Multidisciplinary consensus on cancer management during pregnancy

Cancer during pregnancy is a challenge for multi- and interdisciplinary collaboration due to the diagnostic, prognostic and therapeutic implications, the need for an integrated harmonization of medical action for the pregnant patient and the embryo or foetus and the characteristics of each gestational period, which will determine the protocol to be proposed and its limitations. For this reason, a group of experts appointed by participating scientific societies, which includes the Spanish Society of Medical Oncology (Sociedad Española de Oncología Médica—SEOM), the Spanish Association of Surgeons (Asociación Española de Cirujanos—AEC), the Spanish Society of Gynaecology and Obstetrics (Sociedad Española de Ginecología y Obstetricia—SEGO), the Spanish Society of Nuclear Medicine and Molecular Imaging (Sociedad Española de Medicina Nuclear e Imagen Molecular—SEMNIM), the Spanish Society of Oncological Radiotherapy (Sociedad Española de Oncología Radioterápica—SEOR) and the Spanish Society of Medical Radiology (Sociedad Española de Radiología Médica—SERAM), have worked together to establish consensus recommendations that allow the harmonization of management and ultimately the optimization of the healthcare of pregnant patients with cancer. When cancer is detected in a pregnant woman, the week of gestation in which the diagnosis is made must be considered, as well as the characteristics of the tumour. It is strongly recommended that a multidisciplinary team assesses the situation and guides the patient and her family during the informing, diagnosis and treatment process. Likewise, the foetus should be monitored and managed by specialized obstetricians who are part of a multidisciplinary cancer committee (AU)

Multidisciplinary consensus on cancer management during pregnancy.

Cancer during pregnancy is a challenge for multi- and interdisciplinary collaboration due to the diagnostic, prognostic and therapeutic implications, the need for an integrated harmonization of medical action for the pregnant patient and the embryo or foetus and the characteristics of each gestational period, which will determine the protocol to be proposed and its limitations. For this reason, a group of experts appointed by participating scientific societies, which includes the Spanish Society of Medical Oncology (Sociedad Española de Oncología Médica-SEOM), the Spanish Association of Surgeons (Asociación Española de Cirujanos-AEC), the Spanish Society of Gynaecology and Obstetrics (Sociedad Española de Ginecología y Obstetricia-SEGO), the Spanish Society of Nuclear Medicine and Molecular Imaging (Sociedad Española de Medicina Nuclear e Imagen Molecular-SEMNIM), the Spanish Society of Oncological Radiotherapy (Sociedad Española de Oncología Radioterápica-SEOR) and the Spanish Society of Medical Radiology (Sociedad Española de Radiología Médica-SERAM), have worked together to establish consensus recommendations that allow the harmonization of management and ultimately the optimization of the healthcare of pregnant patients with cancer. When cancer is detected in a pregnant woman, the week of gestation in which the diagnosis is made must be considered, as well as the characteristics of the tumour. It is strongly recommended that a multidisciplinary team assesses the situation and guides the patient and her family during the informing, diagnosis and treatment process. Likewise, the foetus should be monitored and managed by specialized obstetricians who are part of a multidisciplinary cancer committee.

Abdominal blast injuries: different patterns, severity, management, and prognosis according to the main mechanism of injury.

PURPOSE: To review the frequency, different patterns, anatomic severity, management, and prognosis of abdominal injuries in survivors of explosions, according to the main mechanism of injury. METHODS: A MEDLINE search was conducted from January 1982 to August 2013, including the following MeSH terms: blast injuries, abdominal injuries. EMBASE was also searched, with the same entries. Abdominal blast injuries (ABIs) have been defined as injuries resulting not only from the effects of the overpressure on abdominal organs, but also from the multimechanistic effects and projectile fragments resulting from the blast. Special emphasis was placed on the detailed assessment of ABIs in patients admitted to GMUGH (Gregorio Marañón University General Hospital) after the Madrid 2004 terrorist bombings, and in patients admitted to HYMC (Hillel Yaffe Medical Centre) in Hadera (Israel) following several bombing episodes. The anatomic severity of injuries was assessed by the abdominal component of the AIS, and the overall anatomic severity of casualties was assessed by means of the NISS. RESULTS: Abdominal injuries are not common in survivors of terrorist explosions, although they are a frequent finding in those immediately killed. Primary and tertiary blast injuries have predominated in survivors from explosions in enclosed spaces reported outside of Israel. In contrast, secondary blast injuries causing fragmentation wounds were predominant in suicide bombings in open and/or semi-confined spaces, mainly in Israel, and also in military conflicts. Multiple perforations of the ileum seem to be the most common primary blast injury to the bowel, but delayed bowel perforations are rare. Secondary blast injuries carry the highest anatomic severity and mortality rate. Most of the deaths assessed occurred early, with hemorrhagic shock from penetrating fragments as the main contributing factor. The negative laparotomy rate has been very variable, with higher rates reported, in general, from civilian hospitals attending a large number of casualties. CONCLUSIONS: The pattern, severity, management, and prognosis of ABI vary considerably, in accordance with the main mechanism of injury.

[Intussusception in the adult: a rare cause of mechanical obstruction]. / Invaginación intestinal en el adulto. Una causa infrecuente de obstrucción mecánica.

Intussusception is an infrequent cause of mechanical intestinal obstruction in the adult. We present herein two clinical cases of intussusception with different etiologies. In the first case, the underlying cause was a lipoma, and in the second, it was metastasis from melanoma. In both cases the intussusception was identified through computed tomography and treatment was intestinal resection. Pathologic anatomy provided the definitive diagnosis. Etiology is diverse and it is more common for obstruction to be due to organic lesions that are malignant at the level of the colon and benign at the level of the small bowel. Currently there are more preoperative diagnoses thanks to the advances made in imaging study techniques. Intestinal resection continues to be the treatment of choice in the majority of cases, because of the high percentage of malignant lesions as the underlying cause.

Transfusión de sangre. Un tesoro que hay que reservar para las crisis / No disponible

No disponible

Injury patterns from major urban terrorist bombings in trains: the Madrid experience.

BACKGROUND: Terrorist urban mass casualty incidents (MCI) in the last 3 years have targeted commuter trains at rush hour, producing large numbers of casualties. Civilian care providers are usually not familiar with the types of blast injuries sustained by victims of these MCI. METHODS: We focus on the injury patterns sustained by casualties of the Madrid, 11 March 2004, terrorist bombings, at the seven hospitals that received most victims. Data were gathered of casualties who had injuries other than superficial bruises, transient hearing loss from barotrauma without eardrum perforation, and/or emotional shock. The degree of severity in critical patients was assessed with the ISS. RESULTS: The bombings resulted in 177 immediate fatalities, 9 early deaths, and 5 late deaths. Most survivors had noncritical injuries, but 72 (14%) of 512 casualties assessed had an Injury Severity Score (ISS) >15. The critical mortality rate was of 19.5%. The most frequently injured body regions were the head-neck and face. Almost 50% of casualties had ear-drum perforation, and 60% of them were bilateral. There were 43 documented cases of blast lung injury, with a survival rate of 88.3%. Maxillofacial and open long-bone fractures were most prevalent. Gustillo's grade III of severity predominated in tibia-fibular and humeral fractures. Upper thoracic fractures (D1-6 segment) represented 65% of all vertebral fractures and were associated with severe blast to the torso. Severe burns were uncommon. Eye injuries were frequent, although most were of a mild-to-moderate severity. Abdominal visceral lesions were present in 25 (5%) patients. A multidisciplinary approach was necessary in most operated patients, and orthopedic trauma procedures accounted for 50% of the caseload in the first 24 h. CONCLUSIONS: Ninety-three percent of the fatalities of the Madrid trains terrorist bombings were immediate, and most survivors had noncritical injuries. Closed doors increased the immediate fatality rate in the trains. Severely wounded casualties presented specific patterns of injuries, some of them life-threatening and unusual in other types of trauma mechanisms. Ear-lobe amputations and upper thoracic spine fractures were markers of critical injuries.

11 March 2004: The terrorist bomb explosions in Madrid, Spain--an analysis of the logistics, injuries sustained and clinical management of casualties treated at the closest hospital.

At 07:39 on 11 March 2004, 10 terrorist bomb explosions occurred almost simultaneously in four commuter trains in Madrid, Spain, killing 177 people instantly and injuring more than 2000. There were 14 subsequent in-hospital deaths, bringing the ultimate death toll to 191. This report describes the organization of clinical management and patterns of injuries in casualties who were taken to the closest hospital, with an emphasis on the critically ill. A total of 312 patients were taken to the hospital and 91 patients were hospitalized, of whom 89 (28.5%) remained in hospital for longer than 24 hours. Sixty-two patients had only superficial bruises or emotional shock, but the remaining 250 patients had more severe injuries. Data on 243 of these 250 patients form the basis of this report. Tympanic perforation occurred in 41% of 243 victims with moderate-to-severe trauma, chest injuries in 40%, shrapnel wounds in 36%, fractures in 18%, first-degree or second-degree burns in 18%, eye lesions in 18%, head trauma in 12% and abdominal injuries in 5%. Between 08:00 and 17:00, 34 surgical interventions were performed in 32 patients. Twenty-nine casualties (12% of the total, or 32.5% of those hospitalized) were deemed to be in a critical condition, and two of these died within minutes of arrival. The other 27 survived to admission to intensive care units, and three of them died, bringing the critical mortality rate to 17.2% (5/29). The mean Injury Severity Score and Acute Physiology and Chronic Health Evaluation II scores for critically ill patients were 34 and 23, respectively. Among these critically ill patients, soft tissue and musculoskeletal injuries predominated in 85% of cases, ear blast injury was identified in 67% and blast lung injury was present in 63%. Fifty-two per cent suffered head trauma. Over-triage to the closest hospital probably occurred, and the time of the blasts proved to be crucial to the the adequacy of the medical and surgical response. The number of blast lung injuries seen is probably the largest reported by a single institution, and the critical mortality rate was reasonably low.

Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings.

BACKGROUND: At 07:39 am on March 11th, 2004, ten terrorist bomb explosions occurred almost simultaneously in four commuter trains in Madrid, Spain, killing instantly 177 people and injuring >2,000. There were 14 subsequent in-hospital deaths, bringing the definite death toll to 191 victims. This article describes the organization of the clinical management and patterns of injuries in casualties who were taken to the closest hospital, with emphasis on the critical patient population. RESULTS: There were 312 patients taken to that center, and 91 were hospitalized, 89 of them (28.5%) for >24 hrs. Sixty-two patients only had superficial bruises or emotional shock, but the remaining 250 patients had more severe lesions. The data on 243 of the latter form the basis of this report. Tympanic perforation occurred in 41% of 243 victims with moderate-to-severe trauma, chest injuries in 40%, shrapnel wounds in 36%, fractures in 18%, first- or second-degree burns in 18%, eye lesions in 18%, head trauma in 12%, and abdominal injuries in 5%. Between 8:00 am and 5:00 pm, 34 surgical interventions were performed on 32 victims. Twenty-nine casualties (12% of the total or 32.5% of those hospitalized) were deemed in critical condition, and two of them died within minutes of arrival. The other 27 survived to be admitted to intensive care units, and three of them died, bringing the critical mortality rate to 17.2% (5/29). The mean Injury Severity Score and Acute Physiology and Chronic Health Evaluation II scores of critical patients were 34 and 23, respectively. Among these critical patients, soft-tissue and musculoskeletal injuries predominated in 85% of cases, ear blast injury was identified in 67%, and blast lung injury was present in 63% (17 cases). Fifty-two percent suffered head trauma. CONCLUSIONS: There was probably an overtriage to the closest hospital, and the time of the blasts proved crucial for the adequacy of the medical and surgical response. The number of blast lung injuries seen is probably the largest reported by a single institution, and the critical mortality rate was reasonably low.

Adhesive small bowel obstruction: predictive value of oral contrast administration on the need for surgery.

INTRODUCTION: adhesive small bowel obstruction (SBO) is a common cause of hospital admission. Nonoperative management is initially recommended unless there is suspicion of strangulation, but its optimal duration is controversial. The aims of our study was to evaluate the usefulness of radiographic small bowel examination with contrast medium to predict the need for surgery in SBO. MATERIAL AND METHODS: this prospective study carried out from January 1999 to December 2001, included 100 patients with clinical and radiological criteria of adhesive SBO. We described the past medical history, as well as clinical picture, blood tests and radiological findings in these patients. Fifty cubic centimeters of 5% barium suspension were given orally, and plain abdominal radiographs were taken at 4, 8, 16, and 24 hours afterwards. A liquid diet was given as soon as the contrast medium appeared in the right colon. Otherwise, surgical intervention was considered based on the outcome of the patient and the criteria of the emergency surgical team. RESULTS: in 70 patients, barium contrast appeared in the right colon, and a liquid diet was tolerated by 69 of them (98.6%). Mean hospitalization time for this group was 43 +/- 17 hours. In the remaining 30 patients, no evidence of barium contrast in the right colon was seen, and 25 of them underwent surgery (75%), while the other 5 tolerated a liquid diet. Mean hospitalization time for this second group of patients was 13.8 +/- 11 days. Sensitivity, specificity, positive predictive value, and negative predictive value for the absence of contrast medium in the right colon within 24 hours as a predictor of surgery were 93, 96, 98 and 83%, respectively. There was a statistical significant relationship (p < 0.01) between the "Presence of contrast medium in the right colon" and "Oral diet tolerance". Only the variable "Number of previous surgical interventions" tended to reach statistical significance (p = 0.07). Tolerance of liquid diet was more likely when patients had more than one previous abdominal surgery. CONCLUSIONS: early oral administration of a radiological contrast medium in patients with adhesive SBO can effectively predict the need for a surgical procedure. It can shorten not only hospital stay, but also the potential morbidity of late surgery, secondary to a prolonged and unsuccessful nonoperative treatment.

Toracotomía urgente en traumatismos penetrantes y cerrados: incidencia, características demográficas y análisis de resultados en un registro hospitalario de traumatizados graves / Urgent thoracotomy in blunt and penetrating trauma: incidence, demographic characteristics and analysis of results in a hospital registry of severe trauma

Objetivo. En países de nuestro entorno europeo la necesidad de toracotomía urgente por traumatismo es escasa. Nuestro objetivo ha sido analizar la gravedad de los pacientes con traumatismo penetrante (TP) y cerrado (TC) que han necesitado toracotomía urgente, con el fin de valorar si la toracotomía por traumatismo en nuestro medio no conlleva peores resultados, en términos de supervivencia, que el estándar internacional. Métodos. Hemos analizado las características demográficas, indicaciones, tipos, escalas de gravedad (RTS, AIS, ISS y NISS) y TPS (TRISS Probability of Survival), así como las muertes potencialmente evitables y posibles errores de manejo inicial de los pacientes traumatizados que han necesitado una toracotomía dentro de las primeras 48 h. Resultados. Entre agosto de 1993 y agosto de 2002 se ha recogido en nuestro registro de traumatizados graves un abordaje torácico urgente, único o combinado con otras vía de abordaje, en 51 pacientes. En 26 y 25 pacientes la toracotomía fue por TP y TC, respectivamente. En el grupo con TP el tiempo medio de transporte fue de 49 min. Las indicaciones del abordaje torácico fueron: 3 casos por situación in extremis en el Departamento de Urgencias, 11 por shock al ingreso, 10 por lesiones específicas en pacientes que no estaban en shock y 2 por hemorragia persistente a través de un tubo de drenaje. Un 11,5 por ciento necesitaron abordaje toracoabdominal combinado. La lesión más frecuente fue la herida por arma blanca cardíaca AIS V. El RTS, ISS y NISS medios fueron de 8,2, 23 y 30, respectivamente. La mortalidad a 30 días fue de 7 casos (27 por ciento). En función del TPS dos de los fallecidos aparecen como muertes potencialmente evitables. En el grupo con TC el tiempo medio de transporte fue de 63 min. Las indicaciones de la toracotomía fueron: 3 casos por situación in extremis, 3 por shock al ingreso, 14 por lesiones especificas en pacientes que no estaban en shock y 5 por hemorragia torácica persistente. Un 32 por ciento necesitaron un abordaje toracoabdominal combinado. Hubo lesiones cardíacas o de grandes vasos en 11 pacientes (44 por ciento). El RTS, ISS y NISS medios fueron de 8,9, 34 y 41, respectivamente. La mortalidad a los 30 días fue de 12 casos (48 por ciento), y 2 aparecen como muertes potencialmente evitables en función del TPS. Conclusiones. En las toracotomías por TP los "tiempos de transporte" parecen prolongados a la luz de las recomendaciones de la bibliografía. La necesidad de reanimación cardiopulmonar (RCP) avanzada in situ o durante el traslado ha sido un factor de pronóstico fatal en nuestra serie. En el TC una causa muy frecuente de toracotomía urgente ha sido la rotura aórtica y de cavidades cardíacas. La necesidad de laparotomía asociada ha sido frecuente, y conlleva una alta mortalidad. La baja incidencia global de toracotomía urgente por traumatismo en nuestro medio no parece influir negativamente en los resultados de supervivencia, aunque se han detectado errores de evaluación y manejo susceptibles de corrección (AU)

Early resolution of Ogilvie's syndrome with intravenous neostigmine: a simple, effective treatment.

PURPOSE: Our aim was to assess the value of a parasympathomimetic drug (neostigmine) in the early resolution of acute colonic pseudo-obstruction (Ogilvie's syndrome). METHODS: A prospective study was undertaken in 18 consecutive patients (mean age, 76 (range, 31-87) years) with acute colonic pseudo-obstruction. After a varying period of conservative treatment in all cases, 16 patients with persistent, massive abdominal distention were given intravenous neostigmine. RESULTS: A rapid and satisfactory clinical and radiologic decompression of the large bowel was obtained in 12 patients (75 percent) after a single dose of the drug; another patient had complete resolution after a second dose, and the other 3 patients had only partial resolution, in one of them after a second dose of the drug. No patient required surgical decompression of the bowel. CONCLUSION: These results give support to the theory of excessive parasympathetic suppression in most cases of Ogilvie's syndrome. The treatment with intravenous neostigmine has proved very effective, preventing in many cases prolonged periods of uncomfortable and potentially hazardous conventional conservative management and avoiding surgical treatment in a consecutive series of patients.

[Acute obstruction of the colon secondary to biliary lithiasis]. / Obstrucción aguda de colon secundaria a litiasis biliar.

Gallstone ileus is an unusual cause of mechanical obstruction of the gastrointestinal tract; but obstruction of the colon by a gallstone is an even more rare event, and there are few references in the literature. We describe the cases of two elderly women who were admitted to the Emergency Service with a mechanical obstruction of the colon and air in the biliary tract. A barium-enema examination showed the presence of a foreign body in the sigmoid colon; this was found to be a gallstone in a subsequent colonoscopy in one of the patients; a precise preoperative diagnosis was not possible in the other. In both cases the obstruction was caused by a gallstone impacted in the sigmoid colon and a cholecystocolonic fistula was evident in a postoperative barium enema examination. Correction of the obstruction is the main objective of initial treatment. The repair of the fistula can be performed at the same time or at a later date.

Squamous cell carcinoma complicating perianal hidradenitis suppurativa.

Hidradenitis suppurativa or Verneuil's disease is usually a chronic, recurrent, suppurative and cicatricial disorder. It most often affects the skin of the axillae, groins and perineum, and less commonly the buttocks and upper thighs. A squamous cell carcinoma located in the hidradenitis-affected area is a rare complication. We present a review of the twenty-six published cases adding one of our own.