Factores asociados a epilepsia farmacorresistente en niños atendidos en un hospital de referencia nacional / Factors associated with drug-resistant epilepsy in children treated at a national referral hospital

Antecedentes: Según la Organización Mundial de la Salud (OMS) cerca de 70 millones de personas en el mundo padecen epilepsia. Los países de medianos y bajos ingresos presentan 70-80% de los casos; se estima que afecta 4-13% de los niños hasta los 16 años, de los cuales la epilepsia farmacorresistente (EFR) se desarrolla en 10-23%. Objetivo: Determinar factores de riesgo asociados a EFR en pacientes pediátricos atendidos en Hospital María, Especialidades Pediátricas (HMEP), Tegucigalpa, marzo 2017-marzo 2022. Métodos: Estudio de casos-controles. A partir del total de pacientes menores de 18 años con diagnóstico de epilepsia atendidos en el Servicio de Neurología HMEP, se definió Caso como pacientes con diagnóstico de EFR y Controles como pacientes con epilepsia no farmacorresistente (ENFR). A partir de expedientes clínicos, se evaluaron factores sociodemográficos, antecedentes personales y familiares, factores clínicos, estudios de imagen y electroencefalograma. El estudio fue aprobado por el Comité de Ética Institucional. Resultados: Se analizaron 81 casos y 162 controles. La edad más afectada en casos fue preescolar (35.8%), en controles fue edad escolar (41.4%). El sexo masculino presentó similar distribución en ambos grupos (51.8% y 51.2%). La procedencia rural fue más frecuente en los casos que en controles (58.0% versus 48.8%). Se identificaron los siguientes factores asociados a EFR: Antecedentes familiares de epilepsia (ORa 2.32, IC95%1.22­4.41, p=0.01), alteración focal en examen físico (ORa 2.23, IC95%1.10­4.55, p=0.02), neurodesarrollo anormal (ORa 2.78, IC95%1.18­6.54, p=0.02). Discusión: El control adecuado de las crisis epilépticas incide directamente en la calidad de vida y sobrevida de los pacientes. La identificación correcta de los niños con epilepsia con los factores asociados identificados en este estudio, que coinciden con lo descrito internacionalmente, permitirá hacer un mejor tamizaje y priorizar la referencia temprana a un neurólogo pediatra contribuyendo a mejorar la calidad de vida de los pacientes...(AU)

ConCerv: a prospective trial of conservative surgery for low-risk early-stage cervical cancer.

OBJECTIVE: The objective of the ConCerv Trial was to prospectively evaluate the feasibility of conservative surgery in women with early-stage, low-risk cervical cancer. METHODS: From April 2010 to March 2019, a prospective, single-arm, multicenter study evaluated conservative surgery in participants from 16 sites in nine countries. Eligibility criteria included: (1) FIGO 2009 stage IA2-IB1 cervical carcinoma; (2) squamous cell (any grade) or adenocarcinoma (grade 1 or 2 only) histology; (3) tumor size <2 cm; (4) no lymphovascular space invasion; (5) depth of invasion <10 mm; (6) negative imaging for metastatic disease; and (7) negative conization margins. Cervical conization was performed to determine eligibility, with one repeat cone permitted. Eligible women desiring fertility preservation underwent a second surgery with pelvic lymph node assessment, consisting of sentinel lymph node biopsy and/or full pelvic lymph node dissection. Those not desiring fertility preservation underwent simple hysterectomy with lymph node assessment. Women who had undergone an 'inadvertent' simple hysterectomy with an unexpected post-operative diagnosis of cancer were also eligible if they met the above inclusion criteria and underwent a second surgery with pelvic lymph node dissection only. RESULTS: 100 evaluable patients were enrolled. Median age at surgery was 38 years (range 23-67). Stage was IA2 (33%) and IB1 (67%). Surgery included conization followed by lymph node assessment in 44 women, conization followed by simple hysterectomy with lymph node assessment in 40 women, and inadvertent simple hysterectomy followed by lymph node dissection in 16 women. Positive lymph nodes were noted in 5 patients (5%). Residual disease in the post-conization hysterectomy specimen was noted in 1/40 patients-that is, an immediate failure rate of 2.5%. Median follow-up was 36.3 months (range 0.0-68.3). Three patients developed recurrent disease within 2 years of surgery-that is, a cumulative incidence of 3.5% (95% CI 0.9% to 9.0%). DISCUSSION: Our prospective data show that select patients with early-stage, low-risk cervical carcinoma may be offered conservative surgery.

Oncological and obstetrical outcomes after neo-adjuvant chemotherapy followed by fertility-sparing surgery in patients with cervical cancer ≥2 cm.

OBJECTIVE: There is significant debate between up-front radical trachelectomy versus neo-adjuvant chemotherapy before fertility-sparing surgery in patients with tumors ≥2 cm. The aim of this study was to report on the oncological and obstetrical outcome of neo-adjuvant chemotherapy followed by fertility-sparing surgery, in patients diagnosed with cervical cancer ≥2 cm. METHODS: This was a retrospective review of patients diagnosed with cervical cancer measuring ≥2 cm to ≤6 cm, who were scheduled to undergo neo-adjuvant chemotherapy before fertility-sparing surgery, at six institutions from four Latin American countries between February 2009 and February 2019. Data collected included: age, International Federation of Gynecology and Obstetrics (FIGO) 2009 stage, histology, tumor size, pre-treatment imaging work-up, chemotherapy agents and number of cycles, toxicity, clinical and imaging response rate, type of fertility-sparing surgery, pathology results, timing of lymphadenectomy, follow-up time, and obstetrical and oncological outcomes. RESULTS: A total of 25 patients were included, with a median age of 27 years (range 20-37): 17 patients had stage IB1, 7 had stage IB2 cervical cancer, and 1 patient had stage IIA1 (FIGO 2009); 23 patients had squamous cell carcinoma and 2 patients had adenocarcinoma. The median number of chemotherapy cycles was 3 (range 3-6) and no toxicity grade 3-4 was reported. Lymphadenectomy was performed before chemotherapy in 6 (24%) patients. After neo-adjuvant chemotherapy 20 patients were scheduled for radical trachelectomy (11 abdominal and 9 laparoscopic) and 5 patients for conization. After surgery, no residual disease was found in 11 patients (44%). Fertility was preserved in 23 patients (92%) and 10 patients became pregnant (43.5%). After a median follow-up time of 47 months (13-133), 3 patients had recurrent disease (3/23=13%), 2 were alive without disease, and 1 patient had disease at last contact. CONCLUSION: Neo-adjuvant chemotherapy followed by fertility-sparing surgery is feasible in well selected patients with cervical tumors ≥2 cm. Future studies should focus on the timing of lymphadenectomy and type of cervical surgery.

[Appendicular desmoid tumor: unusual case and review of the literature]. / Fibromatosis tipo desmoide de apéndice cecal: reporte de caso inusual y revisión de la literatura.

BACKGROUND: Desmoid type fibromatosis is a benign neoplastic process non-encapsulated locally invasive and aggressive, which arises from a proliferation of bland-looking fibroblasts and myofibroblasts. The most frequent location of fibromatosis is extraabdominal (60%), abdominal wall (25%) and intra-abdominal (8-15%), rarely can originate in the viscera (0.73%), such as the pancreas, gastroesophageal junction, diaphragm and appendix. The annual incidence of desmoid tumor is estimated at 2 to 5 cases per million. In this article, we report a case of unusual presentation, originated in the cecal appendix. CASE: A 41-year-old female patient with acute pelvic pain, admitted to surgical ward with a clinical and ultrasound diagnosis of probably ovarian pedicle tumor. An explorative laparotomy revealed a solid mass of 15 cm in diameter arising from the cecal appendix, with the anatomopathological study corresponding to a desmoid tumor of the cecal appendix. CONCLUSIONS: The desmoid tumor can arise from several extra and intra-abdominal locations, the latter being the rarest and most aggressive. Accurate preoperative diagnosis is very difficult and almost always patients enter to surgery with suspected diagnosis of intraabdominal tumor of unknown etiology. The risk factors associated to its appearance are not yet characterized. The complete surgical resection of the tumor -with free surgical margins (R0)- is the treatment of choice; however, the risk of recurrence is high even with optimal tumor removal.

Alternative management for gynecological cancer care during the COVID-2019 pandemic: A Latin American survey.

OBJECTIVE: To determine the acceptance rate of treatment alternatives for women with either preinvasive conditions or gynecologic cancers during the COVID-19 pandemic among Latin American gynecological cancer specialists. METHODS: Twelve experts in gynecological cancer designed an electronic survey, according to recommendations from international societies, using an online platform. The survey included 22 questions on five topics: consultation care, preinvasive cervical pathology, and cervical, ovarian, and endometrial cancer. The questionnaire was distributed to 1052 specialists in 14 Latin American countries. A descriptive analysis was carried out using statistical software. RESULTS: A total of 610 responses were received, for an overall response rate of 58.0%. Respondents favored offering teleconsultation as triage for post-cancer treatment follow-up (94.6%), neoadjuvant chemotherapy in advanced stage epithelial ovarian cancer (95.6%), and total hysterectomy with bilateral salpingo-oophorectomy and defining adjuvant treatment with histopathological features in early stage endometrial cancer (85.4%). Other questions showed agreement rates of over 64%, except for review of pathology results in person and use of upfront concurrent chemoradiation for early stage cervical cancer (disagreement 56.4% and 58.9%, respectively). CONCLUSION: Latin American specialists accepted some alternative management strategies for gynecological cancer care during the COVID-19 pandemic, which may reflect the region's particularities. The COVID-19 pandemic led Latin American specialists to accept alternative management strategies for gynecological cancer care, especially regarding surgical decisions.

Fibromatosis tipo desmoide de apéndice cecal: reporte de caso inusual y revisión de la literatura / Appendicular desmoid tumor: unusual case and review of the literature

RESUMEN Antecedente : La fibromatosis tipo desmoide es un proceso neoplásico benigno no encapsulado localmente invasivo y agresivo, que se origina de la proliferación de fibroblastos y miofibroblastos aparentemente normales. La localización más frecuente de la fibromatosis es extra-abdominal (60%), pared abdominal (25%) e intra-abdominal (8-15%), en raras ocasiones puede originarse en las vísceras (0,73%), como el páncreas, unión gastroesofágica, diafragma y apéndice. La incidencia anual de tumor desmoide se estima de 2 a 5 casos por millón. En el presente artículo, reportamos un caso de presentación inusual, originado en el apéndice cecal. Caso : Paciente de sexo femenino de 41 años con dolor pélvico agudo, que ingresa a sala de operaciones con diagnóstico clínico y ecográfico de probable tumor de ovario a pedículo torcido. En el intraoperatorio se evidenció una tumoración sólida de 15 cm de diámetro que dependía del apéndice cecal, correspondiendo el estudio anatomopatológico a tumor desmoide de apéndice cecal. Conclusiones : El tumor desmoide puede originarse en diversas localizaciones extra e intra-abdominales, siendo esta última la más rara y agresiva. El diagnóstico preoperatorio exacto es muy difícil y casi siempre los pacientes ingresan al quirófano con sospecha diagnostica de tumoración intraabdominal de etiología desconocida. Los factores de riesgos asociados a su aparición aún no se encuentran caracterizados, siendo la resección quirúrgica completa del tumor -con márgenes quirúrgicos libres (R0)- el tratamiento de elección; sin embargo, el riesgo de recurrencia es alto incluso con la remoción óptima del tumor.

ABSTRACT Background : Desmoid type fibromatosis is a benign neoplastic process non-encapsulated locally invasive and aggressive, which arises from a proliferation of bland-looking fibroblasts and myofibroblasts. The most frequent location of fibromatosis is extra- abdominal (60%), abdominal wall (25%) and intra-abdominal (8-15%), rarely can originate in the viscera (0.73%), such as the pancreas, gastroesophageal junction, diaphragm and appendix. The annual incidence of desmoid tumor is estimated at 2 to 5 cases per million. In this article, we report a case of unusual presentation, originated in the cecal appendix. Case : A 41-year-old female patient with acute pelvic pain, admitted to surgical ward with a clinical and ultrasound diagnosis of probably ovarian pedicle tumor. An explorative laparotomy revealed a solid mass of 15 cm in diameter arising from the cecal appendix, with the anatomopathological study corresponding to a desmoid tumor of the cecal appendix. Conclusions : The desmoid tumor can arise from several extra and intra-abdominal locations, the latter being the rarest and most aggressive. Accurate preoperative diagnosis is very difficult and almost always patients enter to surgery with suspected diagnosis of intraabdominal tumor of unknown etiology. The risk factors associated to its appearance are not yet characterized. The complete surgical resection of the tumor -with free surgical margins (R0)- is the treatment of choice; however, the risk of recurrence is high even with optimal tumor removal.

Compromiso parametrial en pacientes con cáncer de cérvix IB-1 tratadas con histerectomía radical en Perú / Parametrial involvement in cervical cancer IB1 patients treated with radical hysterectomy in Peru

Objetivos. Evaluar la frecuencia y factores asociados al compromiso parametrial (CP) en pacientes con cáncer de cérvix IB-1 sometidas a histerectomía radical (HR) en el Instituto Nacional de Enfermedades Neoplásicas del Perú. Materiales y métodos. Estudio transversal analítico en 214 pacientes con cáncer de cérvix IB-1 sometidas a HR con linfadenectomía pélvica entre el 2007 y 2012. Se comparó la población con y sin CP según variables clinicopatológicas como edad, tamaño tumoral, profundidad de infiltración, grado histológico y afectación ganglionar pélvica. Resultados. Diez pacientes (4,6%) presentaron CP. El análisis multivariable mostró que la profundidad de la invasión (OR 8,37, IC 95%: 1,24-56,41, p=0,029) y el compromiso de ganglios pélvicos (OR 18,03, IC 95%: 3,30-98,44, p=0,001) resultaron ser predictores independientes del CP. La presencia de tamaño tumoral ≤ 2 cm, invasión ≤ 10 mm, ausencia de permeación linfovascular y ausencia de compromiso ganglionar permitió identificar 97 pacientes de bajo riesgo de CP, de los cuales ninguno tuvo CP en patología. Conclusiones. Confirmamos la baja frecuencia del CP en el subgrupo de cáncer de cervix IB-1 y su asociación con la profundidad de la invasión y con el compromiso ganglionar linfático sugeridos en estudios previos. Esta información permitirá identificar un subgrupo de pacientes con bajo riesgo de CP candidatas a una cirugía menos radical en nuestra institución. (AU)

Objectives. To assess the frequency and factors associated with parametrial involvement (PI) in patients with cervical cancer IB1 who underwent radical hysterectomy (RH) at the National Institute of Neoplastic Diseases in Peru. Materials and methods. Cross-sectional study of 214 patients with cervical cancer IB1 undergoing RH with pelvic lymphadenectomy between 2007 and 2012. The population was compared with and without clinicopathological variables associated with PI such as age, tumor size, depth of infiltration, histological grade and pelvic lymph node involvement. Results. Ten patients (4.6%) had PI. Multivariate analysis showed that the depth of invasion (OR 8.37, 95% CI 1.24- 56.41, p=0.029) and pelvic node involvement (OR 18.03; 95% CI 3.30-98.44, p=0.001) were all independent predictors of PI. The presence of tumor size ≤ 2 cm, invasion ≤ 10 mm, absence of lymphovascular permeation and absence of nodal involvement identified 97 patients at low risk of PI, none of whom had PI pathology. Conclusions. We confirmed the low frequency of PI in the cervical cancer IB1 subgroup and its association with the depth of invasion and lymph node involvement suggested in previous studies. This information will allow the identification of a subgroup of patients at low risk of PI for less radical surgery in our institution. (AU)

Tratamiento insulinico en diabetes mellitus tipo 2 / Insulin treatment for type 2 diabetes mellitus

La Diabetes Mellitus, representa la principal enfermedad endocrinológica en nuestro país, en sus estadíos avanzados con lleva a incapacidad debido a complicaciones tardías, como la retinopatía diabética, insuficiencia renal crónica, amputaciones, incrementa el riesgo de eventos cardiovasculares y eventos cerebrovasculares o sufrir complicaciones agudas que comprometan la vida del paciente. Se revisa el manejo ambulatorio de insulina basal en el paciente diabético tipo 2. El manejo apropiado de insulina por el médico contribuirá a alcanzar las metas de glucemia, disminuir las complicaciones crónicas del paciente diabético y evitar el abandono del tratamiento al disminuir el riesgo de hipoglicemia...

Factores pronósticos para pacientes con cáncer de ovario epitelial avanzado tratados con citoreducción óptima en el INEN 1998-2008 / Prognostic factors for patients with epithelial advanced ovarian cancer treated with optimal citoreduccion in INEN 1998-2008

Objetivo: El objetivo de este estudio fue determinar los factores pronóstico de la sobrevida global (SG) y la sobrevida libre de enfermedad (SLE) en las mujeres con cáncer de ovario epitelial (COE) estadio avanzado después de la cirugía citorreductora y quimioterapia de primera línea basada en platino. Material y métodos: Todas las mujeres con cáncer de ovario con estadios clínicos FIGO III y IV que tuvieron cito reducción óptima primaria seguida de seis cursos de quimioterapia basada en platino en el Instituto Nacional de Enfermedades Neoplásicas entre enero de 1998 y diciembre de 2008, fueron identificadas a partir de la base de datos de cáncer de ovario. Se evaluó la sobrevida global, la sobrevida libre de enfermedad y los factores que influyeron en ellas. Resultados: Se estudiaron un total de 56 pacientes. La sobrevida global a 5 años fue de 46,9 %. Se encontraron como factores pronósticos significativos de la sobrevida global al recuento plaquetario (p=0.002) y al dosaje de hemoglobina (p=0.003) preoperatoria. Y como factores pronósticos significativos de sobrevida libre de enfermedad al recuento plaquetario (p=0.002) y la enfermedad residual post operatoria (p=0.002).Conclusiones: El recuento de plaquetas preoperatorio y el volumen de enfermedad residual postoperatoria son factores pronósticos de la sobrevida libre de enfermedad, mientras que la hemoglobina sérica preoperatoria y el recuento plaquetario preoperatorio lo son para la sobrevida global.

Objective: The objective of this study was to determine prognostic factors of overall survival (OS) and disease-free survival (DFS) in women with epithelial ovarian cancer in advanced stage (EOC) after cytoreductive surgery and first-line chemotherapy based on platinum. Material and methods:All women with ovarian cancer FIGO clinical stages III and IV who had optimal primary cytoreduction followed by six courses of platinum-based chemotherapy at the Instituto Nacional de Enfermedades Neoplásicas between January 1998 and December 2008, were identified from the database of ovarian cancer. We assessed overall survival, disease-free survival and factors influencing them. Results: We studied a total of 56 patients. Overall survival at 5 years was 46.9%. Were found as significant prognostic factors of overall survival at platelet count (p = 0.002) and the dosage of hemoglobin (p = 0.003) preoperatively. And as significant prognostic factors for disease-free survival at platelet count (p = 0.002) and postoperative residual disease (p = 0.002).Conclusions: The preoperative platelet count and volume of postoperative residual disease were predictive of disease-free survival, whereas preoperative serum hemoglobin and platelet counts were for overall survival.