adultos e 3, terapia intensiva pediátrica. Os fatores achados foram agrupados em quatro categorias: 1) conhecimento; 2) aspectos relacionados com a tomada de decisões; 3) quem decide; 4) tipo de decisão tomada. Por sua vez, essas categorias foram agrupadas em temas que fazem alusão aos fatores que influenciam a toma de decisões dos especialistas para adequar os esforços terapêuticos. Conclusões: a adequação dos esforços terapêuticos é importante para evitar procedimentos médicos fúteis que prolonguem o sofrimento. Foram evidenciados alguns fatores que influenciam a tomada de decisões dos especialistas: falta de preparação dos profissionais de saúde no tema, uso reduzido de escalas que permitam melhorar a informação do prognóstico e desconhecimento sobre vontades antecipadas; estes são alguns dos fatores que devem ser fortalecidos para gerar ações que melhorem a abordagem da temática.

Morbilidad y mortalidad en pacientes llevados a gastrectomía por cáncer gástrico / Morbidity and mortality in patients undergoing gastrectomy for gastric cancer

Introducción. El cáncer gástrico es la cuarta causa de muerte por cáncer a nivel mundial, con más de un millón de casos diagnosticados cada año. La cirugía con intención curativa sigue siendo el pilar del manejo para los pacientes resecables. La identificación de pacientes con mayor riesgo de morbimortalidad es importante para el proceso de toma de decisiones, sin existir hasta el momento una herramienta ideal. La revisión y el análisis de la experiencia de un centro oncológico de referencia pueden generar información útil. Métodos. Estudio observacional de cohorte histórica, en el que se incluyeron los pacientes llevados a gastrectomía por adenocarcinoma gástrico en el Instituto Nacional de Cancerología, Bogotá, D.C., Colombia, entre el 1° de enero del 2010 y el 31 de diciembre del 2017. Resultados. Se evaluaron 332 pacientes, de los cuales el 57,2 % eran hombres con edad promedio de 61 años. La mortalidad en esta serie fue del 4,5 % y la morbilidad de 34,9 %. El factor asociado con mayor riesgo de muerte fue la edad, con un HR de 1,05 (p=0,021). Se encontró un mayor riesgo en el grupo de pacientes con ASA mayor a II (p=0,009).El 17,4 % presentaron complicaciones mayores a IIIA de la clasificación de Clavien-Dindo. Conclusiones. En el presente trabajo las cifras de morbilidad y mortalidad son similares a las reportadas en la literatura. Solo la edad y la clasificación de ASA mostraron asociación con valor estadístico significativo para complicaciones postoperatorias

Introduction. Gastric cancer is the fourth leading cause of cancer death worldwide with more than one million cases diagnosed each year. Surgery with curative intent remains the mainstay of management for resectable patients. Identify patients at increased risk of morbidity and mortality is important for the decision making process, with no ideal tool available yet. Review and analysis of the experience of a referral cancer center may generate useful information. Methods. Historical cohort observational study. Patients undergoing gastrectomy for gastric adenocarcinoma at the National Cancer Institute in Bogotá, Colombia, between January 1, 2010 and December 31, 2017 were included. Results. We included 332 patients of which 57.2% were men with mean age of 61 years. Mortality in this series was 4.5% and morbidity was 34.9%. The factor associated with higher risk of death was age with a HR of 1.05 statistically significant value (p=0.021). A higher risk was found in the group of patients with ASA greater than II (p=0.009). The 17.4% presented complications greater than IIIA of the Clavien Dindo classification. Conclusions. In this study morbidity and mortality seem similar to those reported in the literature. Only age and ASA score showed an association with significant statistical value for postoperative complications

Miasis en pacientes con cáncer en el Instituto Nacional de Cancerología entre 2008 y 2018: Serie de Casos / Myiasis in cancer patients receiving medical care at a reference center in Bogotá, Colombia: 2008-2018. A case series

Resumen Introducción: La miasis puede ser considerada una enfermedad desatendida; corresponde a la infestación de larvas de dípteros en piel, heridas o cavidades naturales. La literatura para pacientes oncológicos con infestación es limitada para Colombia. Métodos: Se realizó una serie de casos de miasis en pacientes atendidos en el Instituto Nacional de Cancerología de 2008 a 2018; se obtuvieron datos de las historias clínicas con el fin de caracterizar variables sociodemográficas, oncológicas y tratamiento recibido. Resultados: Se encontraron 32 registros: 27 cumplieron con los criterios de inclusión, mediana de edad 69 años, 74% fueron hombres, 48% procedían de área rural, 33,3% de áreas con alturas superiores a 2000 msnm, 70% presentaban cáncer de cabeza y cuello, seguidos por cáncer de mama 14%; 40% ECOG 2-3; 77% visualizaron larvas antes de consultar; ningún paciente presentó sepsis al momento de consultar, 29% presentaban secreción en zona infestada, 85% recibieron ivermectina y curaciones por parte de enfermería; 70% recibió antibióticos sistémicos, y 60% otros tratamientos además de la remoción mecánica e ivermectina, la mediana de leucocitos al ingreso fue de 10280 y de eosinófilos 110. Conclusión: Ésta es la primera serie de casos informada de miasis en pacientes oncológicos para América. Es más frecuente en pacientes con neoplasias en áreas expuestas, aunque se puede presentar en zonas no expuestas; la infestación por larvas tiende a no ser purulenta. Se deben hacer estudios sobre el uso de ivermectina, otros antibióticos y las implicaciones pronósticas de esta patología en los pacientes con cáncer avanzado.

Abstract Introduction: Myiasis can be considered a neglected disease; it corresponds to the infestation of dipteran larvae in skin, wounds, or natural cavities. Literature for oncological patients with this infestation is limited for Colombia. Methods: A case series of myiasis was carried out in patients treated at the National Cancer Institute of Colombia from 2008 to 2018. Data were obtained from medical records in order to characterize sociodemographic and oncological variables and the treatment received. Results: Thirty-two records were found, 27 of them met the inclusion criteria. Median age was 69 years, 74% were men, 48% came from rural areas, 33.3% from areas with altitudes greater than 2,000 meters above sea level, 70% had head and neck cancer, followed by breast cancer in 14%; 40% had ECOG 2-3, and 77% visualized larvae before consulting. No patient presented with sepsis at the time of consultation, 29% presented with discharge in the infested area, 85% received ivermectin and treatment by the nursing staff; 70% received systemic antibiotics, and 60% other treatments in addition to mechanical removal and ivermectin. Median of leukocytes at admission was 10,280, while median of eosinophils was 110. Conclusion: This is the first reported case series of myiasis in cancer patients for Latin America. It is more common in patients with neoplasms in exposed areas, although it can occur in unexposed areas too. Larval infestation tends not to be purulent. Further studies are needed on the use of ivermectin, other antibiotics, and the prognostic implications of this pathology in patients with advanced cancer.