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médico-científico de la asociación médica de puerto rico
Año 2014 - Volumen 106 - Número 3
CONTENIDO
BOLETIN
Médico Científico de la Asociación Médica de Puerto Rico
Año 106 Número 2 - Abril a Junio de 2014
3 Mensaje del Presidente
Dra Wanda G. Vélez Andújar
Original Articles/Articulos Originales
5 CARACTERISTICAS PSICOLOGICAS Y RESILIENTES DE UNA MUESTRA DE MUJERES PUERTORRIQUEÑAS CON CIRUGIA
DE RECONSTRUCCION MAMARIA POR CANCER
Cybell Burgos-Felix PSyD, Jose Rodriguez-Gomez MD, Maribel Matos-Roman PhD
17 SMOKING TOBACCO USE AMONG OPERATING ROOM PERSONNEL
Javier Gonzalez-Castro MD, Jeamarie Pascual MD, Luisam Tarrats MD, Carlos Gonzalez-Aquino MD.
21 COMPLIANCE OF GUIDELINES FOR THE DIAGNOSIS OF MYCROCYTIC ANEMIA AT DAMAS HOSPITAL: A Pilot Study
Diana Rivera MD, Miguel Magraner MD, Rafael Breddy MD.
Case Report/Reporte de Casos
29 ACREMONIUM SPECIES ASSOCIATED FUNGEMIA: Immunosuppressed Patient
Zaydalee Cardona rodriguez MD, Michelle Gonzalez Ramos MD
32 GERMLINE RETINOBLASTOMA WITHOUT INHERITED GENE MUTATION: A Case Report.
Jose A. Quintero Estades MS, Natalio J.Izquierdo MD
36 AN UNCOMMON PRESENTATION OF FOLLICULAR THYROID CARCINOMA: When Chronic Back Pain should raise a Flag
Milliette Alvarado MD, Margarita Ramirez-Vick MD, Liurka Lopez MD, Maria J. Marcos-Martinez MD, Fanor M. Saavedra MD, Juan C. Negron-Rivera
MD, Marielba Agosto MD, Meliza Martinez MD, Rafael Gonzalez MD, Myriam Allende-Vigo MD.
40 MULTIPLE MYELOMA WITH TESTICULAR INVOLVEMENT: A case Report and Review of the Literature
Rodrigo Kraft Rovere, Bruno Wensing Raimann, Lauren Menna Marcondes, Eduardo Teston Bondan, Felipe Gioppo Toledo Nunes, Giuliano dos Santos
Borges.
42 INSTRUCCIONES PARA AUTORES
43 GLIOSARCOMA PEDIATRICO: Reporte de un Caso y Revision de la Literatura
Luis Rafael Moscote-Salazar, Gabriel Alcala-Cerra, Juan Jose Gutierrez-Paternina, Pedro Jose Penagos Gonzalez, Camilo Zubieta Vera, George Chater-Cure,
Carlos Alberto Meneses, Miguel Saenz.
Review Articles/Artículos de Reseña
48 THYROID CANCER IN CHILDREN
Gabriel Rivera MS, Humberto Lugo-Vicente MD
55 USE AND MEDICALIZATION OF MARIHUANA IN CANCER PATIENS
Elsa Pedro Pharm D, Frances M. Rodriguez Pharm. D
60 THE “STEMI CODE”- INTERVENTIONS TO REDUCE TIME TO REPERFUSION THERAPY: A Novel Apporach and Review
of the Literature.
Gerald Marin Garcia MS, Fernando L. Soto Torres MD.
63 LA ENSEÑANZA DE LOS ASPECTOS LEGALES DE LA PRACTICA MEDICA A LOS ESTUDIANTES DE MEDICINA EN PUERTO
RICO
Luis j. Lugo Velez MD
Catalogado en Cumulative Index e Index Medicus Listed
in Cumulative Index
and Index Medicus
No. ISSN-0004-4849.
Registrado en Latindex -Sistema Regional de Información en
Línea para Revistas
Científicas de América
Latina, el Caribe, España y Portugal
OFICINAS ADMINISTRATIVAS:
Asociación Médica de Puerto Rico
PO Box 9387 • SANTURCE, Puerto Rico 00908-9387
Tel 787-721-6969 • Fax: 787- 724-5208 - Email: [email protected]
ANUNCIOS EN BOLETIN, WEBSITEy NEWSLETTER:
Tel.: (787) 721-6939 Ext. Informártica - [email protected] - Web
Site: www.asocmedpr.org
Pintura de la portada:
La Autopsia, Enrique Simonet, 1890
Ilustración digital de cubierta y diseño gráfico realizados por Juan Laborde-Crocela en la Oficina de Informática de la AMPR. Impreso en los talleres
gráficos digitales de la Asociación Médica de Puerto Rico - E-mail:[email protected]
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 1
Mensaje del Presidente
Asociacion Medica de Puerto Rico
Junta de Directores 2013/2014
Y
Dra. Wanda G. Vélez Andújar
Ya empezó el otoño! Se terminaron las vacaciones...
Nuestras escuelas de medicina tienen sus estudiantes
encaminados en alcanzar la meta de obtener el título de
médico. Los hospitales siguen adiestrando a los recién
graduados en los programas de internados y se continúa
educando a los residentes.
Dra. Wanda G. Velez Andujar
Presidente
Dr. Eliud López Vélez
Dr. Ricardo Marrero Santiago
Vicepres. Cámara Delegados
Presidente electo
Dr. Natalio Izquierdo Encarnación
Presidente saliente
Dr. José R. Villamil Rodríguez
Tesorero
Dr. Gonzalo González Liboy
Delegado AMA
Dr. Rolance G. Chavier Roper
Delegado AMA
Dr. Luis A. Román Irizarry
Dra. Ilsa Figueroa
Delegado Alt. AMA
Secretaria
Dra. Hilda Ocasio Maldonado
Vicepresidente AMPR
En la Asociación Médica de Puerto Rico nos complacemos en participar de esos logros a través de brindarles la
oportunidad de “publicar” sus trabajos científicos. La meta
para divulgar los hallazgos de las investigaciones no es otra
que publicarlos. Este es quizás el último eslabón en la cadena de ese continuo esfuerzo de observación y estudio del
tema en consideración. La investigación es un trabajo añadido al manejo de los pacientes. Por el esmero y cuidado que
se les tiene que brindar, el trabajo de investigación pudiera
tornarse muy arduo, quizás llegar a convertirse en “abrumador”. No obstante, cuando se logra ver el trabajo publicado,
la satisfacción es tal que se olvida lo áspero que pudo haber
sido el camino.
Dr. Rafael Fernández Feliberti
De esta satisfacción es que la Asociación Médica de Puerto
rico participa y nos sentimos más que orgullosos y complacidos de la calidad del trabajo que publicamos.
Dr. Salvador Torrós Romeu
Así que, felicitamos a todos los autores de los trabajos de
investigación médica. Les auguro mucho éxito siempre.
Dr. Raúl A. Yordán
Delegado Alterno AMA
Pres. Distrito Este
Vicepresidente AMPR
Dr. Jaime M. Díaz Hernandez
Vicepresidente AMPR
Dra. Mildred R. Arché
Pres. Distrito Central
Dr. Rubén Rivera Carrión
Dr. Benigno López López
Pres. Distrito Sur
Pres. Cámara Delegados
Dr. Humberto Lugo Vicente
Presidente de la Junta Editora del Boletin
2 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 3
CARACTERÍSTICAS
PSICOLÓGICAS Y
RESILIENTES DE UNA
MUESTRA DE MUJERES
PUERTORRIQUEÑAS
CON CIRUGÍA DE
RECONSTRUCCIÓN
MAMARIA POR
CÁNCER
Cybell Burgos-Félix PsyDa*, José Rodríguez-Gómez MDa , Maribel Matos-Román
PhDa
a
Programa Doctoral en Psicología Clínica, Universidad Carlos Albizu,
Recinto de San Juan Puerto Rico.
*Autor principal: Cybell Burgos-Félix Psy.D - HC 03 BOX 6513-3
Humacao, PR 00791. E-mail: [email protected]
E
RESUMEN
El propósito de este estudio pionero fue
describir las características sociodemográficas, psicopatológicas y resilientes de una
muestra de mujeres puertorriqueñas que se
habían sometido a una cirugía de reconstrucción mamaria por cáncer. Esta investigación
se realizó con el fin de proporcionar información y aumentar el conocimiento sobre la
reconstrucción de mama por cáncer la cual
podría ser utilizada por los programas públicos y privados de apoyo psicológico para
pacientes con de cáncer de mama en Puerto Rico. Participaron en el estudio diez mujeres puertorriqueñas, mayores de veintiún
años. Se le administró una planilla de datos
sociodemográficos, la lista de cotejo de síntomas-36, la escala de factores internos de
resiliencia y una entrevista semi-estructurada (acercamiento cualitativo). Se identificó
en la muestra investigada características
psicopatológicas, como por ejemplo, somatización y depresión; y características resilientes como: alto nivel de espiritualidad, autonomía, introspección y satisfacción.
Palabras Claves: sicología, cáncer, mama,
reconstrucción, mujer, Puerto Rico
INTRODUCCION
El cáncer es una de las principales causas de muerte en
todo el mundo (1). El cáncer de mama es la condición maligna de mayor frecuencia y la principal causa de muerte
por cáncer en las mujeres a nivel mundial (2). El cáncer
es uno de los principales problemas de salud pública en
Puerto Rico y causas de muerte, tanto en hombres como
en mujeres (3). El cáncer es la segunda causa de muerte en
Puerto Rico y provoca alrededor 5,000 muertes cada año.
En el año 2010, cerca de 13,000 puertorriqueños desarrollaron algún tipo de cáncer. Para el periodo 2005-2010
fueron diagnosticadas 34,775 mujeres con algún tipo de
cáncer, siendo el cáncer de mama el más diagnosticado con
un 30.2% (4). Esta información es una alerta, para que los
profesionales de la salud se interesen en su investigación
y, a través de los hallazgos puedan aportar para mejorar la
calidad de vida de estas pacientes.
El Cáncer de Mama
Los tumores en la mama pueden ser benignos (no cancerosos) o malignos (cancerosos) (5). La detección del cáncer
de mama en forma simple, consiste en examinar las mamas
de la mujer para identificar la posible presencia de bultos
o tumores fácil de reconocer al tacto, algo que la misma
mujer puede realizar. Sin embargo, en forma mas especifica existen dos tipos principales de pruebas para detectar
el cáncer de mama; el examen clínico de mama (realizado
por el medico o profesional de la salud) y la radioimágenes
i.e., mamografía o sonomamografía (6). Una vez identificado el cáncer de mama, usualmente se realizan pruebas de identificación cito-patológicas para saber el tipo de
células cancerosas y si están se han diseminado dentro de
la mama o metastizado a otras partes del cuerpo. A este
proceso se le llama clasificación por estadios, forma de
categorización necesaria para una adecuada prognosis del
paciente (7).
Actualmente, las mujeres con cáncer de mama cuentan con
muchas opciones de tratamiento. Algunos tipos de tratamiento son: cirugías (i. e., mastectomía y reconstrucción
de mama), radioterapia, terapia hormonal, quimioterapia e
inmunoterapia o sus combinaciones, entre otros, no convencionales o experimentales. Es usualmente el médico
quien debe describirle a la paciente las opciones de tratamiento, los resultados que se esperan y los posibles efectos secundarios. En cualquier estadio de la enfermedad, la
paciente debería contar con cuidados médicos de apoyo
disponible e integrado para controlar el dolor, físicos y
psicológicos, y cualquier otro síntoma que surja, para
aliviar los efectos secundarios del tratamiento y calmar
las posibles preocupaciones emocionales y sociales que
pudiesen afectar su calidad de vida y recuperación (5). La
paciente con cáncer de mama debe ser también atendida por especialistas de la salud mental (i.e., psiquiatra,
psicólogos, enfermeras psiquiátricas) (8).
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Reconstrucción Mamaria
La reconstrucción mamaria es una modalidad quirúrgica para aquellas mujeres a que han experimentado una
mastectomía. Algunas mujeres a las cuales se les sugieren
hacerse una mastectomía deciden reconstruirse la mama,
otras mujeres prefieren usar una prótesis dentro del sostén
y otras deciden no hacer nada con relación a su apariencia después de la cirugía. La reconstrucción de la mama
puede ser inmediata (durante la mastectomía) o diferida
(posterior a la mastectomía) (9). Existen diferentes tipos
de cirugías de reconstrucción de mama como la técnica
de expansión cutánea y la técnica que emplea tejidos. La
técnica de expansión cutánea consiste en expandir la piel
y posteriormente, colocar una prótesis. La técnica que emplean tejidos (técnicas denominadas autólogas o colgajos)
propios para crear una mama y consiste en la movilización
o el trasplante de tejidos de otras zonas del cuerpo como
los son el abdomen y la espalda (10).
sicológico y siquiátrico en las mujeres que han enfrentado
un diagnóstico de cáncer de mama (13, 14). Los hallazgos
son variados, debido a que hay estudios que identifican
que este funcionamiento se ve afectado en formas diametralmente opuestas.
Estudios que identifican efectos adversos en las mujeres
con cáncer de mama, demuestran características como; incremento en las áreas de estrés, neuroticismo y resignación
y aumento en los niveles de nerviosismo (13,15). En otros
estudios se aumentaron los niveles de ansiedad y de depresión (15, 16, 17). De igual forma, también se reportan
verse afectada la imagen corporal (i.e. se sienten menos
atractivas y femeninas), al igual que reportan problemas
en su funcionamiento sexual (i.e. disminución de actividad
sexual) (15, 17). No obstante, en otro estudio identificaron
efectos positivos como el grado de espiritualidad/religiosidad, la cual se asoció significativamente con el bienestar
en la calidad de vida y el manejo efectivo del estrés de las
Si la mujer está pensando en la reconstrucción de mama, mujeres sobrevivientes de cáncer de mama (14).
deberá consultar a un cirujano plástico antes de la mastectomía, aun cuando la reconstrucción se haga después De igual forma, se reconoce que la calidad de vida increde la mastectomía. El cirujano plástico puede explicar los menta, si cuentan con el apoyo social (13, 14). Sin embarriesgos y beneficios de cada tipo de reconstrucción (5). go, el funcionamiento sexual se ve afectado, usualmente,
La reconstrucción de mama va más allá de una cirugía. en las sobrevivientes de cáncer de mama (18). En otro esLos pasos adicionales pueden incluir agregarle un pezón, tudio los resultados revelaron un estilo de afrontamientos
modificar la forma o el tamaño de la mama reconstruida y más positivo como el de espíritu de lucha, pero también
operar la otra mama para que ambas se noten iguales (11). elevaron las medidas de control de emociones y tipos de
El conocer todas las opciones puede ayudarle a la mujer a afrontamiento negativos tales como indefensión, preocuprepararse para su cirugía con una perspectiva más realista pación ansiosa, fatalismo y negación (19).
y adaptativa para el futuro (9).
Es importante que una mujer con diagnóstico de cáncer
Vulnerabilidad Psicológica y Resiliencia sea atendida por profesionales de salud mental ya que esto
del Paciente con Cáncer
mejora su adaptabilidad y calidad de vida, lo cual influirá
Algunas personas con cáncer pueden ser vulnerables psi- en su sobrevivencia (20). Los resultados de algunas invescológicamente y otras pueden ser resilientes. El sujeto vul- tigaciones sugieren que el cáncer de mama acarrea unas
nerable repite el recuerdo traumático en forma consistente complejidades físicas que impacta el referente psíquico, ya
ya sea en forma de “flashback” o pensamientos intrusivos. que, no es solo reconstruir un cuerpo, hay que reconstruir
Cuando una persona con cáncer es vulnerable puede de- la manera en que psicológicamente cada una de estas muberse a varios detonantes, tales como: el diagnóstico, el jeres asumen su cuerpo frente a un diagnóstico de cáncer
tratamiento (i.e., quimioterapia, cirugías) y los pensamien- (21).
tos intrusivos (i.e., culpabilidad) entre otros negativos.
Algunas de las características que reflejan estos pacientes El Funcionamiento Psicológico de las Muson: pesimismo, incredulidad, incertidumbre y abatimien- jeres que han Enfrentado la Experiencia
to. Estos pacientes ven amenazada sus vidas, y su futuro, de la Reconstrucción Mamaria: Aspectos a
por lo que es recomendable que los mismos reciban trata- considerar
miento sicológico y siquiátrico. El sujeto con resiliencia no Las numerosas secuelas sicológicas y siquiátricas padecialmacena el trauma, evita los pensamientos traumáticos y das por las pacientes con cáncer de mama tras la mastecse refocaliza. La resiliencia es la capacidad del ser humano tomía condujeron a algunas a considerar la reconstrucción
para hacer frente a la adversidad de la vida, adaptarse, re- mamaria, para de esta manera, poder restaurar el bienestar
cuperarse, superarla e inclusive ser transformado por ella psicológico y la imagen corporal de las pacientes, algo
y resultar fortalecido. Los individuos resilientes presentan que señala la literatura es importante (22). Hay estudios
las siguientes características: optimismo, espiritualidad, se donde se evaluó a mujeres que se había realizado la refortalecen a sí mismo y están agradecidos de estar vivos construcción mamaria encontrándose que la muestra tuvo
(12).
alteraciones en el estado de ánimo (23). En otro estudio,
los hallazgos identificados fueron, insatisfacción con la
El Funcionamiento Psicológico de las imagen corporal, necesidad de aprobación social, baja auMujeres que han Enfrentado la Experi- toestima, dificultades sexuales, miedo al rechazo y al abanencia del Cáncer de Mama: Aspectos a dono (21).
considerar
Se han realizado varias investigaciones en diversos países Otras investigaciones muestran un impacto resiliente
que han contribuido a comprender el posible impacto como, satisfacción con su imagen corporal (24, 25),
6 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
mejorar la calidad de vida (26, 27), recuperación del aspecto
emocional, aparte de, aumentar la autoestima y permitir el
afloramiento de emociones positivas que ayudan al restablecimiento de su salud física y emocional (25) y emplear
estrategias de afrontamiento más eficaces (27). De igual
forma se identificó características adversas y resiliente,
con algunas mujeres que se sometieron a reconstrucción
inmediata las cuales presentaron alteraciones del humor y
menos bienestar. Por el contrario, aquellas mujeres que se
sometieron a la cirugía de reconstrucción diferida (tardía),
experimentaron la misma en un contexto psicológico diferente, esto es, experimentaron mejor adaptación ya que
pudieron hacer “duelo” por su mama (28).
Resiliencia y el Cáncer
La resiliencia es un término que proviene del latín (resilio/
rebotar), que significa “volver”(12). Se define como la capacidad que tiene el ser humano para enfrentar, manejar y
superar adecuadamente cualquier situación difícil e incorporar nuevas ideas (29). La psicología tradicional enfoca
la mayoría de sus investigaciones hacia la sicopatología,
como por ejemplo, la depresión y la ansiedad de las personas, y no a las fortalezas que tiene para sobreponerse y
habituarse a una nueva condición de vida. Esta carencia de
información ha despertado el interés de estudiar las áreas
positivas; la sicología positiva no busca relevar las teorías
basadas en las debilidades, al contrario busca descubrir
las fortalezas del individuo para trabajar sus debilidades
(30). El ascendente número de personas que sobreviven
a una enfermedad oncológica plantea nuevas necesidades
de tratamiento para atender sus necesidades emocionales y
mejorar su calidad de vida. Experimentar una enfermedad
peligrosa, como lo es el cáncer, tiene el efecto de una experiencia de crecimiento personal y fortalece la expectativa ante la vida siempre y cuando las personas tengan una
visión positiva y adaptativa (31). Los comportamientos
resilientes inciden directamente en la disminución de la
mortalidad de los pacientes enfermos de cáncer. Por ende,
la resiliencia le permite al paciente oncológico ajustarse
constructivamente a su nueva realidad (32).
Establecimiento del Problema y Justificación de la Investigación
Esta investigación se realizó debido a que en la búsqueda
de información se encontró una alta incidencia de casos
nuevos reportados y mortalidad de cáncer de mama en
mujeres puertorriqueñas, acompañado de escasa investigación en los aspectos psicológicos debido a una reconstrucción mamaria por cáncer, incluyendo, la escasez de
programas para atender a estas pacientes en Puerto Rico
(3, 4, 21). También se identificó en la literatura que existen
resultados variados sobre el impacto psicológico a nivel de
cáncer de mama y la reconstrucción de mamaria por cáncer. Una gran parte de los pacientes que sobreviven al cáncer muestran elementos positivos, como crecimiento, desarrollo personal y bienestar, en cambio otros pueden mostrar
elementos negativos tales como malestar emocional. Los
elementos positivos y negativos pueden convivir después
de la experiencia de la enfermedad (33). Los profesionales
de la salud que se especializan en el área de cáncer están de acuerdo en que los aspectos psicológicos no se deben ignorar. Por el contrario atender, apoyar y fortalecer
aspectos emocionales podría resultar en un incremento significativo en la calidad de vida de estos pacientes
(34). Todo lo antes expuesto son motivos suficientes para
realizar una investigación que incluirá las áreas sociodemográficas, los factores psicopatológicos y resilientes de
mujeres que fueron diagnosticadas con cáncer de mama y
optaron por la cirugía de reconstrucción mamaria.
Objetivo de la Investigación
Describir las características sociodemográficas, psicopatológicas y resilientes de una muestra de mujeres puertorriqueñas que fueron diagnosticadas con cáncer de mama y
optaron por la cirugía de reconstrucción mamaria; en los
periodos antes, durante y después de la cirugía.
METODO
Diseño de Investigación
En esta investigación se utilizó concurrentemente el método cuantitativo y cualitativo (metodología mixta) para
responder a al objetivo de la investigación con un diseño
expos facto. Primeramente se obtuvo los datos sociodemográfico a través de una planilla. Después, se obtuvo
concurrentemente los datos cuantitativos a través de pruebas autoadministrables: la Lista de Cotejo de Síntomas 36
(LCS-36) y la Escala de Factores Internos de Resiliencia
(EFIR). Los datos cualitativos se consiguieron a través de
una entrevista semiestructurada.
Participantes
La muestra de las participantes en la investigación, estuvo compuesta de 10 mujeres puertorriqueñas voluntarias,
de 21 años o más. Estas mujeres le habían realizado una
cirugía de reconstrucción de mama entre un año o más.
Selección de la muestra.
La muestra del estudio fue una por disponibilidad. La misma fue obtenida a través de diferentes métodos: como por
ejemplo a través del Centro de Prevención y Apoyo Contra
el Cáncer, hojas de promoción, acercamiento personal, por
vía telefónica, o por vía técnica de “bola de nieve” (35).
Instrumentos
Para recopilar la información necesaria se utilizaron los
siguientes documentos:
Cernimiento para la selección de participantes según los
criterios de inclusión y exclusión del estudio. El cernimiento fue pre-requisito para la participación en el estudio. El
cual consistió de siete preguntas, las cuales evaluaron si la
participante cumplía con los criterios.
Hoja de consentimiento informado.
Se utilizó como pre-requisito para la participación en el
estudio. A través de la misma se orientó a la participante
sobre el propósito de la investigación y sobre lo que conlleva su participación. La misma cumplió con lo establecido por la Asociación Americana de Psicología en cuanto a
las investigaciones realizadas con seres humanos.
Planilla de información sociodemográfica.
Consistió de 33 preguntas, las cuales se utilizaron para
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recolectar información, como edad, nivel de escolaridad, Procedimientos Generales
información sobre el cáncer de mama, la cirugía de recon- La investigación consistió de dos fases. En la primera fase,
una vez identificadas a las posibles participantes se le construcción de mama, entre otros temas.
tactaba por teléfono o vía personal para invitarlas a parPreguntas guías para la entrevista ticipar del estudio. Se les informó sobre los objetivos y el
procedimiento de participación. Aquellas que accedieron
semi-estructurada.
Consistió de 22 preguntas, las cuales se utilizaron para a participar, se les administró el Cernimiento para la seexplorar información sobre las características psicopa- lección de Participantes según los Criterios de Inclusión
tológicas y resilientes de las participantes antes, durante del estudio. Si la participante cumplió con los criterios de
y después de la cirugía de reconstrucción de mama por inclusión se citó en un lugar donde cumpliera con la privacidad y confidencialidad. En la segunda fase, se les encáncer.
tregó los documentos de participación, se les explicó los
procedimientos y el propósito del estudio. Se completó el
Lista de cotejo de síntomas 36 (LCS-36).
La LCS-36, versión en español, validada para Puerto Rico, consentimiento informado, la planilla de datos sociodecon un alfa de Cronbach de 0.978, lo que implica que la mográficos, se les solicitó que completaran los instrumenprueba goza de consistencia interna (29). Es un cuestion- tos autoadministrables como la SCL-36 y la EFIR y se le
ario de auto informe breve que consiste de 36 reactivos realizó una entrevista semi-estructurada.
(36). La misma pretendió servir como instrumento para
el cernimiento de la sicopatología severa en adultos. La Análisis Estadísticos
LCS-36 tiene seis sub-escalas: depresión, somatización, Se llevaron a cabo análisis estadísticos descriptivos y prueansiedad fóbica, impedimento funcional, hostilidad/sospe- bas-t de ‘Student’.
cha y sicotismo. Cada reactivo del instrumento se contesta
utilizando una escala Likert que fluctuó de 1 (no en lo ab- RESULTADOS
soluto) a 5 (extremadamente) y evaluó el malestar experiLos resultados obtenidos se presentaron en cuatro secmentado con cada síntoma.
ciones. La primera sección incluye los resultados descripEscala de factores internos de resiliencia. tivos de la planilla de información sociodemográfica. En la
La escala es un auto informe que consta de 34 reactivos segunda sección se presentó los hallazgos de la entrevista
en una escala de gradación de frecuencia del 0 al 4 que va semi-estructurada, la cual identificó las características sidesde Nunca (0) hasta Siempre (4). La misma esta valida- copatológicas y resilientes de las participantes que optaron
da para Puerto Rico, con un alfa de Cronbach de 0.90, el por la cirugía de reconstrucción mamaria por cáncer. La
cual es adecuado para el constructo que mide y pretendió entrevista semi-estructurada se dividió en tres partes: proservir como instrumento para la evaluación de los factores ceso previo a la cirugía de reconstrucción mamaria, postresilientes de la muestra del estudio. La escala identifica cirugía y al momento de la entrevista. En la tercera y cuarta
siete factores de resiliencia agrupados en tres componen- sección se presentaron los resultados descriptivos y pruetes. El componente de espiritualidad fue relacionado con ba-T ‘student’ de la Lista de Cotejo de Síntomas 36 (LCSun solo factor el cual se denominó como espiritualidad. 36) y la Escala de Factores Internos de Resiliencia (EFIR).
El componente de destrezas conductuales y emocionales
está relacionado con los factores de satisfacción, manejo Análisis Descriptivos de las Variables Sode problemas, estabilidad emocional y optimismo. El com- ciodemográficas
ponente de competencias cognitivas está relacionado con Participaron en el estudio 10 mujeres adultas puertorriqueños/as con 21 años o más, con una edad promedio de
los factores de autonomía e introspección (29).
8 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
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57.10 (DE = 8.293). Se realizó un análisis de frecuencia
con el objetivo de evaluar la distribución de las participantes en las variables sociodemográficas del estudio. Los
resultados obtenidos de este análisis se presentan en las
Tablas 1, 2, 3 y 4.
Análisis de la Entrevista Semi-estructurada
La entrevista semi-estructurada con las participantes del
estudio se dividió en tres categorías principales: proceso
previo a la cirugía de reconstrucción mamaria, proceso
post-cirugía y la situación momento de la entrevista. Las
preguntas fueron dirigidas a identificar las razones para realizarse la cirugía y las características psicopatológicas y
resilientes experimentadas en los diferentes procesos. Se
registró las contestaciones ofrecida por las participantes y
se abundaba en el tema según las respuestas ofrecidas. Las
repuestas que se expondrán a continuación fueron las más
mencionadas por las participantes del estudio. Para presentar estos resultados se realizó un análisis de medida de
tendencia central (i. e., distribución de frecuencia).
Tabla 1: Distribución de Frecuencias y Porcentajes de la
Situación y evaluación previa a la cirugía Información Sociodemográfica de Información Personal de
de reconstrucción de mama.
las Participantes del Estudio
La primera pregunta de esta categoría fue la siguiente:
¿qué razón(es) le llevaron a tomar la decisión de realizar la
cirugía de reconstrucción de mama? Algunas de las participantes expusieron más de una razón al momento de tomar
la decisión de la cirugía. La información antes mencionada
se presentó en la Tabla 5.
La segunda pregunta de esta categoría fue ¿qué síntoma(s)
emocional(es) y físico(s) experimentó previo a realizarse
la cirugía de reconstrucción de mama? A través de esta
pregunta se pretendía identificar características psicopatológicas (ver Tabla 6) y resilientes (ver Tabla 7) que experimentaron las participantes durante el proceso previo a
la cirugía de reconstrucción de mama.
Situación y evaluación después de la
cirugía de reconstrucción de mama.
La primera pregunta de esta categoría fue ¿qué síntoma(s)
emocional(es) y físico(s) experimentó después de realizarse la cirugía de reconstrucción de mama? A través
de esta pregunta se pretendía identificar características sicopatológicas (ver Tabla 8) y resilientes (ver Tabla 9) que
experimentaron las participantes durante el proceso postcirugía de reconstrucción de mama.
Situación y evaluación al momento de la
entrevista con relación a la cirugía de reconstrucción de mama.
La primera pregunta en esta categoría fue ¿qué síntoma(s)
emocional(es) y físico(s) está experimentando actualmente
en relación a la cirugía de reconstrucción de mama? A
través de esta pregunta se pretendió identificar las características psicopatológicas (ver Tabla 10) y luego las características resilientes (ver Tabla 11) que estaban experimentando al momento de la entrevista con relación a la
reconstrucción de mama.
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 9
Viene de Pag. 9
Tabla 6: Características Emocionales y Físicos que las
Afectaron Previo a la Cirugía de Reconstrucción Mamaria
Tabla 2: Distribución de Frecuencia y Porcentajes de la
Información Sociodemográfica Relacionada al Cáncer de
Mama y la Cirugía de Reconstrucción Mamaria
Tabla 7: Características Emocionales y Físicos que las
Ayudaron en el Proceso Previo la Cirugía de Reconstrucción Mamaria
Tabla 8: Características Emocional(es) y Físico(s) que las
Afectaron Después de Realizarse la Cirugía de Reconstrucción de Mama
Tabla 3: Distribución de Frecuencia y Porcentajes de la
Información Sociodemográfica Relacionada a Cubierta de
Salud y Estresores Económicos de las Participantes
Tabla 9: Características Emocional(es) y Físico(s) que las
Ayudaron Después de Realizarse la Cirugía de Reconstrucción de Mama
Tabla 4: Distribución de Frecuencia y Porcentajes de la Información Sociodemográfica Relacionados a Salud Mental
Tabla 10: Características Emocional(es) y Físico(s) que las
Tabla 5: Razón(es) para Realizarse la Reconstrucción Afectaron al Momento de la Entrevista en Relación a la
Mamaria
Cirugía de Reconstrucción de Mama
10 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
Se realizó un análisis inferenciales como por ejemplo prueba
t de muestras independientes para la LCS-36 y la EFIR, en
relación a las participantes que sí culminaron la cirugía de
reconstrucción mamaria y las participantes que no han culminado las cirugías de reconstrucción mamaria. En la puntuación total de la SCL-36 y en cada uno de los componentes
principales de la EFIR no se identificó diferencia estadísticamente significativa. Se realizaron otras pruebas t de muestras independientes en relación a los años que han pasado
de la cirugía de reconstrucción mamaria para la LCS-36 y
la EFIR. Los años de la cirugía se dividieron de la siguiente
manera de uno a 5 años, de seis a 10 años y de once años o
más. En la puntuación total de la SCL-36 y en cada uno de
Tabla 11: Características que Experimentaron y las los componentes principales de la EFIR no se identificó difAyudaron al Momento de la Entrevista en Relación a la erencia estadísticamente significativa.
Cirugía de Reconstrucción de Mama
DISCUSION
A continuación se discutirá los hallazgos más significativos
de las características sociodemográficas de la muestra investigada.
Participaron en el estudio 10 mujeres adultas puertorriqueños/as con una edad promedio de 57.10 (DE = 8.293).
El hecho de ser mujer es el factor de riesgo principal del cáncer de mama (37) aunque sabemos que no podemos excluir a
los hombres. La mujer tiene 100 veces más probabilidad de
padecer de cáncer de mama que el hombre (38). Según la
literatura citada los antecedentes familiares es un factor de
riesgo, alrededor del 20% al 30% de las mujeres con cáncer
Tabla 12: Clasificaciones para las Sub-Escalas y la Puntu- de mama tienen antecedentes familiares de la enfermedad
ación Total de la Lista de Cotejo de Síntomas 36
(37, 38). Sin embargo, el 80.0% (n = 8) de la muestra de este
estudio tiene historial de cáncer en la familia y el tipo de
cáncer familiar con mayor porcentaje fue el cáncer de mama
con un 40.0% (n = 4). El 90% (n = 9) de las participantes
fueron diagnosticadas con cáncer de mama entre las edades
de 39 a 48 años de edad. Este hallazgo de la investigación es
importante ya que según la Sociedad Americana del Cáncer
y la Biblioteca Nacional de Medicina de E.E.U.U., la mayoría de los casos de cáncer de mama avanzado se encuentra
en mujeres de más de 50 años (37, 38). El 100.0% (n = 10)
de las participante indicaron que en el equipo médico que
le brindó servicios no había un psicólogo(a). El 50% (n=5)
reportó buscar ayuda psicológica o psiquiátrica. Los profesionales de la salud que se especializan en el área de cáncer
Tabla 13: Clasificaciones para los Componentes y Factores están de acuerdo en que los aspectos sicológicos no se deben
de la Escala de Factores Interno de Resiliencia
ignorar. Por el contrario atender, apoyar y fortalecer aspectos
emocionales podría resultar en un incremento significativo
en la calidad de vida de estos pacientes (34)
Análisis Estadísticos de la Lista de Cotejo de Síntomas 36 (SCL-36) y la Escala de Algunas personas con enfermedades oncológicas pueden exFactores Internos de Resiliencia (EFIR)
perimentar características sicopatológicas y resilientes (12).
Se realizó un análisis de distribución de frecuencia para En nuestra muestra las participantes estudiadas presentaron
identificar la clasificación de cada sub-escala de la LCS-36 características psicopatológicas y resilientes en los procey la EFIR. También se realizó análisis prueba t de muestras so antes, durante y después de la cirugía de reconstrucción
independientes para la LCS-36 y la EFIR, en relación a la mamaria por cáncer.
participante que sí culminaron la cirugía de reconstrucción
mamaria y las participantes que no culminaron las cirugías Discusión de la entrevista semi-estructurada en el proceso
de reconstrucción mamaria. Otra prueba t de muestras in- previo a la cirugía de reconstrucción de mama por cáncer.
dependientes en relación a los años que han pasado de la Los resultados reflejaron que las participantes presentaron
cirugía de reconstrucción de mama. Los resultados obteni- más características sicopatológicas que resilientes previo a
dos de estos análisis se presentan en las Tabla 12 y 13.
la cirugía de reconstrucción mamaria por cáncer.
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 11
Es im portante señalar que las participantes comunicaron
que algunos factores que provocaron el aumento de las características psicopatológicas fueron, los efectos secundarios a los tratamientos como por ejemplo la quimioterapia,
la radioterapia, la mastectomía y las cicatrices debido a la
cirugía. También mencionaron el tener pensamientos negativos y recurrentes de que iban a morir, depender de otros
para realizar sus tareas cotidianas, miedo a ser rechazada o
abandonadas (i.e., esposos), le cuestionaron a Dios porqué
le ocurrió la enfermedad de cáncer de mama, el diagnóstico
y segunda recurrencia de cáncer.
Discusión de la entrevista semiestructurada en el proceso post-cirugía de reconstrucción mamaria.
Los hallazgos evidenciaron que aunque existían características sicopatológicas hubo un aumento de las características
resilientes. Los factores que mencionaron las participantes
que las ayudaron en el proceso fueron: fe en Dios, deseo de
seguir luchando, entender y aceptar su condición de salud,
el sentir menor dolor y el aumento de las prácticas religiosas
(i.e., orar y asistir a la iglesia). También, comunicaron la
satisfacción con la cirugía, el poder realizar las cosas por sí
misma, no tener que utilizar el sostén con la prótesis y el mirarse al espejo y ver las dos mamas. Los factores principales
que provocaron las características sicopatológicas se mencionaran a continuación; efectos secundarios al tratamiento,
tener que someterse a varias cirugías por la reconstrucción
de mama y porque se afectó el funcionamiento motor del
brazo que se encuentra al lado de la mama extirpada y reconstruida (i.e. debilidad).
Discusión de la entrevista semiestructurada, LCS-36 y la EFIR al momento de la entrevista con relación a la cirugía de reconstrucción mamaria.
Al momento de la entrevista se reflejó más características
resilientes que sicopatológicas en nuestra muestra. Los factores que provocaron las características resilientes fueron:
la satisfacción con la cirugía, la comunicación efectiva y
apoyo (i.e. familiares y centro de ayuda a pacientes de cáncer). Estos datos convergen con los resultados de la Escala
de Factores Internos de Resiliencia. Los cuales reflejaron
una clasificación alta en los factores de espiritualidad, autonomía, introspección y satisfacción. Los factores que
indujeron a las características sicopatológicas fueron: que
perduran algunos síntomas secundarios (i.e. debilidad en el
brazo) y algunas de las participantes no están satisfechas
con la cirugía (i.e. cicatrices grandes). En la Lista de Cotejo
de Síntomas 36 se elevaron las sub-escalas de somatización
y depresión.
El cáncer de mama y la reconstrucción de mama acarrea
unas complejidades físicas que impacta el referente síquico; no es solo reconstruir un cuerpo, hay que reconstruir la
manera en que sicológicamente cada una de estas mujeres
asumen su cuerpo frente a un diagnóstico de cáncer (21). La
muestra de este estudio es evidencia de que los diferentes
procesos impactan el aspecto psicológico, por esta razón y
todas las respuestas expuestas por las participantes no se
puede ignorar, por lo cual hay que tomar acción y ofrecerle
el apoyo psicológico que ameritan durante todas las etapas.
Limitaciones
Una de las limitaciones fue el tamaño de la muestra. Es
posible que si la muestra fuese más grande y la distribución de las participantes fuese una más equitativa, se pudiese evaluar las diferencias y lograrse también una mayor
dispersión de las puntuaciones en las escalas de la LCS-36
y la EFIR.
Recomendaciones para Investigaciones
Futuras
Se recomienda para futuras investigaciones el ampliar la
muestra de participantes. De esta forma podemos tener
una visión más amplia de los factores internos de resiliencia y las características psicopatológicas. Por último, se
pueden hacer análisis secundarios de datos para comparar
la muestra de esta investigación con las muestras de otras
investigaciones en donde se haya utilizado la EFIR para
determinar factores internos de resiliencia y la LCS-36
para determinar sintomatologías psicopatológicas.
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ABSTRACT
The purpose of this pioneer study was to describe
the socio-demographics, psychopathological and resilient characteristics in a sample of Puerto Rican
women who opted for breast reconstruction surgery
after breast cancer. This research was done in order
to provide information and increase research knowledge about breast reconstruction that could be used
by public and private breast cancer psycho-psychiatry support programs for patients in Puerto Rico.
Research participants were ten Puerto Rican women,
aged twenty-one years or older. A socio-demographic
questionnaire, The Symptom Checklist- 36, Internal
Factors of Resilience Scale, and a Semi-structured
interview (qualitative approach) were administered.
Main sample findings included psychopathological
characteristics such as somatization and depression,
and resilient characteristics such as, high spirituality,
autonomy, introspection and satisfaction.
30. Torres, C.Y., & Galvis, I. La resiliencia como alternativa terapéutica
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 13
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Rico
† Excelente fuente de antioxidantes (vitaminas C, E y selenio)
Use bajo supervisión médica como parte de un plan de manejo de diabetes. © 2014 Abbott Laboratories Inc. APR-140009 Litho en P.R.
IC O S
ED
M
RECOM
N
#
*
DA
R
D A PO
Javier González-Castro MDa*, Jeamarie
Pascual MDa, Luisam Tarrats MDa, Carlos
González-Aquino MDa
Todos los martes de 6 a 8pm.
En la sede de la Asociacion Medica de Puerto Rico.
Consiste en una actividad orante paso a paso y adaptado a la persona, taller liberador y
sanador a través del conocimiento de Dios y de uno mismo.
El TOV no tiene costo de inscripción.
Para todo publico (no solo medicos)
Informes: Dra. Michelen (787) 624-0573
a
Department of Otolaryngology Head and Neck Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico.
*Corresponding author: Javier González-Castro MD - Metro Plaza Towers
303 Calle Villamil Apt. 901 San Juan, PR, 00907. E-mail address: javi8g@
gmail.com
O
ABSTRACT
Objective: To evaluate the prevalence of smoking in operating room personnel and compare
this with that of the general public. Given the
first hand exposure of these individuals to patients with smoking related illnesses, we believe
they should have a decreased tendency to smoke.
Methods: A survey instrument was given to operating room personnel in order to learn the prevalence of smoking and other tobacco use related
data. Prevalence for the general population and
other healthcare related populations was investigated using various search engines and compared
with our results. Results: A total of 113 individuals completed the survey, 6% were found to be
current smokers and 15% were found to be past
smokers. Data from the Center for Disease Control shows that the prevalence of cigarette smoking among United States adults is 19%, which is
significantly higher than what we found in our
population (p<0.01). In Puerto Rico, the prevalence of smoking is 11%, which is also higher
than our study population (p=0.05). Among current smokers, 86% have tried to quit at least once
(p=0.02), and all claimed to have knowledge of
the possible complications associated with smoking. Conclusions: Smoking tobacco remains the
number one cause of preventable death in the
United States despite many efforts to educate the
general public on the dangers associated with its
use. A more visual or hand’s on encounter with
the effects of smoking may help decrease tobacco burden in the general population.
Index words: smoking, tobacco, operating,
room, personnel
INTRODUCTION
The use of smoking tobacco has been prevalent worldwide
since as early as 5,000-3,000 BC (2). It’s addictive nature, lack
of knowledge and overwhelming publicity made it a pervasive part of American society. In the early 1900’s, data began
to surface on the danger associated with smoking, however
campaigns spearheaded by tobacco companies with the aid of
some physicians and scientists were developed to obscure the
truth about the risk of smoking tobacco (1). In 1964 the Surgeon General’s report was published and light was finally cast
on the unequivocal fact that smoking is hazardous to health
(1, 3). Public and privately funded publicity has been widespread in recent years aimed at educating the general public on
the dangers related to smoking and the many medical conditions that it can cause. Furthermore, several state and federal
laws have been passed in recent years to discourage the use
of tobacco and avoid harmful effects to its users and to those
around them (4).
Despite great advances in scientific evidence regarding the
risks of smoking tobacco, there is still a significant proportion
of individuals who continue to smoke. Although the prevalence of cigarette smoking among US adults in general has
significantly decreased from 2005 to 2010, (20.9% to 19.3%;
p<0.05 for trend), smoking is still the number one cause of
preventable death (5). In Puerto Rico, the prevalence of smoking among adults 18 years or older is 10.6 % (9.3--11.9 95%
CI) (6).
Healthcare professionals (HCP) are not only committed to
treating patients with medical conditions, they also play an exemplary role in their hospitals and communities. They “have
the opportunity and responsibility to assist patients efforts to
quit tobacco use and to ensure that non-smokers continue to
avoid the addiction”(7). The purpose of this project is to evaluate the prevalence of smoking in operating room (OR) personnel, specifically scrub nurse, nurse anesthetists, circulating
nurse and nursing supervisors. These individuals are dedicated to the management of patients with multiple surgical conditions including cancer and other conditions found to have
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 17
links to smoking. Being exposed, and having seen first
hand the procedures necessary to treat patients with
smoking related illnesses, OR personnel should have a
decreased tendency of smoking when compared to the
general population. We also seek to find out if exposure to
smoking related illness has had any effect on their smoking status.
METHODS
This is a cross sectional study using a survey instrument
given to operating room (OR) personnel, specifically
scrub nurse, nurse anesthetists, circulating nurse and nursing supervisors. Authorization was obtained for distribution from the OR medical director and Institutional review
board approval was granted by the University’s Committee of Human Research. We created a 16-point questionnaire in an attempt to obtain information including: smoking tobacco use, exposure to tobacco related illnesses, as
well as some descriptive data. The survey contained an
introductory page that provided information about smoking and tobacco related diseases, as well as the objective
of our project. The survey was distributed to the OR personnel and filled out with one of the researchers during
shift changes and between cases. One week was given for
interested respondents to fill out the survey; results were
received and tabulated for data analysis. A descriptive
analysis was performed to define the study population.
We used frequencies to describe the following categorical variables: sex, occupation, smoking status, history of
ever quitting, history of been exposed to cares of diseases
related to smoking and number of case exposure, nicotine
dependence, and reasons for quitting. Central tendencies
were utilized to describe continuous variables such as age
and amount of cigarette consumption. A bivariate analysis
was performed to determine associations among the different study variables. A Pearson’s chi-squared test was
utilized to determine statistical significance with a p-value
≤ 0.05. In order to compare the smoking prevalence of
our study with that of Puerto Rico and United States a
one-sample proportion Z-test was performed using a 95%
confidence interval to determine statistical significance.
All statistical analysis was done using STATA ©, Data
Analysis and Statistical, Copyright 1996–2011 StataCorp/
Texas LP Software.
RESULTS
The survey instrument was handed out to roughly 250 OR
nurses of which 116 responded, for a 46% response rate.
Of these 116 respondents, 3 were eliminated due to inconsistencies in their answers, giving us the final sample size
of 113 (45% response rate). Some respondents, as expected, did not answer all questions, which explains the difference in the number of subjects in the tables and figures.
The descriptive data in table 1 shows that most of the respondents were between 30 and 49 years old; females predominate in our sample size by only a small margin. Circulating nurses represent 42% of our sample size. Figure
1 shows a graphic representation of the smoking status in
our patient population; most respondents are non-smokers
(n=89, 79%), followed by former smokers (n=17,
15%) and finally current smokers with a prevalence of 6%
(n=7). When combining the last two, we found that 21%
of our sample has smoked at some point, and we named
this group the ever-smokers.
The most frequent reason for smoking among the past and
current smokers was to relieve stress (n=18/23, 78%), followed by those who could not find a way to quit (n=5,
22%). Of this ever-smokers group, 91% state that they
have tried to quit and 59% state that they have tried on
more than one occasion. Of those that did successfully quit
smoking, 53% did so because they learned of the complications related to smoking. 13% quit because a family
member was diagnosed with a smoking related disease,
and another 13% quit because they themselves were diagnosed with a smoking related disease. Three individuals
(20%) quoted “other” as the reason for quitting; responses here included religion and family as their motivation.
Among current smokers, (n=7), 86% have tried to quit at
least once (p=0.02), and all claimed to have knowledge of
the possible complications associated with smoking.
Regarding OR exposure to cases in which the patient had
a smoking related disease, we found that 83% (n=94) had
been exposed, while 17% (n=19) had not been exposed.
Of those that had been exposed, 79 respondents specified
how many cases they see in a week on average. There was
a fairly even distribution among respondents; 36% (n=29)
were involved in 2-3 cases, 28% (n=22) in only one, 23%
(n=18) more than five and 13% (n=10) were involved in 4
to 5 cases (see Table 2).
Data from the Center for Disease Control shows that the
prevalence of cigarette smoking among US adults in general has significantly decreased from 2005-2010, (21% to
19%; p<0.05 for trend), but still remains quite high (5). In
Puerto Rico, the prevalence of smoking among adults 18
years or older is 11% (9-12; 95% CI).6 Using a one-sample proportion Z-test with a 95% confidence interval to
determine statistical significance, we compared these
results with the results of our survey and found that the
prevalence of cigarette smoking among US adults is significantly higher than what we found in our population
(p<0.01). In Puerto Rico, the prevalence of smoking is
11% (3), which is also higher than our study population
(p=0.05).
A Pearson’s chi-squared test was used to see if there were
any significant correlations between the separate variables, there was no significant correlation between the
reason for quitting and gender, occupation or exposure to
tobacco. There were an increased number of respondents
who had tried to quit at least once, who had also been involved in cases with tobacco related disease, but this was
not statistically significant.
Table 3 shows a Pearson chi-squared test between smoking status and age, gender, occupation and involvement in
cases with tobacco related illness. Patients younger than
30 years old were more likely to be smokers, but this was
not statistically significant. The male gender was found
to be more likely to be both current and past smokers
18 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
DISCUSSION
Despite aggressive anti-tobacco campaigns and recent
legislation to discourage its use, cigarette smoking continues to represent a major health care burden and the most
common cause of preventable death in the US. Faced with
this fact, we ask ourselves if there is anything else that
can be done to more effectively educate the population on
the ill effects of smoking. With this goal in mind a survey
of operation room personnel was conducted to assess the
smoking tendency of this population and the effect that
witnessing first hand smoking related illness had in their
smoking habits and attitudes. We hypothesized that the
OR personnel should have a lower prevalence of smoking
than the general population given their first hand experience in treating patients with tobacco related pathology.
Our results showed that only 6% of the OR personnel
were smokers, which represents a 4% decrease from
the prevalence of the general adult population in Puerto
Table 1: Descriptive Data
Rico. Furthermore, 91% of those who
have ever smoked have tried to quit
once and 59% have tried on more than
one occasion. Of those that did manage
to quit, most of them cited increased
awareness of the effects of tobacco on
health. In our study 15% of respondents were former smokers and over
half of them cited “learning about the
adverse health effects of cigarettes”
as the main reason to quit. These facts
show that increased knowledge and
exposure do in fact prompt individuals
Table 2: Involvement in cancer related cases among respondents
to try to quit, but the addictive nature
of tobacco makes it very difficult even
for those who know that it is harmful
to their health.
Most current smokers quoted stress as
the main reason for smoking and not
being able to quit. In an inherently
stressful profession as the operating
room has been known to be, smokers
may find themselves caught in a vicious cycle that does not allow them
to quit smoking. In these cases, additional education regarding stress management may be as essential in helping
these individuals fight their struggle
with addiction.
Direct experience of the effects of
Table 3: Pearson chi-squared test between smoking status and age, gender, oc- smoking in the surgical setting can be
cupation and involvement in cases with tobacco related illness.
an unforgettable learning experience
that is likely to contribute significantly
to smoking cessation. However, the exact weight that seewhen compared to females (p=0.018). Scrub nurses had
ing these procedures had on each could not be accurately
the highest prevalence of smoking while nurse anestheanswered in this study. Interestingly, an increase in the
tists had a greater tendency to be past smokers (p=0.046).
number of "cases" does not appear to add more relevance
Finally, those who have never been involved in a case of
to this possible dissuasive factor.
a patient with a smoking related disease were more likely
to be smokers when compared to those who had been involved (p=0.029) (see Table 3).
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 19
Figure 1 shows a graphic representation of the smoking status in our patient population; most respondents
are non-smokers (n=89, 78.76%), followed by former
smokers (n=17, 15.04%) and finally current smokers
with a prevalence of 6.19% (n=7).
The use of a survey instrument is in itself a limitation,
as it can increase chance for recall bias or fear of participants to be identified despite anonymity. A 45% response
rate, although adequate for this type of study restricts the
generalization of our results. Nevertheless, we believe
that our study brings an appealing point by evaluating the
effect of direct visualization of human specimens affected
by cigarette smoking and how this correlates with an individual’s tendency to smoke. We believe that by adding
a more visual and hands on element to the anti-tobacco
movement, individuals will understand the ill effects of
smoking more clearly.
Smoking tobacco continues to be a significant health hazard in our society (8, 9). In our study, OR personnel show
a decreased tendency to smoke when compared to the
general population. The extent to which surgical exposure
contributes to an individual’s decision not to smoke is not
explicitly answered by our study. However, direct contact
with patients who have smoking related diseases in the
surgical setting does appear to influence our population’s
smoking status. Respondents found education as the most
influential factor in their decision to stop smoking. Although anti-smoking campaigns have been effective, the
general population may benefit from a more visual and
hands on education regarding the ill effects of smoking.
REFERENCES
1. Jackler RK, Samji HA. The price paid: manipulation of otolaryngologists by the tobacco industry to obfuscate the emerging truth that
smoking causes cancer. Laryngoscope. 2012; 122: 75-87.
2. Gately I. Tobacco: A Cultural History of How an Exotic Plant Seduced Civilization, 1st Ed; New York; Grove Press, 2001: 17-22.
3. Smith DR. The historical decline of tobacco smoking among United
States physicians: 1949-1984. Tob Induc Dis. 2008; 9: 4-9.
4. Centers for Disease Control and Prevention. Selected actions of the
U.S. Government regarding the regulation of tobacco sales, marketing,
and use
(excluding laws pertaining to agriculture or excise tax). September 19,
2011 / 60(35);1198-1202 Available at: http://www.cdc.gov/tobacco/
data_statistics/by_topic/policy/legislation/index.htm. Accessed on
January 28, 2012.
5. Centers for Disease Control and Prevention. Vital signs: current cigarette smoking among adults aged ≥18 years --- United States, 2005—
2010. September 9, 2011 / 60(35);1207-1212 Available from: http://
www.cdc.gov/mmwr/preview/mmwrhtml/mm6035a5.htm?s_cid=mm6035a5_wAccessed on January 28, 2012.
6. Centers for Disease Control and Prevention. State-specific prevalence of cigarette smoking and smokeless tobacco use
among adults --- United States, 2009. November
5, 2010
/ 59(43);1400-1406. Available from http://www.cdc.gov/mmwr/
preview/.mmwrhtml/mm5943a2.htm. Accessed on January 28,
2012.
7. Bunn P, Pfister DG. American Society of Clinical Oncology
Policy Statement Update: Tobacco Control—Reducing Cancer
Incidence and Saving Lives. J Clin Oncol 2003; 21:1-10.
8. Patkar A, Hill K, Batra V, Vergare MJ, Leone FT. A comparison of smoking habits among medical and nursing students.
Chest. 2003;124:1415-1420.
9. Hughes PH, Baldwin Jr, DC, Sheehan DV, Conard S, Storr CL.
Resident physician substance use, by specialty. Am J Psychiat.
1991; 149:1348-1354.
RESUMEN
Objetivo: Evaluar la prevalencia de fumadores de
tabaco en el personal de una sala quirurgica y compararlo con la poblacion general. Teniendo en cuenta
la exposición de estas personas a los pacientes con
enfermedades relacionadas con fumar, creemos que
deberían tener una menor tendencia a fumar. Métodos: Una encuesta fue entregada a personal del quirófano en la Universidad de Puerto Rico con el fin de
conocer la prevalencia de tabaquismo y otros datos
relacionados con el consumo de tabaco. La prevalencia en la población general y de otras poblaciones
relacionadas con la salud se investigó utilizando varios rastreadores de búsqueda y fue comparada con
nuestros resultados. Resultados: Un total de 113
personas completaron la encuesta, el 6% resultaron
ser fumadores actuales y el 15% resultaron ser ex fumadores. Los datos del Centro de Control de Enfermedades muestran que la prevalencia de tabaquismo
entre los adultos en Estados Unidos es del 19%, que
es significativamente mayor que lo que encontramos
en nuestra población (p <0,01). En Puerto Rico, la
prevalencia del tabaquismo es del 11%, que también
es superior a la población de estudio (p = 0,05). Entre
los fumadores actuales, (n = 7), el 86% ha intentado
dejar de fumar al menos una vez (p = 0,02), y todos
afirmaron tener conocimiento de las posibles complicaciones asociadas con el tabaquismo. Conclusión:
El consumo de tabaco sigue siendo la principal causa
de muerte evitable en los Estados Unidos a pesar de
muchos esfuerzos para educar al público en general
sobre los peligros asociados con su uso. A más visual
o la mano de el encuentro con los efectos del hábito
de fumar puede ayudar a disminuir la carga de tabaco
en la población general.
20 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
ABSTRACT
Iron deficiency is the most
common nutrient deficiency
in the world. Serum ferritin
measurement is considered
the most reliable test for the
diagnosis of Iron Deficiency
Anemia. At our institution
there seems to be no consensus in terms of the diagnostic workup for patients with
microcytic anemia or the application of guidelines. The
purpose of this investigation
was to examine the compliance of guidelines for the diagnosis of microcytic anemia
at Damas Hospital performed
by admitting physicians
when microcytic anemia is
encountered; compared to the
proposed algorithm by the
American Academy of Family Physicians (AAFP). Of
the patients included in the
study 82% did not underwent
ferritin studies, of this 79%
did not underwent any other
serum laboratories to assess
the cause of the anemia. Of
the patients who did not underwent any serum laboratories 18% went straight to
colonoscopy without further
work up. None of the patients who did undergo serum laboratories for anemia
was further investigated with
colonoscopy. In comparison
with AAFP guidelines, none
of the patients with microcytic anemia was adequately
studied for the cause of disease. None of the guidelines
or algorithms proposed establish a difference between
what should be done depending on the setting in which a
patient is been studied either
inpatient or outpatient.
Index words: compliance,
guidelines, diagnosis, mycrocytic, anemia, Damas Hospital
Diana Rivera MDa*, Miguel Magraner MDb, Rafael
Breddy MDb
Internal Medicine Residency Program, Damas Hospital, Ponce, Puerto Rico.
Department of Medicine, Damas Hospital and Ponce School of Medicine, Ponce Puerto
Rico.
*Corresponding author: Diana Rivera MD - 2213 Ponce By Pass, Ponce, Puerto Rico
00731. E-mail: [email protected]
Presented at 60th Hospital Damas Scientific Meeting, Ponce Puerto Rico, 2012
a
b
Abbreviations:
a. World Health Organization (WHO)
b. Third National Health and Nutrition Examination Survey (NHANES III)
c. Mean corpuscular volume of erythrocytes (MCV)
d. Mean corpuscular volume concentration of hemoglobin (MCH)
e. Iron deficiency anemia (IDA)
f. Center for Control and Diseases Prevention (CDC)
g. United States Preventive Services Task Force (USPSTF)
h. American Academy of Family Physicians (AAFP)
i. Total Iron Binding Capacity (TIBC)
j. Fecal Occult Blood Test (FOBE)
I
INTRODUCTION
Iron deficiency is the most common nutrient deficiency in the world; not
only affecting non-industrialized countries, but widespread through all
populations. The World Health Organization (WHO) estimates that about
2 billion people (more than 30% of the population) worldwide suffer from
anemia and in approximately 50% of these cases, iron deficiency is the
main culprit (1). In a systematic literature review, prevalence rates of anemia in older adults were found to vary between 2.9 and 51 percent in men
and 3.3 and 41 percent in women (2, 3). While nursing home residents
were found to be at high risk for anemia (2,4), the highest prevalence rates
were noted in hospitalized older adults. The Third National Health and
Nutrition Examination Survey (NHANES III) indicated that iron deficiency anemia was present in one to 2 percent of adults (5). The prevalence
of iron deficiency anemia was significantly higher in older adults, being
between 12 and 17 percent in persons 65 years and older (2,6,7).
Anemia is defined as a hemoglobin level less than 12g/dL in women and
less than 14g/dL in men (1). Iron deficiency anemia is considered when the
mean corpuscular volume of erythrocytes (MCV) as well as mean corpuscular volume concentration of hemoglobin (MCH) is decreased. However, several other etiologies for microcytic hypochromic anemia are known
and include hemoglobinopathies, lead poisoning, sideroblastic and chronic
disease anemia. Defining each of these types of anemia is indispensable
to warrant proper treatment. Therefore, diagnostic workup is necessary for
their differentiation.
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 21
Iron deficiency anemia (IDA) commonly occurs because
of iron malabsorption or loss, through obvious or occult
bleeding. Other uncommon causes include, pulmonary
hemosiderosis, intravascular hemolysis, congenital iron
deficiency or in patients with erythropoietin supplementation which cannot meet the required iron with current
stores.
The diagnosis of iron deficiency requires the patient to be
anemic, as defined by the WHO and Center for Control
and Diseases Prevention (CDC) (8), and show laboratory
evidence of ferropenia. Several additional tests exist that
can collaborate with the diagnosis of IDA, including total
iron binding capacity and transferrin saturation. However,
serum ferritin measurement is considered the most reliable test for the diagnosis of IDA (9,10).
Currently, the United States Preventive Services Task
Force (USPSTF) recommends screening pregnant women for IDA but found insufficient evidence to recommend
for or against routine screening in the other asymptomatic
individuals. Even though a large portion of the population
knowingly has IDA, in practice it is seldom investigated properly if at all regardless of the serious diseases that
may be overlooked if a definite cause is not established (7,
8). A reviewed paper in the Journal of the American Academy of Family Physicians (AAFP) proposes a diagnostic
strategy shown below (see Figure 1 and 2) (8).
At our institution, there seems to be no consensus in terms
of the diagnostic workup for patients with microcytic
anemia or the application of guidelines. This application
could result in the improvement in the quality of management of patients.
Normal values for lab variables were as follow:
Hb levels
Male < 13mg/dL
Female < 12mg/dL
MCV < 85 fL
Ferritin [15-150ng/mL]
Total Iron Binding Capacity [TIBC] [240-450mcg/dL]
Iron levels [60-170mcg/dL]
Folate [4.5-32.2ng/mL]
Vitamin B12 [208-963pg/mL]
Reticulocyte Count [0.5-2.5%]
Peripheral Smear
RESULTS
Records of admissions at Damas Hospital during January
2012 were reviewed for a total of 744 patients with hemoglobin levels below 13. Of this 364 were excluded for
MCV levels in the normal range as per laboratory levels.
Thirty-two were excluded since MCV levels were above
normal values and 320 were excluded since they were outside of the age range of less than 50 years. Only 28 patients complied with the inclusion criteria. Of these 68%
were women and 32% men. The mean age for patients
included was 66 years old. The mean hemoglobin levels
were 9.8 mg/dL. Mean of MCV was 75.8 fL. In terms of
evaluation of ferritin, 18% of the patients were studied
for ferritin levels. Twenty-one percent of the patients
were studied for iron levels as well as TIBC and 25% did
FOBE. 18% underwent colonoscopy testing. All colonoscopies performed were done prior to the completion of
any serum laboratory workup (see Figures 3 and 4, and
Tables 1 to 7) .
Table 2: Research subjects hemoglobin distribution.
If strict comparison with the proposed algorithm by the AAFP is done, none of the patients
with microcytic anemia was adequately studied for the cause of his disease. It is important
to establish that none of the guidelines or algorithms proposed establish a difference between
what should be done depending on the setting
in which a patient is been studied, if either inpatient or outpatient.
Moreover if the patient is in fact studied with
serum laboratories consistent with iron deficiency anemia, not all are likely to undergo
colonoscopy in a inpatient setting, therefore
we cannot know for sure if the colonoscopy
was performed as an outpatient procedure of
if it was performed prior to admission. Microcytic anemia workup rarely needs to begin
with colonoscopy as first investigative tool.
The majority of the patients included in the
study suffered of normocytic anemia instead
of a microcytic one, anyhow further investigations should be made to exclude iron deficiency and colon malignancies in this age group,
since having a normocytic anemia is not exclusive for iron deficiency, and therefore, if a deficiency is found replacement therapy should
be started. The reason for this finding should
be further investigated in terms of the cause,
to evaluate if there are other independent variables directly affecting the characteristics of
the red blood cell indices in this anemia.
The purpose of this investigation was to examine the compliance of guidelines for the diagnosis of microcytic anemia at Damas Hospital performed by admitting physicians
when microcytic anemia was encountered compared to
the proposed algorithm by the AAFP.
MATERIAL AND METHODS
This was a cross-sectional study of case series of patients
admitted to Damas Hospital from March to May 2012
with diagnosis of IDA. The electronic medical record
software ‘SoftLab’ utilized at Damas Hospital provided
the necessary data. Patients were selected using numerical
ranges of hemoglobin and MCV of iron deficiency anemia
as per the WHO criteria. Patients selected were followed
in terms of additional testing and workup performed as
included in their medical records. Additional testing included ferritin, iron levels, Total Iron Binding Capacity
(TIBC), reticulocyte count, peripheral smear, Fecal Occult Blood Test (FOBE), colonoscopy, vitamin B12 levels,
and folate levels. Age range included all Hispanic male
and female (NIH Criteria) patients above 50 year. Demographic data was included for statistical analysis. Comparisons and final analysis was performed using the proposed guidelines for diagnosis and management as per the
American Academy of Family Physicians.
Table 1: Research subjects age distribution.
DISCUSSION
Analysis of the algorithm proposed by the AAFP recommends that upon encountering microcytic anemia the first
test to perform is serum ferritin levels. Of the patients included in the study 82% did not underwent ferritin studies, of this group 79% did not underwent any other serum
laboratories to assess the cause of anemia. Of the patients
who did not underwent any serum laboratories 18% went
straight to colonoscopy without further work up. None of
the patients who did undergo serum laboratories for anemia were further investigated with colonoscopy.
22 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
Figure 1: Diagnostic Algorithm for Iron Deficiency Anemia. Source:
Killip S., Bennett JM., Chambers MD. Iron Deficiency Anemia. AFP
2007(5)75.
In addition, presumptions can be made in terms
of the population included and age ranges
which are likely to suffer from chronic conditions commonly causing normocytic normochromic anemia, but needs to be investigated.
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 23
Acknowledgment
We want to thank to Mr. Carlos Pérez, From Hospital
Damas Laboratory, who granted access to electronic information and Dr. Himilce Velez, from Ponce School of
Medicine and Health Sciences Public Health Program for
her support in bio statistical analysis.
Ages below 50 years were excluded from the study to
avoid inclusion of pregnant women as well as pediatric
patients since another guideline from the USPSTF is already recommended.
Figure 4: Distribution of causes for record’s exclusion.
Figure 2: Algorithm for Evaluation and treatment for Iron Deficiency
Anemia. Source: Killip S., Bennett JM., Chambers MD. Iron Deficiency Anemia. AFP 2007; (5)75
Figure 5: Research subjects MCV distribution.
The study has several limitations including the short term
for record review as only one month was evaluated. Also
only the inpatient record of laboratories and procedures
were reviewed, it is unknown if the patients were fully
studied in the outpatient setting, during another hospitalization or later on.
RESUMEN
Deficiencia de hierro es la deficiencia nutricional más
común en el mundo. La medición de la ferritina sérica se considera la prueba más fiable para el diagnóstico de anemia ferropénica, sin embargo en la práctica rara vez se investiga adecuadamente. En nuestra
institución parece no haber consenso en cuanto a la
evaluación diagnóstica de los pacientes con anemia
microcítica o la aplicación de una guía. El propósito
de esta investigación fue examinar el cumplimiento
de las directrices para el diagnóstico de la anemia
microcítica en el Hospital Damas realizado por los
médicos en el Hospital Damas, en comparación con
el algoritmo propuesto por la AAFP. De los pacientes
incluidos en el estudio 82% no se sometió a estudios
de ferritina, de estos, 79% no se sometió a ningún
otro estudio de laboratorio para evaluar la causa de
la anemia. De los pacientes que no se sometieron a
ningún laboratorio, 18% se le hizo directamente una
colonoscopia sin mediar otro estudio. A ninguno de
los pacientes que se sometieron a estudios de laboratorio para diagnóstico de anemia se le realizó colonoscopia. En comparación con las pautas de AAFP,
ninguno de los pacientes con anemia microcítica se
estudió adecuadamente para el diagnóstico de la enfermedad. Ninguna de las directrices o los algoritmos
propuestos establecen una diferencia entre lo que
debe hacerse en función del entorno en el que se ha
estudiado un paciente, bien sea de forma ambulatoria
u hospitalizado.
REFERENCES
1. WHO http://www.who.int/nutrition/topics/ida/en/index.html
2. Guralnik JM, Eisenstaedt RS, Ferrucci L, Klein HG, Woodman RC.
Prevalence of anemia in persons 65 years and older in the United States:
evidence for a high rate of unexplained anemia. Blood. 2004(8)2263.
3. BeghéC, Wilson A, Ershler WB. Prevalence and outcomes of anemia
in geriatrics: a systematic review of the literature. Am J Med. 2004;116
Suppl 7A:3S.
4. Nilsson-Ehle H, Jagenburg R, Landahl S, Svanborg A, Westin J.
Haematological abnormalities and reference intervals in the elderly. A
cross-sectional comparative study of three urban Swedish population
samples aged 70, 75 and 81 years. Acta Med Scand. 1988(6)595.
5. Looker AC, Dallman PR, Carroll MD, Gunter EW, Johnson CL.
Prevalence of iron deficiency in the United States. JAMA. 1997
(12):973.
6. Price EA, Mehra R, Holmes TH, Schrier SL. Anemia in older persons: etiology and evaluation. Blood Cells Mol Dis. 2011(2)159.
7. Lucas CA, Logan ECM, Logan RFA. Audit of the investigation and
outcome of iron-deficiency anaemia in one health district. J R Coll
Physicians Lond 1996(30)33–5.
8. Killip S., Bennett JM., Chambers MD. Iron Deficiency Anemia. AFP
2007(5) 75
9. Ioannou GN, Spector J, Scott K, Rockey DC. Prospective evaluation
of a clinical guideline for the diagnosis and management of iron deficiency anemia. Am J Med. 2002(113)281–7
10. Guyatt GH, Oxman AD, Ali M, Willan A, Mcllroy W, Paterson C.
Laboratory diagnosis of iron deficiency anemia: an overview. J Gen
Intern Med 1992(7) 145-53
Figure 6: Research subjects compliance distribution.
Figure 3: Route of patients’ selection.
Instituto de Educación Médica
de la Asociación Médica de Puerto Rico
Proveedor oficial de créditos de educación continua reconocidos por la Junta de Licenciamiento de
Disciplina Médica. Realizamos jornadas científicas y acreditamos a otras instituciones
Figure 7: Research subjects workup perform distribution.
24 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
[email protected]
(787) 721-6969
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 25
Case Report/Reporte de Casos
Zaydalee Cardona Rodríguez MDa*,
Michelle González Ramos MDa
a
Infectious Diseases Program, Department of Internal Medicine, University of Puerto Rico School of
Medicine, San Juan, Puerto Rico.
*Corresponding author: Zaydalee Cardona Rodriguez MD - 155 Avenida Arterial Hostos, Condominio Golden Court II, Box 316, San Juan, Puerto Rico 00918. E-mail: [email protected]
ABSTRACT
Acremonium species are filamentous, cosmopolitan fungi frequently isolated from plant debris and soil that have emerged as an important cause of
morbidity and mortality in immunocompromised patients. We present data
from two hematologic malignancy patients with Acremonium fungemia
who had refractory disease despite initial treatment with Amphotericin B
with clinical response after changing therapy to Voriconazole. Acremonium
should be considered in the differential diagnosis of patients with clinical
presentation suggestive of fungal infection and special attention should be
given to the treatment challenge it represents.
Index words: acremonium, species, fungemia, novel, pathogen, immunosuppressed
I
INTRODUCTION
Case Series
Invasive infections caused by opportunistic molds are a
significant cause of morbidity and mortality in immunocompromised hosts. During the past two decades these
infections have been increasing, especially in patients
with hematological malignancies. The widespread use of
antifungal prophylaxis has contributed to the observed
increase in infections due to emerging fungi (1). Other
factors include long-term immunosuppressive therapy,
indwelling catheters, cytoreductive therapy for neoplasia,
broad-spectrum antibacterial therapy and prolonged survival of immunocompromised patients (1).
Case #1
A 68 year-old-male who had presented general malaise,
neutropenia and thrombocytopenia was diagnosed with
acute myelogenous leukemia and admitted for chemotherapy. He developed neutropenic fever and was started on
broad-spectrum antibiotics. He developed a generalized
itchy and tender maculopapular rash. Physical examination revealed marked onychomycosis. He was started on
Amphotericin B lipid complex (L-amB) and consulted for
skin biopsy. Despite antifungal therapy, the patient developed sepsis. Blood cultures were positive for Acremonium spp. Voriconazole was added to L-amB and central
line was removed. He recovered his hemodynamic status,
fever ceased and rash markedly improved. Skin biopsy report revealed Acremonium spp. He was discharged home
on Voriconazole after fourteen days of combination antifungal treatment.
Acremonium spp. is a saprophytic hyaline mold ubiquitous in the human environment that has emerged as an
opportunistic pathogen in the immunocompromised host
(1-3). The rarity of Acremonium-related infections makes
it difficult to come to a decision on the most appropriate treatment modality. Most reports document clinical
failure with Amphotericin B (1). We present data from
two patients infected with Acremonium who had refractory disease despite treatment with Amphotericin B
and had clinical response after therapy was changed to
Voriconazole.
28 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
Case #2
A 74 year-old-female diagnosed with acute myelogenous
leukemia was found with recurrent disease and restarted
on chemotherapy. She developed neutropenic fever and
was started on broad-spectrum antibiotics.
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 29
Fluconazole was added afterwards due to persistent fever. She began experiencing blurry vision and left first
toe erythema. Ophthalmology ruled out infection. She
persisted with fever spikes and antifungal was escalated
to Caspofungin. She developed an erythematous maculopapular eruption with black centers and necrotic borders
involving upper trunk and face, and a painful macule over
the first toe that was biopsied. Cultures were reported
with yeast and hyphae growth. Escalation to L-amB and
Voriconazole was done for suspected fusariosis.
Patient defervesce five days after adjustment in antifungal
treatment. Biopsy revealed fungal elements in dermis and
lumina of vessels favoring disseminated mycosis. Final
blood culture report identified the organism as Acremonium spp.
DISCUSSION
Before the onset of aggressive chemotherapy causing severe immunosuppression, invasive infections from saprophytic molds were extremely rare. In the past two decades,
an increase in systemic infections caused by Acremonium
has been reported.
Seven species of Acremonium have been reported to cause
human infection with Acremonium strictum being the
most common (4). This genus is distinguished by formation of narrow hyphae bearing solitary, unbranched, needle-shaped phialiades (4-6). Acremonium spp. are known
to colonize skin, upper respiratory tract and conjunctiva.
They may cause severe illness in situations where local
immune response is compromised (1, 7). Indwelling catheters, burns, trauma, surgery and underlying skin diseases are factors, which lead to skin barrier damage, putting
patients at risk for infection. In patients with neutropenia
or macrophage dysfunction, a localized Acremonium infection may disseminate to various organs and tissues due
to their in vivo sporulation and the production of hyphae,
which are released into the bloodstream (1, 8). This capability of dissemination could indicate a particular virulence factor and might explain the difficulties confronted
in managing this disease (8).
Acremonium infections could be underrepresented in the
literature due to difficulties confronted by laboratories in
its identification. Due to the morphological similarity of
this mold with Fusarium, it is likely that some cases of
Acremonium infections have been erroneously reported.
In many laboratories Acremonium is only reported as genus, for which the incidence of different species in the
clinical setting is unknown. The rarity of Acremonium
spp-related infections and the few reported cases make it
difficult to determine the most appropriate treatment regimen. Early catheter removal and antifungal therapy have
been suggested as important strategies for the management of Acremonium associated fungemia.
For almost four decades, Amphotericin B deoxycolate has
been the cornerstone of therapy for most invasive fungal
infections due to its broad antifungal spectrum and its
30 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
concentration-dependent fungicidal action. L-amB formulations have been shown to be as active as conventional amphotericin B but less nephrotoxic in the treatment
of invasive infections. Although standardization of methodology for susceptibility testing is still suboptimal, data
has shown that newer azoles (Voriconazole and Posaconazole) are effective against Acremonium spp.
Optimal treatment for Acremonium infections is not well
defined (7). Some reports have shown Voriconazole to
be more effective than Amphotericin B (7). Acremonium
infections are difficult to treat due to the intrinsic resistance to current antifungal agents (1). We experienced
resolution of infection with Voriconazole in patients with
Amphotericin B refractory disease. The advantages of this
medication include its oral formulation, a favorable safety
profile, an adequate oral bioavailability (96%) and good
tolerance, which makes much easier the management of
patients once they are clinically stable.
Early diagnostic procedures, such as culture and in vitro
susceptibility testing, should be performed in order to improve the outcome of Acremonium infections in the immunocompromised host (7).
CONCLUSIONS
The fungal pathogens that have emerged during the past
decade have been affecting an expanding population of
immunocompromised hosts. New antifungal selective
pressures and shifting environmental conditions are two
important factors believed to be associated to the emergence of these infections. In light of past and present epidemiological trends, invasive fungal infections will probably remain a frequent and important complication.
7. Camplesi M, de Moraes A, Meneses H, Rodrigues C, Rodrigues M.
Acremonium kiliense:Case report and review of published studies.
Mycopathology 2013; 176:417-421.
8. Schell WA, Perfect JR. Fatal disseminated Acremonium strictum
infection in a neutropenic host. J Clin Microbiol.1996;34:1333-1336
RESUMEN
Las especies de Acremonium son hongos filamentosos, cosmopolitas, con frecuencia aislados de restos
de plantas y el suelo que se han convertido en una
causa importante de morbilidad y mortalidad en pacientes inmunocomprometidos debido a su capacidad
para causar infección invasiva. Las infecciones causadas por Acremonium son difíciles de manejar debido a la resistencia intrínseca a anti-fungales actuales.
Presentamos los datos de dos pacientes con malignidad hematológica infectados con Acremonium que
presentaron enfermedad refractaria a pesar del tratamiento con Amfotericina B y tuvieron respuesta
clínica después de que el tratamiento fue cambiado
a Voriconazole. Acremonium debe considerarse en
el diagnóstico diferencial de pacientes con un cuadro
clínico sugestivo de infección por hongos y atención
especial se debe dar al desafío que representa su
tratamiento.
Plataforma
digital
salud & bienestar
La Asociación Médica de Puerto Rico acaba de
lanzar su revista SALUD & BIENESTAR, dirigida
al publico para instruirlo acerca de los temas de
salud de mayor importancia.
Acremonium spp. may cause severe illness in patients with
impaired immune system. Given the increase in number
of cases and taking into consideration the frequent use of
novel treatments for cancer, HIV and autoimmune diseases, Acremonium should be considered in the differential
diagnosis of patients with clinical presentation suggestive
of fungal infection and special attention should be given
to the treatment challenge it represents.
Esta publicación forma parte del proyecto PLATAFORMA DIGITAL SALUD & BIENESTAR, todo un
sistema dedicado a transmitir, entre profesionales de salud y al público, información proveniente de diversas partes del mundo en formato de
video y artículos.
REFERENCES
El sistema conformará una red comunitaria con
una biblioteca de video y textos agrupados por
tema, relacionados con la salud.
1. Purnak T, Beyazit Y, Sahin GO, Shorbagi A, Akova M. A novel fungal pathogen under the spotlight-Acremonium spp. associated fungaemia in an immunocompetent host. Mycoses 2009;54:78-80.
2. Diaz FA, Zylberman M. Catheter-related Acremonium kiliense
fungemia in a patient with Ulcerative Colitis under treatment with Infliximab. Case report in Infectious diseases 2011:710740.
3. Israel E, Hirschwerk D, Jhaveri KD. Acremonium skin and soft
tissue infection in a kidney transplant recipient. Transplant journal
2013;95:20-21.
4. Perdomo H, Sutton DA, Garcia D, et al.; Spectrum of clinically relevant Acremonium species in the United States. Journal of Clinical Microbiology 2011;49:243-256.
5. Durbec M, Bienvenu AL, Picot S, Dubreuil C, Cosmidis A, Tringali
S. Maxillary sinus fungal infection by Acremonium. European Annals
of Otorhinolaryngology 2011;128:41-43.
6. Geun Joe S, Lim J, Young Lee J, Hee Yoon Y. Case report of Acremonium intraocular infection after cataract extraction. Korean Ophthalmol J 2010;24:119-122.
Los profesionales tendrán tambien un espacio
como autores de notas y videos, entrevistas y todos los medios que pondremos a su disposición
para publicarlos.
Una vez más la AMPR, JUNTO A LA CLASE
MÉDICA, HACIENDO LA DIFERENCIA
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 31
GERMLINE RETINOBLASTOMA
WITHOUT INHERITED GENE
MUTATION: A Case Report
José A. Quintero-Estades MSa, Natalio J. Izquierdo MDb*
University of Puerto Rico School of Medicine, Medical Sciences Campus, San Juan, Puerto Rico.
Department of Surgery, University of Puerto Rico School of Medicine, Medical Sciences Campus, San Juan, Puerto
Rico.
*Corresponding author: Natalio J. Izquierdo MD - 369 De Diego St. Torre San Francisco Suite 310, San Juan, P.R.
00923, E-mail: [email protected]
a
b
ABSTRACT
Retinoblastoma is the most common primary ocular malignancy in childhood and can
occur as a germline or somatic mutation. Recent studies have suggested a higher incidence of retinoblastoma in Hispanic children as compared to non-Hispanic white
children of the same ages. We report the ocular findings of a 20 years old Hispanic
male with a history of bilateral retinoblastoma. Although screening is currently performed with the red reflex test, analysis of current literature suggests the need to reassess screening recommendations for retinoblastoma.
Index words: retinoblastoma, Puerto Rico
INTRODUCTION
E
detachment in the right eye that led to an emergency retinopexy; pars plana vitrectomy, membrane peeling, endolaRetinoblastoma (Rb) is the most common primary ocu- ser and silicone oil instillation.
lar malignancy in childhood with an incidence of one in
18,000 to 30,000 live births worldwide (1). Previous stud- Patient’s best-corrected visual acuity (BCVA) was 20/40
ies have reported that the incidence of Rb in Hispanic boys in the right eye with no light perception in the left eye.
and girls is higher as compared to non-Hispanic white chil- Patient’s retinoscopy was -3.50 +0.50 X 95 in the right eye
dren of the same ages (2).
and -0.50 in the left eye. Patient had pseudophakia with
a posterior chamber intraocular lens in the right eye and
Patients with retinoblastoma most often present with leu- aphakia of the left eye. Patient has positive Marcus-Gunn
kocoria, strabismus and poor vision, although other more pupil in left eye. He had peripapillary atrophy in right eye
rare presenting signs have been reported (3). It is import- and microphtalmos in left eye. He had complete regresant for primary care physicians and caretakers to be aware sion of the tumor into calcified scars, with calcified vitreof possible presenting signs as delayed diagnosis has been ous seeds, detached posterior hyaloid and healthy looking
associated to poorer prognosis in globe salvage and patient fovea in the right eye. The left eye showed total retinal
survival (3,4). We report on ocular findings of a Hispanic detachment and regressed Rb with a white-yellow discolpatient with retinoblastoma.
oration of the detached retina measuring about 3 x 2 mm.
Case History
Patient is a 20 years-old Hispanic male with a history of
congenital bilateral retinoblastoma treated with chemoreduction, cryotherapy and external beam radiotherapy.
Patient had cataract surgery by phacoemulsification with
peripheral iridectomy and anterior vitrectomy in the left
eye at 2 years and 10 months old. Patient had cataract surgery by phacoemulsification with placement of intraocular
lens in the right eye at 6 years old. Patient was treated with
Nd-Yag laser in right eye at 9 years old and laser peripheral iridotomy in right eye at 14 years old. Also at 14 years
old, patient had right rhegmatogenous macula-off retina
Picture 1. Optic nerve and vessels, an intact macula and regressed tumors with cottage cheese-like appearance and the
radiation effect in the peripheral retina of patient’s right eye.
Picture 1 shows the optic nerve and vessels, an intact macula and regressed tumors with cottage cheese-like appearance and the radiation effect in the peripheral retina of patient’s right eye. Picture 2 depicts optic nerve and vessels
with an intact macula and a large mass of regressed tumor
with cottage cheese-like appearance over the nasal area.
Picture 3 demonstrates patient’s left eye with total retinal
detachment.
DISCUSSION
Germline mutations in the Rb1 gene are found in 3040% of patients with retinoblastoma (5). These patients
are more likely to develop bilateral disease, which can be
32 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
Picture 2. Optic nerve and vessels with an intact macula and a large mass of regressed tumor with cottage cheese-like
appearance over the nasal area.
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 33
explained by the Knudson two-hit hypothesis (6). The twohit hypothesis states that cancer develops after mutations
to both copies of the tumor suppressor gene Rb1. Patients
with germline mutations already have a defective copy in
all cells of their bodies, and therefore need only one mutation in any cell of the retina to develop disease. This is
often called hereditary retinoblastoma, which refers to the
50% chance the patient has to pass the defective copy of
the gene to their offspring. However, the term “hereditary”
does not imply that one or both parents were affected as
75% of these patients have a negative family history (5),
consistent with the findings in our patient.
The rest of patients with Rb have somatic mutations that
develop in only one cell of one eye. Since two mutations
have to occur in the same cell, these patients most often
develop unilateral disease and at a later age. These patients
are often said to have “non-hereditary” disease, as they
cannot pass the defective gene to their offspring. This type
of retinoblastoma is also often called “sporadic”. However,
we found the use of this term confusing, as sporadic is also
used to refer to mutations not inherited from parents, and
in Rb, most germline mutations are also sporadic. This is
the case of our patient, who had germline retinoblastoma,
but did not inherit his Rb gene mutations from any of his
parents.
In patients with germline retinoblastoma, second primary
tumors are the leading cause of death in developed countries (7). External beam radiotherapy (EBRT) increases
the risk of second primary tumors and the combination of
EBRT and chemotherapy further increases the risk for second primary tumor formation compared to EBRT alone (7).
Our patient has not developed second primary tumors 20
years after diagnosis, even when having risk factors such
as germline disease and combination therapy of EBRT
with chemotherapy.
Although screening is done for Rb as part of well child
visits, there is not enough information to assess the effectiveness of current screening recommendations. The
main screening technique used is the red reflex test, which
looks for leukocoria. An abnormal red reflex test is a sign
of eye disease, however a normal red reflex test has been
show to not be able to rule out retinoblastoma8. This lower
than optimal sensitivity is not consistent with the expected
sensitivity of a screening test and raises question on the
validity of the red reflex test as a screening tool. Studies
have found that family or friends detect 75-80% of Rb cases with primary care physicians detecting 5-8% of cases
(4,8). Furthermore, Abramson and co-workers (8) found
family or friends detected the disease in 92% of patients
that presented with leukocoria. This data quantifies the
doubts for the current screening process and suggests for
the need of better screening techniques. Family members
noticed leukocoria in our patient, consistent with findings
in the literature.
Abramson and co-workers (8) found ocular survival in
patients presenting with leukocoria to be 9% at 5 years,
which means detection at the stage of leukocoria is not
satisfactory and we should look to detect retinoblastoma
at an earlier time in disease course. Earlier detection of
the disease will allow for more successful treatments and
a lower rate of eye removal. Our patient was diagnosed
and treated during his first year of life. Despite the poor
prognosis, patient’s right eye was salvaged and with a best
corrected visual acuity of 20/40; patient’s left eye was not
salvaged. Early detection and treatment in our patient was
vital to salvaging his right eye.
Abramson and co-workers (8) showed that patients who
were routinely examined from birth by dilated fundus
examinations had a higher chance of presenting as Reese-Ellsworth Group I, were diagnosed earlier and had
higher ocular survival than patients who did not have such
surveillance. Specifically, patients that received clinical
surveillance from birth, were diagnosed at an average of 8
months compared to 20 months in the general population
(8). A lower age at diagnosis has been well documented to
be associated to higher chances of ocular survival, which
again supports the use of more aggressive clinical surveillance as part of Rb screening.
Butros and co-workers (9) found that only about 18% of
patients had no delay from presenting signs to diagnosis.
Of the patients with a delay in diagnosis, 30% had a delayed referral from the primary care physician (PCP) to the
ophthalmologist and 77% had a delay in seeking treatment,
defined as the time from the onset of presenting signs to
the time at which a physician was notified (9). It is important therefore for primary care physicians to be very aware
and have a high index of suspicion when encountering any
of the possible presenting symptoms for retinoblastoma
so they can make a quick referral. Furthermore, the primary care physician needs to educate the caretakers better
so that they alert the physician of any eye abnormalities,
which can be achieved by adding a simple question to the
medical history and well child visits.
A thorough ophthalmologic examination is usually recommended at 3-4 years (9). However, the median age at diagnosis is around 24 months for unilateral disease and even
earlier for bilateral disease (9). Earlier extensive examination might be a possible solution to better screening for
retinoblastoma. Another possible solution is dilated ophthalmoscopic examination of all children as a screening
approach. In the meanwhile, we have to educate primary
care physicians on the importance of the red reflex test and
of immediate referral to an ophthalmologist if an abnormal
test, family history or any other eye abnormality is found.
Limitations of this study include that only one patient’s ocular findings are described and that data is qualitative in
nature and cannot be assessed for statistical significance.
Further studies to find the incidence of Rb in Puerto Rico
are needed.
In conclusion, to our knowledge this is the first report on
the ocular findings of a patient with Rb in Puerto Rico.
Our findings are consistent with the poor prognosis of Rb
patients if someone other than a health care provider discovers the disease, with leukocoria as a presenting sign.
Further studies should compare presenting signs, patient
34 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
Picture 3. BScan ultrasound shows patient’s left eye with total retinal detachment
survival and ocular survival of Rb patients in Puerto Rico
to verify that findings in the United States are similar to
those in Puerto Rico and that therefore, it is appropriate to
reassess screening techniques for Rb in Puerto Rico.
REFERENCES
1) Abramson DH, Frank CM, Susman M, Whalen MP, Dunkel IJ, Boyd
NW. Presenting signs of retinoblastoma. The Journal of Pediatrics. 1998;
132: 505-508.
2) Abramson DH, Schefler AC. Update on retinoblastoma. Retina. 2004;
24: 828-848.
3) Howe HL, Wu X, Ries LA, et al. Annual report to the nation on the status
of cancer, 1975-2003, featuring cancer among U.S. Hispanic/Latino populations. Cancer. 2006; 107: 1711-1742.
4) Balmer A, Zografos L, Munier F. Diagnosis and current management of
retinoblastoma. Oncogene. 2006; 25: 5341-5349.
5) Kaiser P, Scott I, O’Brien J, Murray T. Retinoblastoma. Retrieved April
16, 2014, from http://www.djo.harvard.edu/site.php?url=/patients/pi/436.
6) Knudson A. Mutation and Cancer: Statistical Study of Retinoblastoma.
Proceedings of the National Academy of Sciences of the United States of
America. 1971; 68(4): 820-823.
7) Rodjan F, de Graaf P, Brisse H, et al. Second cranio-facial malignancies in
hereditary retinoblastoma survivorspreviously treated with radiation therapy:
Clinic and radiologic characteristics and survival outcomes. European Journal of Cancer. 2013; 49: 1939-1947.
8) Abramson DH, Beaverson K, Sangani P, et al. Screening for Retinoblastoma: Presenting Signs as Prognosticators of Patient and Ocular Survival.
Pediatrics. 2003; 112: 1248-1255.
9) Butros LJ, Abramson DH, Dunkel IJ. Delayed Diagnosis of Retinoblastoma: Analysis of Degree, Cause, and Potential Consequences. Pediatrics.
2002; 109(3): E45.
RESUMEN
Retinoblastoma es el cáncer ocular primario mas común en la
niñez y puede ocurrir por una mutación germinal o somática.
Estudios recientes sugieren que la incidencia de retinoblastoma es más alta en niños de origen hispano comparado con
niños blancos no hispanos de las mismas edades. Reportamos
los hallazgos oculares de un paciente hispano de 20 años con
historial de retinoblastoma bilateral. A pesar de que actualmente se hace la prueba del reflejo rojo como cernimiento
de retinoblastoma, análisis de la literatura actual sugiere que
debemos reconsiderar las recomendaciones de cernimiento
para retinoblastoma.
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 35
AN UNCOMMON PRESENTATION OF
FOLLICULAR THYROID CARCINOMA:
When Chronic Back Pain should raise a Flag
Milliette Alvarado MDa, Margarita Ramirez-Vick MDa*, Liurka Lopez MDbc, Maria J
Marcos-Martinez MDbc, Fanor M. Saavedra MDd, Juan C. Negron-Rivera MDe, Marielba Agosto MDa, Meliza Martinez MDa, Rafael Gonzalez MDa, Myriam Allende-Vigo MDa
a
Endocrinology, Diabetes and Metabolism Section, Internal Medicine Department, University of Puerto Rico, School of Medicine, Puerto Rico
Health Science Center, San Juan, Puerto Rico.
b
Department of Pathology and Laboratory Medicine, University of Puerto Rico, School of Medicine, Puerto Rico Health Science Center, San Juan,
Puerto Rico.
c
Puerto Rico Medical Services Administration.
d
Neurosurgery Section, University of Puerto Rico, School of Medicine, Puerto Rico Health Science Center, San Juan, Puerto Rico.
e
Nuclear Medicine Section, University of Puerto Rico, Puerto Rico Health Science Center, San Juan, Puerto Rico.
*Corresponding author: Margarita Ramirez-Vick MD - University of Puerto Rico Medical Sciences Campus, PO Box 365067, San Juan, PR 009365067. E-mail: [email protected]
Poster Presentation at American Association of Clinical Endocrinologists 23rd Annual Scientific and Clinical Congress-2014.
Figure 1: T1 contrast enhanced sagittal (left) and axial (right) images of
the thoracic spine showing a mass centered at the left aspect of T3 vertebral body extending to posterior elements, also involving left posteroinferior aspect of T2 vertebral body and left adjacent paraspinal muscles,
causing compression of the thecal sac and obliteration of CSF column.
T2-T3 and T3-T4 neuroforamina are obliterated by the mass.
Figure 2: Thoracic vertebra (T3) Corpectomy, T3
Titanium interbody cage and T2 to T4 posterior instrumentation.
ABSTRACT
Follicular thyroid carcinoma is the second most common type of thyroid cancer, and its incidence has increased dramatically in recent years. Although it typically presents as a thyroid nodule, it can spread to distant
sites via hematogenous dissemination. Bone metastasis is diagnosed clinically in 2%-13% of patients with
differentiated thyroid cancer; nevertheless spinal cord compression complicating thyroid carcinoma is rare and
only few cases has been reported in the literature. This case illustrates a strange case of a minimally invasive
follicular carcinoma that showed an aggressive behavior, and thus the importance of considering metastatic
thyroid carcinoma in the differential diagnosis of chronic back pain progressing to spinal cord compression
carrying a severe morbidity.
*
8
Index words: uncommon, presentation, follicular, thyroid, carcinoma, chronic, back, pain
I
INTRODUCTION
In recent years, the incidence of differentiated thyroid cancer (DTC) has increased dramatically, more than any other
malignancy, as the cases of follicular thyroid carcinoma
(FTC), accounting for almost 10% of cases in iodine sufficient areas (1,2). Cases of thyroid cancer presenting with
aggressive late-stage disease with distant bone metastases
have also risen. Although DTC had in general been associated with good prognosis and survival, in cases where
distant disease is present, the overall survival decreases
significantly (3). Bone metastases have the potential to
cause severe morbidity, including pain, neurologic deficit,
spinal cord compression and paraplegia (4). We present a
patient that developed spinal metastatic FTC causing cord
compression after an initial minimally invasive follicular
carcinoma.
Case History
A 56-year-old-female patient with arterial hypertension,
chronic low back pain, multinodular goiter and hypothy
roidism on thyroid hormone replacement, underwent left
hemithyroidectomy on March, 2006 due to the presence
of a left sided solid thyroid nodule measuring 1.6 x 1.3 x
1.5 cm. Prior fine needle aspiration (FNA) of this lesion
was consistent with follicular tumor of the thyroid gland.
Pathologic diagnosis of the left hemithyroidectomy was
reported as follicular adenoma. Patient continued her routine medical care at another institution. Approximately six
and a half years later, the patient developed a worsening
left sided back pain initially believed to be herniated disk
disease, for which she sought multiple treatments without
any pain relief. A spinal mass was found on an MRI and
she was referred for Neurosurgery evaluation. The pain
became unbearable and debilitating, prompting an emergent visit to emergency department, where imaging study
revealed an aggressive mass centered at T3 vertebral body
with severe spinal canal stenosis causing compression of
the spinal cord (see Figure 1), with no evidence of lymph
node enlargement or further structural involvement. Patient underwent T3 vertebrectomy with internal fixation
(see Figure 2), by the Neurosurgery Service with final
pathologic diagnosis showing thyroid tissue compatible
36 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
Figure 3: Thoracic vertebra (T3) biopsy showing infiltrative follicular
thyroid carcinoma between bony spicules (arrow), mostly a microfollicular pattern (H&E, X40 magnification).
with metastatic follicular thyroid carcinoma (see Figure 3). Subsequent neck ultrasound was performed showing a solid well-defined isoechoic thyroid nodule at the lower right lobe measuring
1.4 cm in largest diameter; FNA was done with a cytological
diagnosis of Follicular Neoplasm or Suspicious for a Follicular
Neoplasm (see Figure 4a). Patient was clinically and biochemically euthyroid, and underwent completion thyroidectomy on
December 2013 with non-malignant results (see Figure 4b). A
second review of the 2006 hemithyroidectomy was performed by
the Pathology Service at our Institution, with new interpretation
consistent with a well-differentiated follicular thyroid carcinoma
as it showed focal capsular invasion with indeterminate lymphovascular invasion (see Figure 5). After preparation with steroid
therapy, patient underwent radioiodine therapy with 170 mCi of
I-131 by the Nuclear Medicine Service.
*
Figure 4: Fine-needle aspiration of a right thyroid
nodule was suspicious for a follicular neoplasm.
Cells showed sheets of crowded follicular cells, with
slightly enlarged nuclei with granular chromatin (a)
(Papanicolaou stain, x400 magnification). A right
hemithyroidectomy showed this nodule was a hyperplastic Hürtle cell nodule
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 37
*
Z
Follicular carcinoma is the second most common
type of thyroid cancer, typically presenting as a
thyroid nodule, but when it spreads it usually does
via hematogenous route, with distant metastases occurring in about 10-15% of cases (2). Bone metastases are diagnosed clinically in 2-13% of patients
with differentiated thyroid cancer; the great majority occurring in the axial skeleton where blood
flow is high, forming mostly osteolytic lesions, as
bone offers an advantageous microenvironment for
tumor growth (8). Spinal metastases typically affect the thoracic (60-80%), lumbar (15-30%) and
cervical spine (<10%), with the posterior aspect of
the vertebral body the most common site of initial
involvement. The spinal canal to spinal cord ratio
is smallest in the thoracic spine, making this area
more prone to cord compression, as was documented in our patient. Patients with spinal metastases
tend to present with pain that becomes progressive
and unremitting over time, with motor and sensory
dysfunction also presenting in advanced disease (9).
Magnetic resonance imaging (MRI) is now the gold
standard in evaluating cases of spinal cord compression (10). In such patients both surgical resection
of symptomatic metastasis and radioactive iodine
(RAI) therapy have been associated with improved
survival. Moreover, in those lesions in which acute
edema from metastatic lesions may produce complications, therapy with external radiation and glucocorticoid must be considered to minimize potential
tumor expansion (11). Most importantly, each case
needs to be individualized and a dedicated multidisciplinary approach must ensue.
This case report illustrates a very rare case of a minimally invasive follicular carcinoma with well-differentiated epithelium that showed an aggressive behavior. It is important to consider metastatic thyroid
Figure 5: A review of previous left hemithyroidectomy resulted in the carcinoma in the differential diagnosis of chronic
diagnosis of follicular carcinoma (a). Note the presence of tumor (as- back pain, that may rarely, yet possibly progress to
terisk) invading outside the tumor capsule (arrow) (b). (a: H&E, 40x
spinal cord compression carrying a severe morbidimagnification; b: H&E, 40x magnification).
ty. Clearly, early detection of these signs and symptoms should warn the clinician, calling for prompt
DISCUSSION
diagnosis and treatment.
Follicular thyroid carcinoma is defined as a thyroid follicular epithelial cell neoplasm, with evidence of capsular and/ REFERENCES
or vascular invasion (5). It has been traditionally classified
as low- and high-risk forms based on their overall survival 1. Venkat R, Guerrero MA. “Recent Advances in the Surgical Treatment
Differentiated Thyroid Cancer: A Comprehensive Review.” The Scidata (6). The histopathology varies from a well-differenti- of
entific World Journal. 2013, Vol. 2013. 7 pages. Article ID 425136.
ated epithelium, in which the microfollicular architecture is Accessed on May 5, 2014. <http://dx.doi.org/10.1155/2013/425136>.
maintained, to poorly differentiated lesions, which are in- 2. Lee SL, Ananthakrishnan S. ”Overview of follicular thyroid cancer.”
variably associated with a worse prognosis (7). Moreover, In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Jan 17, 2014.
two types have been recognized in terms of their degree 3. Carhill AA, Vassilopulou-Sellin R. “Durable effect of Radioactive
in a Patient with Metastatic Follicular Thyroid Carcinoma”. Case
of invasiveness, the minimally invasive follicular cancer Iodine
Reports in Endocrinology. 2012. Vol. 2012, 5 pages. Article 231912. Ac(MIFC) and the widely invasive follicular cancer (WIFC). cessed on January 8, 2014. <http://dx.doi.org/10.1155/2012/231912>.
The MIFC pattern is defined as an encapsulated follicular 4. Quan GM, Pointillart V, Palussière J et al. “Multidisciplinary Treatneoplasm showing definite capsular and/or vascular inva- ment and Survival of Patients with Vertebral Metastases from Thyroid
Thyroid. 2012, 22:125-130.
sion, while the latter shows widespread invasion into the Carcinoma.”
5. Gimm O, Dralle H. “Differentiated thyroid carcinoma”. In: Holzthyroid parenchyma or into the blood vessels. It has been heimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based
described that the minimally invasive thyroid carcinoma is and Problem-Oriented. Munich: Zuckschwerdt; 2001. Accessed on
characterized by a lower degree of aggressiveness with a January 7, 2014. Available from: <http://www.ncbi.nlm.nih.gov/books/
NBK6979/>.
relative indolent course (6).
38 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
6. Collini P, Sampietro G, Rosai J et al. « Minimally invasive (encapsulated) thyroid carcinoma of the thyroid gland is the low risk counterpart
of widely invasive follicular carcinoma but not of insular carcinoma ».
Virchows Arch. 2003, 442 :71-76.
7. Vishveshwaraiah PM, Mukunda A, Laxminarayana KK et al. “Metastatic follicular thyroid carcinoma to the body of the mandible mimicking an odontogenic tumor”. J Can Res Ther 2013, 9:320-323.
8. Muresan MM, Olivier P, Leclère J et al. “ Bone metastases from differentiated thryoid carcinoma.” Endocr Relat Cancer. 2008 ,15:37-49.
9. Ramadan S, Ugas M, Berwick R et al. « Spinal Metastasis in thyroid
cancer ». Head & Neck Oncology. 2012, 4:39.
10. Sundaresan N, Sachdev VP, Steinberger A et al. "Decompression
and Stabilization of Spinal Metastasis: The Mount Sinai School of Medicine Experience" Advanced Techniques in Central Nervous System
Metastases. The American Association of Neurological Surgeons.1998,
Chapter 15: 219-31.
11. Cooper DS, Doherty GM, Haugen BR et al. “Revised American
Thyroid Association Management Guidelines for Patients with Thyroid
Nodules and Differentiated Thyroid Cancer”. American Thyroid Association (ATA) guidelines taskforce on thyroid nodules and differentiated thyroid cancer. Thyroid. 2009, 19:1167–1214.
Acknowledgement
Enrique Alvarado Burgos, MD - Diagnostic Radiology
Department, UPR-School of Medicine- who help in the
interpretation of the diagnostic images.
RESUMEN
Se presenta el caso de una mujer de 56 años de edad
con historial de hipotiroidismo y bocio multinodular,
a quien se le había realizado una hemitiroidectomía
del lado izquierdo, consistente con un diagnóstico patológico de adenoma folicular. Años después, debido
a dolor de espalda progresivo y debilitante, estudios
de imágenes revelaron una masa agresiva centrada en
el cuerpo vertebral de T3 con estenosis del canal espinal y compresión de cordón severa. Resección de la
lesión vertebral reveló tejido tiroideo compatible con
carcinoma folicular de tiroides metastático. A la paciente se le realizó tiroidectomía total con resultados
no-malignos. Revisión de la hemitiroidectomía inicial
fue evaluada mostrando un carcinoma de tiroides folicular bien diferenciado con invasión capsular focal.
Este caso representa una ocurrencia rara en donde un
carcinoma folicular de tiroides mínimamente invasivo
y bien diferenciado, presentó con metástasis distante y
un comportamiento agresivo, llevando a compresión
del cordón con gran morbilidad.
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 39
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Su voz en la muchedumbre
MULTIPLE MYELOMA WITH
TESTICULAR INVOLVEMENT:
A Case Report and Review of the
Literature
Rodrigo Kraft Roverea*, Bruno Wensing
Raimannb, Lauren Menna Marcondesb,
Eduardo Teston Bondanb, Felipe Gioppo
Toledo Nunesb, Giuliano dos Santos Borgesb
a
Oncology Department, Hospital Santo Antonio, Blumenau, Santa Catarina, Brazil.
b
Oncology Department, Universidade do Vale do Itajai, Itajai, Santa Catarina, Brazil.
*Corresponding author: Rodrigo Kraft Rovere, Departamento de Oncologia, Hospital Santo Antonio, Rua Itajai, 545, CEP 89050100 Blumenau SC, Brasil. E-mail [email protected]
S
ABSTRACT
We report a case of a very unusual metastasis of multiple myeloma to the testis in a 53-year-old-patient,
documented with images and anatomic-pathological
exam. Our case report is of interest because it is one
of the rarest forms ever reported of advanced multiple
myeloma.
Index words: multiple, myeloma, testicular, involvement
INTRODUCTION
Secondary involvement of the genitourinary tract is very
rare, with the testicle being involved in less than 5% of
cases. Most of the times the finding is incidentally found in
advanced disease patients, followed by relapse of previous
diagnosed malignancy and only then as initial manifestation of disseminated oncologic disease (1, 2, 3).
Given the existence of the hematologic-testicular barrier,
the testicle behaves as a sanctuary for hematologic malignancies. In multiple myeloma (MM), testicular involvement is very rare. (3). In a review of 182 extra medullary
multiple myeloma cases, only five cases had testicular involvement (2.7%). In the study of the American Testicular
Tumor Registry, were found only seven cases of testicular
plasmocytoma in 6000 testicular tumors (0,1%) (4, 5)
anemia. Leucocyte counting, LDH and glycemia showed
normal range levels. The total protein level was 6.2 mg/
dL and the albumin/globulin ratio was 2.25 mg/dL. The
immunohistochemical stain of the medullar biopsy showed
plasmocytoma/multiple myeloma involvement revealing
light chain monoclonal disease by the Lambda immunoglobulin, positive for CD138 and negative for CD3 and
CD20, heavy tumoral burden and moderate hematopoietic
reserve. The thoracic, abdominal and pelvic CT-scans were
compatible with multiple osteolitic lesions, mainly in vertebral bodies, scapulae and pelvis. Also, it was noticed a
small hyperdense nodule in the right testis (see Figure 1).
When a plasmocytoma originates in the testicle is called
primary plasmocytoma, and when the testicle plasmocytoma is concomitant to a MM invading the testicle it is
called a secondary plasmocytoma. It is very important to
establish the right diagnosis, because the prognosis of the
latter is far worst (6)
We report a case of a patient diagnosed with MM and testicular involvement.
Case History
53-years-old Caucasian male with a clinical picture of lower back pain for a year was sent for evaluation to the neurosurgery service in January 2011 because of radiologic
findings suggesting MM. At the time of the first visit, the
patient was asymptomatic, denying smoke or alcohol use,
and no relevant comorbidities or familial history. Laboratory exams demonstrated a normocytic and normochromic
40 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
Figure 1: Small hyperdense nodule in the right testis.
Subsequent ultrasound showed a hyper vascularized solid
nodule measuring 0.9 cm with two small satellite nodules
measuring 0.4 and 0.3 cm respectively in the right testis
(see Figure 2). Given the clinical picture, the possibility
of a neoplastic nodule was considered; hence a unilateral
orchiectomy was performed. Pathology revealed a testicle
with a dense atypical plasmocytic infiltrate consisted with
MM (see Figure 3).
DISCUSSION
Multiple myeloma is a nearly incurable disease characterized by the proliferation of clonal plasmocytes in the bone
marrow (7, 8). Multiple myeloma provokes immunophenotypical changes, as well as multiple organic dysfunctions,
such as elevation of immunoglobulin production, anemia,
recurrent infections, renal failure and hypercalcemia with
bone matrix destruction (8).
The physiopathology of the disease is associated with
the adhesion of MM cells to the bone marrow, inducing
the production of cytokines, which leads to cell proliferation-promoting chemo resistance. Various mechanisms
linked directly to specific genetic alterations are involved
in the development of the malignancy. Among the best
known are aneuploidy, chromosome 13 monoploidy and
amplification of the chromosome 1 long arm (9).
Figure 2: Hyoervascularized solid nodule in the right
testis.
Despite the fact that the majority of tumoral cells are located within the bone marrow, they can also be found in
peripheral blood in some patients, more commonly in relapsed disease. In advanced stages of the disease, the myeloma cells may develop autocrine mechanisms that enable them to become stromal independent (10).
Extra medullar involvement in MM is not an uncommon
situation in advanced stages of the disease. Generally the
neoplastic cells invade other tissues such as liver, lung,
lymph nodes, spleen, pancreas and kidney and more rarely
digestive tract, thyroid, heart, skin and gonads, being the
testicles the most rarely found.
Figure 3: Dense atypical plasmocyte infiltrate in the right
The incidence of extra medullar lesion in MM varies 11% testis.
to 73%, but the testicular plasmocytoma is only 0,03% to
0,1% of all the primary or secondary testicular cancers,
making this case report a very rare situation (5, 11).
ranging from 9 days to a maximum of 26 months (14, 15).
According to a review published in 2002, only 51 cases
of testicular plasmocytomas were reported in the medical The treatment experience is limited to the scenario of tesliterature. The first review was published by Helwig et al, ticular plasmocytoma as the sole site of metastasis. Reports
reporting 128 extra medullar plasmocytoma, none of them of treatment with orchiectomy without recurrence in a short
in the testis (12).
time span follow up were registered. About the cases in
which it was part of a disseminated disease, besides the
According to case reports found in a Pubmed search, the orchiectomy, also the testicular radiotherapy and standard
testicular plasmocytoma can be found either incidentally chemotherapy for MM may have a role (16, 17).
in asymptomatic patients (the most frequent form of presentation) or as a painful testicular mass (13).
Our case report is of interest because it is one of the rarest
forms of advanced MM. It is also important to alert that is
The prognosis of such cases is generally poor. In the Ang- of utter importance to search for metastatic sites in MM
hel et al review, 20 out of 34 patients (59%) presented with patients, as in many of the cases it is asymptomatic. Thirprogressive disease with fatal outcome in spite of orchiec- teen months after the diagnosis, the patient is still well and
tomy, chemo- and radiotherapy with overall survival rates asymptomatic, being treated with thalidomide as therapy.
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 41
GLIOSARCOMA PEDIATRICO:
REFERENCES
(1) Almagro UA. Metastatic tumors involving testis. Urology
1988 Oct;32(4):357-60.
(2) Dutt N, Bates AW, Baithun SI. Secondary neoplasms of the
male genital tract with different patterns of involvement in adults and
children. Histopathology 2000 Oct;37(4):323-31.
(3) Rosenberg S, Shapur N, Gofrit O, Or R. Plasmacytoma of the
testis in a patient with previous multiple myeloma: is the testis a sanctuary site? J Clin Oncol 2010 Sep 20;28(27):e456-e458.
(4) Levin HS, Mostofi FK. Symptomatic plasmacytoma of the
testis. Cancer 1970 May;25(5):1193-203.
(5) HAYES DW, BENNETT WA, HECK FJ. Extramedullary lesions in multiple myeloma; review of literature and pathologic studies.
AMA Arch Pathol 1952 Mar;53(3):262-72.
(6) Martin PJ, Ramesh A, Hercules S, Silamban, Dhanasekar T,
Mallikarjuna VS, et al. Extranodal testicular anaplastic versus plasmablastic plasma cell tumor: A rare case with diagnostic dilemma in a developing country. Indian J Med Paediatr Oncol 2011 Jan;32(1):49-54.
(7) Hundemer M, Klein U, Hose D, Raab MS, Cremer FW, Jauch
A, et al. Lack of CD56 expression on myeloma cells is not a marker for
poor prognosis in patients treated by high-dose chemotherapy and is
associated with translocation t(11;14). Bone Marrow Transplant 2007
Dec;40(11):1033-7.
(8) Kyle RA, Rajkumar SV. Criteria for diagnosis, staging, risk
stratification and response assessment of multiple myeloma. Leukemia
2009 Jan;23(1):3-9.
(9) Blade J, Fernandez de LC, Rosinol L, Cibeira MT, Jimenez R,
Powles R. Soft-tissue plasmacytomas in multiple myeloma: incidence,
mechanisms of extramedullary spread, and treatment approach. J Clin
Oncol 2011 Oct 1;29(28):3805-12.
(10) Garzon R, Volinia S, Liu CG, Fernandez-Cymering C, Palumbo T, Pichiorri F, et al. MicroRNA signatures associated with cytogenetics and prognosis in acute myeloid leukemia. Blood 2008 Mar
15;111(6):3183-9.
(11) Levin HS, Mostofi FK. Symptomatic plasmacytoma of the
testis. Cancer 1970 May;25(5):1193-203.
(12) Anghel G, Petti N, Remotti D, Ruscio C, Blandino F, Majolino I. Testicular plasmacytoma: report of a case and review of the
literature. Am J Hematol 2002 Oct;71(2):98-104.
(13) Wang YM, Li FY, Luo JD, Li J, Xie LP, Yang GS. Testicular
plasmacytoma: a case report and review of the literature. Chin Med J
(Engl ) 2008 May 20;121(10):956-8.
(14) Richardson PG, Barlogie B, Berenson J, Singhal S, Jagannath
S, Irwin DH, et al. Extended follow-up of a phase II trial in relapsed, refractory multiple myeloma:: final time-to-event results from the SUMMIT trial. Cancer 2006 Mar 15;106(6):1316-9.
(15) Richardson PG, Barlogie B, Berenson J, Singhal S, Jagannath
S, Irwin D, et al. A phase 2 study of bortezomib in relapsed, refractory
myeloma. N Engl J Med 2003 Jun 26;348(26):2609-17.
(16) Steinberg D. Plasmacytoma of the testis. Report of a case.
Cancer 1975 Oct;36(4):1470-2.
(17) Cavanna L, Fornari F, Civardi G, Di SM, Sbolli G, Foroni R,
et al. Extramedullary plasmacytoma of the testicle. Sonographic appearance and ultrasonically guided biopsy. Blut 1990 Jun;60(6):328-30.
RESUMEN
Se presenta un caso de una metástasis muy poco
común de mieloma múltiple a los testículos en un
paciente de 53 años, documentada con imágenes y
examen patológico. Nuestro caso es de interés debido a que es una de las formas más raras reportada de
múltiple mieloma avanzado. También es importante
alertar que es crucial buscar otros sitios de metástasis
en pacientes con mieloma múltiple que en muchos de
los casos son asintomáticos.
42 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
Reporte de un Caso y Revisión de la Literatura
BOLETIN
Luis Rafael Moscote-Salazara*, Gabriel Alcalá-Cerraa, Juan José Gutiérrez-Paterninab,
Pedro José Penagos Gonzálezc, Camilo Zubieta Vegac, George Chater-Cured, Carlos Alberto Menesese, Miguel Saenzf
Letra TIMES NEW ROMAN para todo
Neurocirujano, Universidad de Cartagena, Cartagena de Indias, Colombia.
Programa de Medicina, Facultad de Medicina, Universidad de Cartagena, Colombia.
c
Grupo Neurología y Neurocirugía Oncológica, E.S.E. Instituto Nacional de Cancerología, Bogotá, Colombia.
d
Neurocirujano, Universidad del Bosque, Bogotá, Colombia.
e
Neurocirujano, Universidad del Rosario, Bogotá, Colombia.
f
Neurocirujano, Universidad Juan N. Corpas, Bogotá, Colombia.
*Correspondencia: Dr. Luis Rafael Moscote Salazar - Servicio de Neurocirugía, Universidad de Cartagena, Facultad de Medicina, Campus de
Zaragocilla, Tercer piso, Cartagena de Indias, Colombia. E-mail: [email protected]
Titulo en MAYUSCULA, tamaño 18 bold.
RESUMEN
Autores en tamaño 14 bold.
Textos tamaño 11, regular, interlinea simple.
Gliosarcoma cerebral es una variante rara de glioblastoma multiforme que se presenta principalmente entre la
sexta y séptima década de la vida. Pocos casos han sido reportados en pacientes menores de diecinueve años.
Presentamos el caso de un varon de cuatro años de edad con cuadro clínico, imágenes y patologia compatible
con gliosarcoma del cerebro. Despues de cirugia el paciente fue manejado con radioterapia complementaria
y tras su seguimiento no ha presentado recidiva tumoral ni déficits neurológicos. El gliosarcoma es altamente
agresivo y la sobrevida media depende de la extensión de la resección quirúrgica.
Referencias en tamaño 9 regular.
Palabras clave: gliosarcoma, pediátrico, reporte, caso, revision, literatura
Las referencias deben sere indicadas entre parentesis, por ejemplo: (5) no con subindice, por ejemplo 5
INTRODUCCION
Caso Clínico.
El gliosarcoma (GS) es un tumor cerebral maligno, caracterizado por un patrón de diferenciación bifásico, con poblaciones celulares neoplásicas de tipo glial y sarcomatoso.
A partir de estudios clínico-epidemiológicos y patológicos,
ha sido considerado como una variante del glioblastoma
multiforme (GBM), constituyendo alrededor del 2-8% de
los casos.1
Paciente masculino de 4 años de edad con cuadro clínico
de 3 meses de evolución consistente en cefalea constante, irritabilidad, marcha atáxica, inestabilidad postural y
vómitos ocasionales. Tras varios ingresos a urgencias por
cefalea e irritabilidad un pediatra solicitó una tomografía
axial computarizada cerebral simple y contrastada que
demostró la lesión tumoral parieto-occipital derecha, por
lo que remitió a neurocirugía pediátrica. Al examen clínico
se encontró emaciado, con peso por debajo del percentil 5
para la edad, talla adecuada para la edad y palidez cutánea.
Al examen neurológico se encontró consciente y alerta. El
perímetro cefálico era normal para la edad. El examen fundoscópico no reveló papiledema. No se encontró parálisis
de nervios craneales. La fuerza muscular en las extremidades se encontró normal. Los reflejos osteotendinosos no
estaban exaltados. No se encontraron reflejos patológicos.
INSTRUCCIONES PARA AUTORES
Escribir el articulo en word (doc) u open office (odt)
Facultades en tamaño 9 regular
Resumen en tamaño 12 bold
Fotos y diagramas en png, tiff, pdf o jpg, en la mejor
resolución posible.
DEBEN INDICAR EN QUE PARTE DEL TEXTO
DESEAN INCRUSTAR LA FOTO, REFERENCIANDOLA.
El material debe ser enviado a:
[email protected]
Será publicado en el primer número disponible
siempre que se hayan cumplido las normas.
Nuestro BOLETIN esta indexado en index medicus y cumulative index, la Asociación Médica
realiza un gran esfuerzo para publicar sus artículos y distribuir la revista, lo cual es un gran honor.
Sin embargo necesitamos de su apoyo para seguir
haciéndolo:
HAGASE SOCIO
DONE (a traves de nuestro website)
a
b
Ante a la falta de criterios diagnósticos específicos, en
principio los tumores de origen glial con fenotipos mesenquimales, fueron denominados GS. Posteriormente, la
clasificación de los tumores del sistema nervioso central
de la Organización Mundial de la Salud de 2007 reconoce
al gliosarcoma primario (GSP) como una neoplasia grado
IV; variante del GBM. En la actualidad se acepta la definición que afirma que el GSP es una lesión circunscrita con
componentes bifásicos glial y mesenquimal metaplásico
claramente identificables. Histológicamente el componente glial cumple los criterios citológicos de GBM y el componente mesenquimal puede mostrar una amplia variedad
de morfologías con distintas líneas celulares, entre ellas fibroblástica, cartilaginosa, ósea, adiposa, muscular lisa y/o
estriada.2
Desde el primer reporte de caso de un GS en 1985 por
Stroebe, más de 100 casos han sido descritos, pero pocos
de ellos en la población pediátrica.3 En el actual reporte
se presenta el caso de un paciente masculino de 4 años de
edad con un GSP parieto-occipital derecho y es revisada la
literatura disponible en la población pediátrica.
Fue realizada una resonancia nuclear magnética (RNM)
cerebral contrastada con gadolinio, que demostró un tumor
parieto-occipital derecho de 5.2 x 4.5 x 6.8 centímetros con
realce heterogéneo con el medio de contraste (ver Figura
1). Mediante una craneotomía parietal fue resecada en su
totalidad. El estudio histopatológico arrojó el diagnóstico
de GS (ver Figura 2).
El paciente fue tratado con radioterapia complementaria,
luego de tres semanas de la cirugía. En los controles sucesivos no han sido detectadas secuelas neurológicas y tras
dos años no ha presentado recidiva tumoral (ver Figura 3).
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 43
Figura 1: Imagen preoperatoria de resonancia nuclear magnética cerebral
contrastada con gadolinio
Figura 3: Secuencias de T2 – FLAIR axial del control de resonancia nuclear magnética dos años postoperatorio.
DISCUSSION
Los GS son tumores raros y corresponden entre 1,8 a 2,8%
de los GBM. Al igual que las otras variantes de GBM, afectan principalmente a adultos entre la sexta y séptima década
de la vida, con una frecuencia ligeramente mayor en el género masculino.2
La Organización Mundial de la Salud ha establecido
los 19 años de edad como límite superior para la definición de adolescencia tardía, por lo cual fue realizada una revisión de los reportes de casos publicados hasta junio de 2011 en pacientes con edad igual o inferior a
Figura 2: A. 19 años; encontrándose 28 casos de GS
Tinción con he- en pacientes pediátricos.4 En los casos rematoxilina-eo- visados, el promedio de edad fue 8,5 años
sina
(100X). SD± 6.7 años (rango de 0 a 19) y con una
Tumor maligno índice de masculinidad 2: 1.
de linaje glial
y mesenquimal, Los GS se pueden clasificar en primarios,
constituido por secundarios o post-radiación.5 Los pricélulas grandes marios son diagnosticados en pacientes sin
de núcleo hip- antecedentes de tumores cerebrales o irrae r c r o m á t i c o diación craneal, los secundarios en aquelvesiculoso con los con diagnóstico patológico de GBM
nucléolos con- re-operados (usualmente por recaída) y los
spicuos,
que últimos en pacientes con antecedentes de
se
disponen irradiación craneal por patologías diferen fascículos entes a GBM. En los casos revisados, el
por lo general 79,3% corresponden a formas primarias.
en un patrón En un paciente (3.4%) con antecedente de
peri-vascular de GBM de células gigantes que había recibiapariencia sar- do radioterapia se diagnosticó el único GS
comatoide. B. secundario y el 17.2% tenían antecedentes
Tinción de re- de radiación craneal realizada por hemanticulina con una gioblastoma, leucemia, astrocitoma grado
prominente dis- II o ependimoma.
posición periMediante el análisis molecular de astroccelular (40X).
itomas inducidos por radiación se han
44 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
demostrado
difer- Cuadro 1. Casos de gliosarcoma en pacientes menores de 19 años.
entes mutaciones en
los genes p53, PTEN
y K-ras que podrían
ser específicas de estos tumores.6 Estas
alteraciones explican
la mayor incidencia
de gliomas malignos
en pacientes que han
sido sometidos a radioterapia. En cuanto
a los GS, se cree que
las formas secundarias serían consecuencia de la radioterapia
para el tratamiento de
los GBM, más que un
cambio en el fenotipo
de las líneas celulares
tumorales. El tiempo
transcurrido desde la
exposición hasta el
diagnóstico de un GS
secundario se encuentra alrededor de las 45
semanas.5
El origen de esta
lesión fue motivo de
controversia. Inicialmente se sostuvo que
el componente sarcomatoso se desarrollaba a partir de la transformación neoplásica
de las estructuras vasculares hiperplásicos
contenidas en el lecho
de un GBM. Estudios posteriores no
demostraron la presencia de marcadores NR: No reportado. F: Femenino. M: Masculino.
endoteliales en los elementos sarcomatosos y actual- en contacto con la duramadre, falx cerebri o el cráneo, sin
mente se considera que tiene origen en una vía aber- embargo, otros tumores pueden ser muy infiltrantes con
rante de la diferenciación mesenquimal de un glioma grandes áreas necróticas.9 En 56.5% (13) de los GS en pamaligno.2 Biernat y cols en 1995 fueron los primeros en cientes pediátricos se logró una resección macroscópicademostrar mutaciones idénticas del gen p53 tanto en el mente completa, lo cual probablemente haya sido favorecicomponente gliomatoso como en el sarcomatoso.7 Reis do por la identificación de un claro plano de separación del
y cols descubrieron mutaciones comunes del gen PTEN, tejido sano.
acumulación nuclear de p53, deleción de p16 y amplificación de CDK4 en ambas áreas del tumor.8 La iden- Los hallazgos en los estudios de imagen son también varitificación de estas alteraciones genéticas y desbalances ables. En tomografía, las lesiones pueden aparecer con
grandes áreas necróticas y realce heterogéneo del medio
cromosómicos han confirmado su origen monoclonal.
de contraste, similar a lo visto en GBM, o como lesiones
Además de las diferencias genéticas, ciertas característi- hiperdensas con márgenes bien definidos y realce homogécas sugieren que es una entidad separada; entre ellas su neo, simulando un meningioma. Son escasas las descriplocalización anatómica y apariencia radiológica. Los GS ciones detalladas de la apariencia en RNM, dado que la
casi nunca son infratentoriales y la mayoría de los reportes mayoría de las series de casos fueron reportadas cuando
describen su predilección por el lóbulo temporal seguido era de la tomografía axial computarizada (TAC) el métopor el lóbulo frontal. La lesión usualmente es encontrada do de imagen más difundido y asequible. Los reportes de
como masas firmes, bien circunscritas, hacia la periferia caso más recientes muestran que los hallazgos en RNM
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 45
r son similares a los observados en TAC; es decir, masas
con realce heterogéneo con bordes que pueden ser irregulares o bien delimitados. El edema peritumoral usualmente
es muy intenso.2
El GS, como variedad del GBM, también es reconocido por
se altamente agresivo y de pobre pronóstico. En adultos, la
sobrevida media es de 4 meses si no se realiza tratamiento complementario y entre 6,25 y 11,5 meses en aquellos
sometidos a quimioterapia y radioterapia.2 También han
sido reportados casos anecdóticos con sobrevidas hasta de
22 años sin recurrencia. En adultos, un mayor intervalo libre de enfermedad ha sido asociado con el predominio del
componente sarcomatoso.5
El análisis de sobrevida con la curva de Kaplan-Meyer
demostró que la sobrevida media estimada en la serie de
casos revisada fue 20.7 meses (rango 0 a 34 meses). La sobrevida de los pacientes con GS primarios fue 22,1 meses
(IC95% 15,7-28,4) y 16,8 meses (IC95% 7.8-25.8) en los
secundarios; grupos en los cuales no fueron encontradas
diferencias estadísticamente significativas (p= 0.27). Tampoco fueron encontradas diferencias significativas en la sobrevida según el género.
El periodo transcurrido hasta la muerte del paciente se
relacionó con la extensión de la resección quirúrgica. En
los pacientes en que se logró una resección completa este
periodo fue de 20.9 meses (IC95% 19,7-30,2) mientras que
en los que tenían remanentes macroscópicos fue de 10,7
meses (IC95% 19,7-30,2). Estas diferencias fueron estadísticamente significativas (p= 0.005)
Dada la rareza de esta entidad en la población pediátrica,
se desconoce si existe alguna medida terapéutica específica, por lo que usualmente se indica la mayor resección
quirúrgica posible, aunado a tratamiento complementario
con radioterapia y quimioterapia.
El GS es una variedad rara de GBM cuya presentación
en pacientes menores de 19 años es muy rara. Uno de los
posibles factores de riesgo es la exposición a radiación
ionizante, como tratamiento para otras lesiones tumorales
que comprometen la cavidad craneal. Los hallazgos patológicos usualmente revelan un tumor firme y bien delimitado, que al examen microscópico presenta un patrón
bifásico, en el que se destaca un componente glial compatible con glioblastoma multiforme y otra mesenquimal
con distintas líneas celulares, entre ellas fibroblástica, cartilaginosa, ósea, adiposa, muscular lisa y/o estriada. Como
en las demás variedades de glioblastoma multiforme, el
pronóstico del GS en la población pediátrica también es
desfavorable con una sobrevida media aproximada de 10
meses luego del diagnóstico, aun suministrando tratamiento complementario.
REFERENCIAS
1. Moiyadi A, Sridhar E, Jalali R. Intraventricular gliosarcoma: unusual
location of an uncommon tumor. J Neurooncol 2010;96:291-294.
2. Han SJ, Yang I, Tihan T, Prados MD, Parsa A. Primary gliosarcoma:
key clinical and pathologic distinctions from glioblastoma with implications as a unique oncologic entity. J Neurooncol 2010;96:313-320.
3. Tude Melo JR, Pitanga AL, Reis RC, Cardoso MA. Infantile glios
arcoma. Arq Neuropsiquiatr 2008;66(1):88-89.
4. Organización mundial de la salud. La salud de los jóvenes: un
desafío para la sociedad, 2000, Informe Salud para todos en el año
2000. Ginebra (Suiza): Organización mundial de la salud; 1986.
5. Han SJ, Yang I, Otero JJ y cols. Secondary gliosarcoma after diagnosis of glioblastoma: clinical experience with 30 consecutive patients. J Neurosurg. 2010;112:990-996.
6. Brat DJ, James CD, Jedlicka AE y cols. Molecular genetic alterations in radiation-induced astrocytomas. Am J Pathol.
1999;154:1431-1438.
7. Biernat W, Aguzzi A, Sure U, Grant JW, Kleihues P, Hegi ME. Identical mutations of the p53 tumor suppressor gene in the gliomatous
and the sarcomatous components of gliosarcomas suggest a common
origin from glial cells. J Neuropathol Exp Neurol 1995;54:651-656.
8. Reis RM, Könü-Lebleblicioglu D, Lopes JM, Kleihues P, Ohgaki
H. Genetic profile of gliosarcomas. Am J Pathol. 2000;156:2:425432.
9. Perry J, Ang LC, Bilbao JM, Muller PJ. Clinicopathologic features of primary and postirradiation cerebral gliosarcoma. Cancer
1995;75:2910-2918.
10. Karremann M, Rausche U, Fleischhack G y cols. Clinical and epidemiological characteristics of pediatric gliosarcomas. J Neurooncol
2010; 97:257-265.
11. Salvati M, Lenzi J, Brogna C y cols. Childhood’s gliosarcomas:
pathological and therapeutical considerations on three cases and critical review of the literature. Childs Nerv Syst 2006;22:1301-1306.
12. Ono N, Nakamura M, Inoue HK, Tamura M, Murata M. Congenital gliosarcoma; so-called sarcoglioma. Childs Nerv Syst
1990;6:416-420.
13. Radkowski MA, Naidich TP, Tomita T, Byrd SE, McLone DG.
Neonatal brain tumors: CT and MR findings. J Comput Assist Tomogr 1988;12:10-20.
14. Kaschten B, Flandroy P, Reznik M, Hainaut H, Stevenaert A. Radiation-induced gliosarcoma. Case report and review of the literature.
J Neurosurg 1995;83:154-162.
15. Okami N, Kawamata T, Kubo O, Yamane F, Kawamura H, Hori
T. Infantile gliosarcoma: a case and a review of the literature. Childs
Nerv Syst 2002;18:351-355.
16. Rizk T, Nabbout R, Koussa S, Akatcherian C. Congenital brain
tumor in a neonate conceived by in vitro fertilization. Childs Nerv
Syst 2000;16:501-502.
17. Cerame MA, Guthikonda M, Kohli CM. Extraneural metastases
in gliosarcoma: a case report and review of the literature. Neurosurgery 1985;17:413-418.
18. Deb P, Sharma MC, Chander B, Mahapatra AK, Sarkar C. Giant
cell glioblastoma multiforme: report of a case with prolonged survival and transformation to gliosarcoma. Childs Nerv Syst 2006;22:314319.
19. Lach M, Wallace CJ, Krcek J, Curry B. Radiation-associated
gliosarcoma. Can Assoc Radiol J 1996;47:209-212.
20. Lee YY, Castillo M, Nauert C, Moser RP. Computed tomography
of gliosarcoma. AJNR Am J Neuroradiol 1985;6:527-531.
21. Takaue Y, Sullivan MP, Ramirez I, Cleary KR, van Eys J. Second
malignant neoplasm in treated Hodgkin’s disease. Report of a patient
and scope of the problem. Am J Dis Child 1986;140:49-51.
22. Goldstein SJ, Young B, Markesberry WR. Congenital malignant
gliosarcoma. AJNR Am J Neuroradiol 1981;2:475-476.
23. Chadduck WM, Gollin SM, Gray BA, Norris JS, Araoz CA, Tryka AF. Gliosarcoma with chromosome abnormalities in a neonate exposed to heptachlor. Neurosurgery 1987;21:557-559.
24. McKeever PE, Wichman A, Chronwall B, Thomas C, Howard
R. Sarcoma arising from a gliosarcoma. South Med J 1984;77:10271032.
25. Kepes JJ, Bastian FO, Weber ED. Gliosarcoma developing from
an irradiated ependymoma. Acta Neuropathol (Berl) 1996;92:515519.
26. Hocwald O, MsFadden D, Osiovich H, Dunham C. Congenital
gliosarcoma: detailed clinicopathologic documentation of a rare neoplasm. Pediatr Dev Pathol 2009;5:398-403.
27. Moreira RK, Koppe D, Zignani J, y cols. Gliossarcoma de
tronco cerebral en paciente pediátrico: relato de caso. Radiol Bras
2004;37:61-63.
28. Sarkar C, Sharma MC, Sudha K, Gaikwad S, Varma A. A clinico-pathological study of 29 cases of gliosarcoma with special reference to two unique variants. Indian J Med Res. 1997;106:229-235.
46 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
ABSTRACT
Brain gliosarcoma is a rare variant of glioblastoma
multiforme that occurs primarily between the sixth
and seventh decades of life. Few cases have been reported in patients younger than nineteen years. We report a four-year-old male with clinical, imaging and
pathology compatible with brain gliosarcoma. Beside
surgery he was managed with adjuvant radiotherapy
and after follow-up is free of recurrence or neurologic deficit. Brain gliosarcoma is highly aggressive and
the median survival is related to the extent of surgical
resection.
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Review Articles/Artículos de Reseña
THYROID CANCER IN CHILDREN
Gabriel Rivera MSa, Humberto Lugo-Vicente MDb*
UPR School of Public Health, Puerto Rico Health Science Center, Rio Piedras, Puerto Rico.
Section of Pediatric Surgery, Department of Surgery, UPR School of Medicine, Puerto Rico Health Science Center, Rio
Piedras, Puerto Rico.
*Corresponding author: Humberto Lugo-Vicente MD – PO Box 10426, San Juan, Puerto Rico, 00922. E-mail: titolugo@
coqui.net
Presented as 3rd Annual Gordon S. Cameron Visiting Professor in Pediatric Surgery at McMaster University and McMaster Children Hospital, Hamilton, Ontario, Canada, June 2014.
a
b
ABSTRACT
Cancer of the thyroid gland in pediatric patients is rare and if left untreated spreads and
become lethal. Thyroid nodules in pediatric patients are four times more likely being malignant than adult nodules. The incidence of thyroid cancer in children increases with age,
sex, race and nodule size. Exposures to low level of head and neck irradiation at young age,
cancer survivors, family history of thyroid cancer and iodine deficiency are specific risk
factors to develop thyroid cancer. Thyroid cancer is subdivided into papillary, follicular and
medullary thyroid cancer varying in histological characteristics. Children who present with
thyroid nodules should undergo ultrasound and fine needle aspiration biopsy to evaluate
malignant potential. If biopsy results are positive for malignancy best option is complete
surgical resection of the thyroid gland with central lymph node dissection followed by radioactive iodine treatment. Surgeons need to take certain precaution to avoid postoperative
complications like hypoparathyroidism or recurrent laryngeal nerve damage. Follow-up is
essential in order to evaluate remission or recurrence. An excellent prognosis in pediatric
patients is the result of such an aggressive approach that can be supported by the low complications rate and low recurrence rate following surgery.
Index words: thyroid, cancer, children, papillary, follicular, medullary
INTRODUCTION
Pediatric thyroid cancer is relatively uncommon, but a
curable disease. It is the third most common solid tumor
in children and adolescents, as well as, the most common
endocrine malignancy of childhood [1, 2]. Pediatric thyroid carcinomas have similar manifestations and etiology as compared with adult. Yet, the presence of thyroid
nodules in children is four times as likely to be malignant
than adult nodules [3]. Prevalence studies, estimated that
20% of thyroid nodules in children are malignant while
only 5% of adult nodules are malignant [4]. The chance
of thyroid nodules being malignant also increases with
history of past radiation exposure, previous malignancies, family history of thyroid cancer or presence of
Medullary Endocrine Neoplasia (MEN). The low incidence and the lack of randomized clinical trials keeps
management and treatment options of thyroid cancer in
children a subject for debate.
cancer (PTC) accounts for approximately 85-90%, follicular thyroid cancer (FTC) for 8-10%, medullary thyroid cancer (MTC) for 2-5%, anaplastic cancer for 1-2%
and rare mixed types for less than 0.1%. Papillary and
Follicular thyroid carcinoma together are known as Differentiated Thyroid Cancer (DTC) because they can be
differentiated based on their histological characteristics
of the thyroid epithelial cells and their biological behavior.
EPIDEMIOLOGY
The incidence of pediatric thyroid cancer increases with
age and peaks at age fifteen to 19 years. In children less
than ten years of age, the incidence of DTC occurs in
one of 1,000,000; in children from 10-14 years of age
the incidence increases to one in 200,000 and in the age
group of 15-19 the incidence increases to one in 75,000
[7] (see Figure 1). This increase in incidence with age
demonstrates the threat that late diagnosis could have
on the health of the child. Moreover, the incidence has
been increasing 1.1% annually due to the increase surveillance and use of imaging in the past years [6, 7, 8].
Several studies observed that the prevalence of thyroid
nodules in children ranges from 0.2% to 5%, compared
with a prevalence of approximately 30% in adults [5].
The incidence of pediatric thyroid cancer is 0.54 cases
per 100,000 children born per year [6]. Papillary thyroid
The incidence of DTC varies by race and gender, with
higher rates seen in white and Hispanic females as compared with black females and males of any other race
[4]. The sex ratio pre-pubertal is similar for male as for
females [6]. However, post-pubertal females are
48 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
four-times more likely
to have thyroid cancer
than males [6, 9, 10].
The average tumor size
of most pediatric thyroid carcinoma is about
2.5 cm. Lymph node
involvement at diagnosis is present in 40-90%
of all children [6]. Distant metastases may be
at the bones, but most
commonly present at
the lungs in 20-30% of
the children [6]. Thyroid multifocal cancer
is mostly observed in
40% of childhood PTC
cases and predominantly on children [6]. If the
age of onset of thyroid
cancer is before ten
years, the patient has a
higher recurrence and
mortality rate than a
patient whose age of
onset is older than ten
years of age [6]. The
prognosis and survival
rate for most DTC is
excellent. Long-term Figure 1: Incidence of Differentiated Thyroid Cancer.
follow-up data was collected from a series of thyroid
regions, mainly observed in sub-developed countries, or
cancer patients, which showed 30 years survival rate of
after suffering autoimmune thyroiditis.
90-99% of children with DTC [6].
CLASSIFICATION
RISK FACTORS
Thyroid cancers originate from the two cell types presSpecific risk factors in children with DTC cannot be
ent in the thyroid gland. The follicular cells give rise
clearly identified, but there are predisposing factors that
to papillary thyroid cancer, follicular thyroid cancer and
increase the probability of a lesion being malignant. Exprobably anaplastic cancers. The parafollicular C-cells
posure to low level of head and neck irradiation has been
give rise to medullary thyroid carcinomas. The most
recognized for more than six decades as influencing the
common pediatric thyroid follicular malignancy is papgrowth and progression of DTC [6]. The risk to develop
illary thyroid carcinoma. It accounts for over 90% of all
cancer was first revealed in children treated with irradiachildhood thyroid cancer and is more common in youngtion for tinea capitis and acne. Later, a massive increase
er age patients than in adults [12, 13]. It is characterized
in the incidence of thyroid cancer in children was obas a multicentric disease because it usually originates in
served after radiation exposure in the nuclear reactor exmany areas of the thyroid gland eventually compromisplosion at Chernobyl in 1985 [6]. Recently, it has been
ing the entire gland [12]. This cancer can also invade
suggested that childhood dental radiographs increases
adjacent extra-thyroidal tissue. PTC has a high incidence
DTC risk two-folds [11].
of cervical lymph node and distant metastases at the time
of diagnosis of 90% and 25%, respectively.
Another group of children at risk are cancer survivors
who have had head and neck irradiation. Thyroid cancer
Follicular thyroid cancer (FTC) is uncommon in chilis the most common second malignancy in children who
dren and tends to be more prevalent in iodine deficiency
have had Hodgkin and non-Hodgkin’s lymphomas and
areas [14]. FTC is more aggressive than PTC. This type
the third most frequent malignancy in leukemia surviof cancer is difficult to differentiate from normal thyroid
vors [6]. Moreover, malignancy can increase in children
tissue or benign follicular adenoma in fine needle aspiwho are born into families where two or more individration (FNA). FTC patients are more prone to vascular
uals in the family have DTC; better known as Familial
invasion, making the disease harder to control. Invasion
Non-medullary DTC. Thyroid nodule’s probability of
of the vascular system also increases the risk of metastabeing malignant may also increase in iodine deficiency
sis to different sites like regional nodes, bones, liver and
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 49
lungs; giving FTC patients a worst prognosis as compared with PTC.
Medullary thyroid cancer (MTC) is a rare type of cancer which produces excessive amount of calcitonin due
to the uncontrolled growth of cancerous parafollicular
C-cells. Calcitonin is the marker for diagnosing the
presence of this type of cancer. MTC accounts for up to
2-5% of all thyroid malignancies [15]. It may develop
spontaneously or after familial inheritance pattern of autosomal dominance. Usually, familial MTC is associated
with Medullary Endocrine Neoplasia type-2 (MEN2).
Over time MEN2 develop a spectrum of C-Cell disorders beginning with C-cell hyperplasia, increases release
of calcitonin and progressing to outgrowth of multiple
foci and microscopic carcinoma [16, 17]. MEN2 types
vary in their secondary presentations, but all of them certainly lead to MTC. MEN2A presents with pheochromocytoma and parathyroid gland proliferation abnormalities. MEN2B manifests pheochromocytoma, mucosal or
oral neuromas and a Marfanoid habitus [15, 18]. Genetic
testing for MEN2 can detect a mutation in the RET proto-oncogene at chromosome number ten. Prophylactic
thyroidectomy is usually offered to these patients due to
the aggressiveness and lethality of these tumors.
SUSPECTED THYROID CANCER
Thyroid cancer should be suspected when thyroid nodules are found in children and adolescents [4, 6]. If a thyroid nodule is found the diagnostic test should include:
thyroid stimulating hormone (TSH) and calcitonin (Ct)
levels as well as ultrasonography (US) and fine needle
aspiration (FNA) of the gland. Calcitonin levels are used
as screening and diagnostic test for MTC. TSH suppression can help identify any hyperfunctioning thyroid nodules. The US findings that suggest malignancy from nodules include the presence of microcalcification, indistinct
margins and variable echotexture [6]. In addition, US can
also help identify intrathyroidal location of nodules, additional nodules and evaluate for involvement of lymph
nodes [4]. FNA is the most accurate means to determine
malignancy, but often limited by the size of the thyroid
nodule [4, 19, 20].
STAGING
In order to treat a thyroid cancer patient a physician must
know the stage of the disease. The TNM staging system
established in 1997 for thyroid solid tumors is a cancer
staging notation system that gives codes to describe the
stage of a patient’s malignancy. The T stands for tumor
size. T1 is a tumor size less than 1 cm, T2 between one
and 4 cm, T3 greater than 4 cm and T4 manifest extrathyroidal invasion. The N stands for regional nodal metastases (N1=presence and N0= absence), and M stands
for distant metastases (M1=presence and M0= absence)
[21]. It is important to note that treatment ought to be
adjusted depending on the staging of the child.
Another staging system is known as the MACIS Scoring System. It is a system based on multivariate analyses
50 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
sed to identify variables predictive of cause-specific
mortality in patients with PTC [21]. MACIS stands for
Metastasis, Age, Completeness of resection, Invasion
and Size. Hye Won Lang et al, determined a MACIS
score cut-off value of less than 4.0 as a useful predictor
of a poor prognosis for children and young adults under
the age of twenty-one [22]. This scoring system should
be adjusted and managed carefully for children under the
age of ten, as these tend to present with a more aggressive disease.
SURGICAL MANAGEMENT
Preoperative preparation of pediatric patients with thyroid cancer involves a general and a thyroid focused
examination [6]. The neck exam should consist of
palpating the thyroid in order to evaluate the size and
the nodularity, as well as assessing the cervical lymph
nodes for metastasis. Surgical candidates in addition to
the neck exam must also undergo vocal cord function
evaluation before the procedure, especially after a primary thyroid procedure [6]. Informed consent should
be attained from the parents. In this consent form, the
parents should understand that thyroid surgery has it’s
own risk and complications such as vocal cord paralysis,
hoarseness, loss of voice, hypoparathyroidism, infection,
hemorrhage and keloid formation. Once the physician
attains the consent form, the patient is scheduled and admitted to the hospital for surgery.
Surgical options for management of patients with DTC
include total thyroidectomy (TT), near-total thyroidectomy (NTT), sub-total thyroidectomy (SubTT) or lobectomy [23]. A TT is a complete resection of the thyroid
gland. When TT can cause irreversible damage to either
the recurrent laryngeal nerve (RLN) or the parathyroid
glands, a NTT is performed. This procedure leaves a
small amount of thyroid tissue in situ, which could later
be inactivated with radioactive iodine therapy. The risk
of hypoparathyroidism and damage to the RLN is further
reduced with a SubTT, in which only the contralateral
lobe, the isthmus and the medial portion of the ipsilateral
thyroid lobe is removed [24]. Lastly, a lobectomy could
be performed which is the resection of an anatomical
lobe.
The required surgery for children with DTC is total thyroidectomy (TT) with central node compartment dissection. Central node compartment dissection (CND), comprising compartment VI of the neck, is the most common
site of lymph node metastatic spread [25, 26]. The compartment extends from the hyoid bone to the sternal manubrium and laterally between the two carotid sheaths
[26]. Routine selective or modified lymph node dissection for FNA proven metastatic cervical lymph nodes
should be performed along with TT since it reduces the
incidence of local recurrence and reduces morbidity of a
second procedure.
In order to perform a flawless and low risk procedure,
surgeons use tools like recurrent laryngeal never stimulator, hemostatic agents and sealants. Intraoperative
u nerve monitoring (IONM) of the recurrent laryngeal
nerve (RLN) is used to evaluate the nerve’s function and
integrity after appropriate anatomic identification. Several studies have demonstrated IONM to be a successful
and easy method for prevention of nerve damage during
thyroid surgery in childhood and young adolescence
[27, 28]. Besides IONM of the RLN, surgeons also use
hemostatic agents and sealants in order to aid ceasing
hemorrhage during surgery. The most used sealants
are Floseal, Tisseel and TahoSil. Each of these sealants
works at different stages of the coagulation cascade, but
they all help to increase coagulation reducing hematoma formation. Surgeons also use hemostatic agents like
the Harmonic scalpel and the Ligasure device that work
via high frequency vibrations to generate heat denaturaturalizing proteins forming a sticky coagulate while simultaneously cutting vessels. These hemostatic devices
reduce operating time significantly.
Performing a total thyroidectomy in pediatric patients
has several advantages on diagnosis and follow-up.
First, thyroglobulin (Tg) is better used as a marker to
evaluate relapse or recurrence. Second, it removes all
potential tumor sites and any remaining tumor developing in the contralateral lobe. Third, removal of all thyroid
gland excludes the possibility of papillary cancer residues transforming into a non-differentiated type anaplastic tumor [23]. Fourth, radioactive iodine (RAI) therapy
serves as a more effective treatment post-surgery. Finally, with a total thyroidectomy the physician has a higher
possibility of finding distant metastases, especially in
the lungs using whole body scintigraphy. Nevertheless,
performing a TT with CND carries an increase risk of
post-operative complications.
Surgical management for patients with MEN2, a disease
that inevitably causes MTC, is quite different from DTC
patients. After early genetic screening and plasma calcitonin level evaluation, pediatric patients should undergo
a prophylactic thyroidectomy. Thyroidectomy should be
performed before MTC has had the opportunity to develop and spread beyond the thyroid bed [16].
POST-OPERATIVE MANAGEMENT
Many pediatric thyroid cancer patients who have already
presented with signs and symptoms are advised to undergo radioactive Iodine (RAI) treatment using 131I. The
mechanism of action of RAI treatment is for the thyroid
gland to absorb radioiodine through the sodium-iodine
pump and eventually destroy any residual cancerous or
noncancerous thyroid tissue left after surgery. This therapy also helps identify any distant metastasis, local metastasis and vascular invasion of the cancer. RAI treatment
is administered orally and usually one therapy course is
needed [6]. The indication for treatment with RAI starts
with evaluating the tumor size and determining if it is
greater than one cm. If it is greater than one cm after
TT with CND patients are administered a dosage based
on their body weight of approximately 1.5 to 3.0 mCi/
kg. Any spread of tumor beyond the thyroid gland is
usually managed with 150 mCi, extrathyroidal extension
with 100-150 mCi and distant metastasis with 200 mCi
depending on the weight of the child [12].
Before performing radioactive ablation a few measures
must be followed in order for treatment to work effectively. Radioactive ablation is usually performed six
weeks after surgery. For the first four weeks patients are
placed in L-triiodothyronine (LT3) at 1 mg/kg/day in 2
or 3 divided doses. The last two weeks before RAI, LT3
is withdrawal [6]. Removing the LT3 allows sufficient
time to obtain a TSH greater than 30 mU/L, which allows for maximal radioiodine uptake by any remnant
thyroid tissue [1, 4]. Along with the LT3 withdrawal on
the last two weeks before therapy, a low iodine diet is administered to the patient. This diet will further maximize
radioactive uptake by the thyroid cells. Chow and colleagues validated that local recurrence rates for patients
who did not receive RAI were significantly higher than
for those who received RAI, 42% and 6.3% respectively
(p = 0.001) [29]. Additionally, Handlekiewicz & Junak
et al. demonstrated that the lack of RAI therapy after surgery increased the risk of recurrence in the thyroid bed
eleven-folds (p=0.03) and increased lymph node metastasis by a factor of 3.2 (p = 0.02) [28].
Radioactive iodine therapy is associated with short- and
long-term risks [8]. The high cumulative activity of RAI
and the radioactive iodine parse may be associated with
an increase in the incidence of secondary primary malignancy (SPM) due to their carcinogenic effect. Yet, after
a secondary analysis of European SPM, Zanzonico et
al. established that there is no evidence of an increase
risk of SPM after RAI treatment in DTC children using
the doses mentioned before [6, 30, 31]. RAI also has
a long-term adverse effect on the gonads. An absorbed
dosage above 1 Gy of 131I increases the possibility of
damaging the gonads and causing gamete mutation. For
females it is recommended to avoid pregnancy for six to
12 months after RAI therapy due to an increase rate of
miscarriages after the first year of therapy [32]. For men,
sperm banking should be considered if the patient is going to receive a dose greater than 378 mCi 131I [6]. RAI
treatment transitory damages the salivary glands causing
sialadenitis. Finally, pulmonary fibrosis is of mayor concern in pediatric patients with diffused lung metastases
because they tend to receive multiple doses of 131I to
completely remove lung metastases.
It is recommended that children who undergo total thyroidectomy received oral calcium and vitamin D for as
long as six weeks after surgery. Serum calcium is monitored post-surgery since it usually drops slightly due to
vascular trauma to the parathyroid gland. Once calcium
levels are normal or near normal the patient is discharged.
Serum calcitonin is still monitored for six months and
every six to 12 months thereafter [1]. For patients who
underwent MTC associated total thyroidectomy, thyroid
hormone replacement is required, as radioactive iodine
treatment has no function.
FOLLOW-UP
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 51
Pediatric thyroid patients should undergo periodic monitoring for the rest of their lives no matter the severity
of their cancer. Follow-up care of children with DTC is
crucial in order to adequately assess whether a patient is
free of disease. Consists of measuring TSH levels, thyroglobulin (Tg) levels, performing ultrasound of the neck
along with whole body radioiodine scans. After surgery
patients who undergo total thyroidectomy are placed in
Levothyroxine (LT4) therapy for six months, suppressing TSH levels to less than 0.1 mU/L. Tg is stimulated
and later evaluated based on blood serum levels. Tg level
assessment is recommended every six to 12 months after
diagnosis until the patient is free of disease. Stimulated
Tg levels less than 0.1ug/L indicate no disease is present. Levels of 0.1 to 2.0 ug/L signify 30% of patients
may have residual disease, and with levels of 2.0 to 10.0
ug/L it is most likely significant residual disease is present [33].
Residual disease portents tumor that is remaining after
surgery. Neck ultrasonography is indicated for all those
children who could possibly have residual disease present. Those with values greater than 10 ug/L should also
undergo CT-Scan and/or MRI scanning of the neck and
chest areas. If lymph node disease is present on the US,
FNA or CT, reoperation is indicated followed by RAI until disappearance of active tissue. If the patient presents
with residual disease but the US, FNA or CT are negative
this patients is still advice to be treated with RAI until
disease vanishes. If no signs of residual disease is present, US should be performed routinely every six months
for 18 months and then every 3 to 5 years. For pediatric
patients the most important follow up examination is the
whole-body radioiodine scan. It is recommended at six
to 12 months after diagnosis using 2-5 mCi. This diagnostic tool is so crucial since it is especially useful in
detecting lung metastasis.
Medullary thyroid carcinomas associated with MEN2
have a different follow-up approach. These patients are
rendered disease free depending on the levels of plasma
calcitonin post-thyroidectomy. Plasma calcitonin is not
enough to assure that the patient is disease free. Blood
testing is also used to measure carcinoembryonic antigen
level and neck ultrasound also helps validate for remission. These patients have to be constantly and carefully
monitored for any indications of developing pheochromocytoma and hyperparathyroidism along with levothyroxine substitution [16].
REMISSION
Now a day physicians are following the “treat-to-negative iodine whole body radioiodine scan” with pediatric patients [1]. This is usually done because we still
do not know the serum Tg level in children in order to
determine the aggressiveness of the treatment plan [1].
Hence, a child is considered disease free if there is a
negative 131I uptake outside of the thyroid bed, a clean
ultrasound of the neck, a negative Positron Emission
Transmission scan, and undetectable Tg less than 1ug/L.
Patients who undergo total thyroidectomy with CND due
52 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
to MEN2 are considered disease free when there is undetected serum calcitonin level and a negative neck US.
RECURRENCE
Recurrence denotes the reappearance of a treated disease
thought to be eradicated. Surgical management with total thyroidectomy has been proven by many studies to
exhibit less number of patients with relapse. Patients
who underwent lobectomy had a local recurrence rate
sevenfold higher than those who endured a total thyroidectomy [21]. Handkiewicz & Junak et al., observed
that less than total thyroidectomy increases thyroid bed
recurrence risk 9.5 times more than children with complete thyroidectomy (p=0.04) [30]. Treatment with RAI
does pose a threat to many children by exposing them to
secondary risks. The lack of postoperative radioiodine
therapy independently increases the risk of recurrence by
a factor of 11.0 (p = 0.03) [30].
Physicians can still predict the probability of recurrence
before managing patients based on a few predictive factors of recurrence. Being a child under the age of ten
years increases the likelihood of recurrence and of reoperation. Spinelli et al. found that 87.5% of patients
younger than fifteen years old who already had cervical
lymph node involvement at diagnosis had to be re-operated, versus 27% of patients older than fifteen with cervical lymph node involvement at diagnosis (p < 0.001)
[34]. Another risk factor for recurrence is the presence
of cervical lymph node involvement at diagnosis. Disease free survivals at five and 10 years were, respectively, 58% and 38% for those patients with initial cervical
lymph node involvement and 94% and 90% for those patients with no involvement of cervical lymph nodes [34].
Additionally, another predictive factor for recurrence is
if the tumor was radiation induced. Radiation induced
PTC children were observed to have a higher incidence
of recurrence than those children who developed non-radiation induced tumors, 63.3% and 2.9%, respectively
[23]. Other predictive factors are presence of multifocal
thyroid disease and a large size tumor. Recurrence is diagnosed based on the same tests used in
follow-up. Therefore, the presence of an absorbed radiation in a 131I whole body scan, indistinguishable corners in neck ultrasound and a high presence of Tg level
is highly indicative of recurrence. Tg levels are a better
marker of recurrence when the child has undertaken radioactive ablation therapy. For patients with MTC a high
thyrocalcitonin level is suggestive for recurrence. Recurrence is managed with surgery and radioactive ablation.
Surgery is most effective if the disease is amenable to
resection. However, the surgeon must keep in mind that
a second surgery and exposure to a high dosage of radioiodine does increase chances of morbidity in children.
PROGNOSIS
Compared to adults with thyroid cancer, children have
a better prognosis with a mortality rate less than 10%.
The 20-year survival rate for these pediatric patients is
90-99% and 70-80% disease free at 5-years after diagnosis [34-42]. The reason for such a good prognosis in
pediatric thyroid carcinoma is due to the well-differentiated histology of the tumors, few metastases occur to
bone, and the excellent response to radioactive iodine
therapy. Nonetheless, there are some adverse factors,
which would lead to a worst prognostic. These factors
are a tumor greater than 3 cm in size, patients younger
than ten years of age, presence of local and distant metastasis and an aneuploidy DNA [9, 35]. Many of these
factors are considered prognostic effectors because they
tend to lead to either, recurrence or mortality.
CONCLUSION
Total thyroidectomy with central node dissection is not
only the preferred procedure to manage children with
thyroid cancer, but it is also the most ideal procedure for
an effective post-operative therapy and follow-up examination.
Pediatric thyroid cancer cases need to be attended with
maximum care and attention since optimal surveillance
techniques and diagnostic intervals have not yet been determined. It is our interest that many other studies collaborate to answer questions like ideal Tg level or ideal
TSH suppression level in order to make the treatment
of pediatric patients effective. Pediatricians should keep
performing routine examinations of the thyroid gland in
order to prevent many of these new cancer cases.
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[42] Gerber, Mark, MD. "Pediatric Thyroid Cancer ." Pediatric Thyroid Cancer. Medscape, 12 July 2013. Web. 13 July 2014.
RESUMEN
Cáncer de las glándula tiroideas en pacientes
pediátricos es raro, pero si no se maneja puede extenderse y ser letal. Nódulos de la tiroides en pacientes pediátricos son cuatro veces más probables de
ser malignos en comparación con los adultos. La
incidencia de cáncer del tiroides en niños aumenta con la edad, el sexo, la raza y el tamaño de los
nódulos linfáticos del cuello. Exposiciones a niveles altos de irradiación en la cabeza y el cuello a
edad temprana, ser sobreviviente de cáncer, tener
familiares con cáncer de tiroides y la deficiencia de
yodo son algunos de los factores de riesgo para desarrollar cáncer del tiroides. El cáncer del tiroides
se subdivide en papilar, folicular y medular. Estos
varían en sus características histológicas. Los niños
que se presentan con nódulos en el tiroides deben
ser sometidos a una serie de procedimientos con
el fin de evaluar la malignidad del nódulo. Si estos resultados resultan positivos, la mejor opción
es remover quirúrgicamente la glándula tiroidea. El
procedimiento más eficiente es la tiroidectomía total con disección central de nódulos linfáticos del
cuello, seguido del tratamiento con yodo radiactivo.
Los cirujanos durante la intervención deben tener
cierta precaución para evitar complicaciones como
hipoparatiroidismo o daño del nervio laríngeo recurrente. El seguimiento es esencial para evaluar la
remisión o recurrencia. Sin embargo, un excelente
pronóstico en pacientes pediátricos es el resultado
de un enfoque agresivo que puede ser apoyado por
pocas complicaciones y bajas tasa de recurrencia
después de la cirugía.
a
c
i
s
í
dad f
i
v
i
t
ac
Elsa Pedro Pharm.D.a, Fránces M. Rodríguez Pharm.D.a
a
School of Pharmacy, University of Puerto Rico, and Comprehensive Cancer Center, Puerto Rico Health Science Center, San Juan,
Puerto Rico.
*Corresponding author: Elsa Pedro, Pharm D – School of Pharmacy, University of Puerto Rico, Medical Science Campus, PO
BOX 365067, San Juan Puerto Rico 00936-5067. E-mail: [email protected]
Segments of this article were presented to the Senate of Puerto Rico as part of the Position Statement of the Oncologic Hospital
Dr. Isaac González Martínez regarding the Medicalization of Marihuana.
Existe una fuente de la juventud.
Millones de personas ya la descubrieron - el secreto para sentirse mejor y
vivir más
tiempo. Se llama actividad
física. Encontrar un programa que funcione para usted y seguirlo puede rendirle
enormes dividendos. El ejercicio habitual
puede prevenir o demorar la aparición de
diabetes y problemas cardíacos. También puede reducir el dolor de la artritis,
la ansiedad y la depresión. Puede ayudar a que las personas mayores sean independientes.
Existen cuatro tipos principales de ejercicios y las personas mayores necesitan
un poco de cada uno:
• Actividades de resistencia - como
caminar, nadar o andar en bicicleta que desarrollan resistencia y mejoran
la salud del corazón y el sistema circulatorio
• Ejercicios de fortalecimiento, que desarrollan tejido muscular y reducen la
pérdida muscular relacionada con la
edad
• Ejercicios para estirar los músculos,
para mantener el cuerpo ágil y flexible
• Ejercicios de equilibrio para reducir
las posibilidades de sufrir una caída.
NIH: Instituto Nacional sobre el Envejecimiento
54 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
USE AND MEDICALIZATION OF
MARIHUANA IN CANCER PATIENTS
ABSTRACT
Anecdotal reports and some clinical studies suggest that marihuana (Cannabis sativa) is
effective in treating a variety of conditions such as glaucoma, migraine, pain, spasticity of
multiple sclerosis, anorexia, insomnia, depression, nausea and vomiting. One of the diseases
mostly associated to a beneficial effect from marihuana is cancer. Twenty-one states of the
United States including the District of Columbia have approved the use of marihuana for
cancer and other medical conditions. In Puerto Rico, public debate on criminal penalty removal and medicalization of marihuana has intensified. It is considered essential for health
professionals to have strong scientific evidence on the effectiveness and safety of medications
or substances when recommending them for treating illness. This article discusses scientific
evidence and information provided by prestigious organizations on the effectiveness and
safety of marihuana and its derivatives in cancer patients.
Index words: use, medication, marihuana, cancer, patient
A
BACKGROUND
Anecdotal reports and some clinical studies suggest that
marihuana (Cannabis sativa) is effective in treating a
variety of conditions such as glaucoma, migraine, pain,
spasticity of multiple sclerosis, anorexia, insomnia, depression, nausea and vomiting, among others.
Original
Reportes y estudios clínicos sugieren que la marihuana
es efectiva para tratar glaucoma, migraña, dolor, espasticidad en esclerosis múltiple, anorexia, insomnio, depresión, nauseas y vómitos entre otros6,7.
Currently, twenty-one states in the United States as well
as the District of Columbia have approved the use of
marihuana for some medical conditions. However, extensive controversies have taken place from a judicial
standpoint. In Gonzales v. Raich, 545 U.S. (2005), the
United States Supreme Court established that marihuana medicalization by a state law is unconstitutional, because it violates the United States Constitution Interstate
Commerce Clause (1, 2). In 2009, Attorney General Eric
Holder issued a formal guide to attorneys stating that the
priority is not to prosecute patients with serious conditions who are abiding to state laws related to the medicinal
use of marihuana (3). A study published in 2012, showed
that in states where the use of marihuana for medicinal
purposes has been legalized there is a greater incidence
of marihuana use, abuse, and dependence (4). This study
does not establish a cause-effect relationship; therefore this is deemed to merit further evaluation. Wall et
al. showed that the use of marihuana was increased in
states where the medicinal use of marihuana has been
approved (5). However, Harper et al. replicated this
study and could not find evidence of a causal relationship (6). Another study, published in 2012, showed that
74% of teenagers in Denver (Colorado) have used an average of 50 times marihuana from patients who use it
for medicinal purposes (7). In Colorado, a small group
of physicians, who are state certified medical marihuana specialists, register 49% of the marihuana used in the
state for medicinal purposes. This has brought up the
concern that the practice of these physicians mainly consist on recommending marihuana for medicinal use and
that a conflict of interest may exist since these physicians
currently charge around $100.00 per patient for recommending marihuana (8).
The discussion on removal of marihuana criminal penalty in Puerto Rico has acquired prominence after the introduction of Senate Bill 517 (9). The main objective of
the Bill is to amend the Penal Code to decriminalize the
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 55
possession of up to one ounce of marijuana. Consequently,
public debate on the use of marihuana for medicinal purposes has intensified. Furthermore, House Bill 1362 proposes
an amendment to the Puerto Rico Controlled Substance Act
of 1971 with the purpose of reclassifying marihuana and its
derivatives from Class I to Class II as a means to legalize
its therapeutic medicinal use (10). The goal of this law is to
create a controlled system of legal production.
Cancer patients could benefit from marihuana medicalization if its use were safe and effective. However, what is the
evidence on marihuana safety and efficacy in this type of
patient? The main purpose of this article is to review the
literature and the recommendations of prestigious organizations regarding this subject and discuss some of the most
prominent existing evidence on the use of marihuana in
cancer patients.
The Institute of Medicine (IOM) conducted a scientific literature review to evaluate the benefits and risks of the use
of marihuana for medicinal purposes upon request of the
White House Office of National Drug Control Policy. The
report was published in 1999 (11). The National Cancer
Institute (NCI) has summarized the scientific studies conducted on the subject (NCI’s PDQ cancer information summary), this summary was last modified on March 25, 2014
(12). The American Cancer Society (ACS) has also published its position regarding this topic, updated as recently
as on April 2013 (13).
FINDING
Nausea and vomiting
Marihuana (Cannabis sativa) contains over 60 cannabinoids. The main cannabinoid acting on the central nervous
system is delta-9-tetrahydrocannabinol (THC). The vomiting center, structure that controls emesis and has cannabinoid receptors, is found in the central nervous system,
for this reason THC has shown to be effective in the management of nausea and vomiting (14). In 1986, oral therapy containing THC was approved for the management of
nausea and vomiting because studies showed it was as or
more effective than available medications on the market at
the time. THC available on the market is known as Marinol® (dronabinol). Cesamet® (nabilone). Is a synthetic
cannabinoid derived from THC which is also available in
the United States. Both have been approved by the Food
and Drug Administration (FDA) for the management of
nausea and vomiting in cancer patients. The National Comprehensive Cancer Network (NCCN) recommends these
cannabinoids as rescue therapy when other medications
have not been effective in preventing nausea and vomiting. The use of newer agents is preferred due to the greater effectiveness they have shown in preventing nausea and
vomiting and the occurrence of fewer adverse effects when
compared to oral cannabinoids. Currently, the standard
therapy for the prevention of nausea and vomiting in cancer patients receiving chemotherapy depends on the level
of emetogenicity of the regimen being used and consists
on a combination of medications whose effectiveness has
been widely studied (1). However, the NCI’s PDQ can
56 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
cer information summary states that these newer agents
have not been directly compared with Cannabis sativa or
oral cannabinoids (12).
and gabapentin, with the use of oral nabilone as adjuvant therapy in cancer patients (N=112, 47 treated, 65
non-treated) (24).
Two studies have evaluated inhaled marihuana combined with oral THC in the management of nausea and
vomiting in cancer patients receiving chemotherapy (1516). Chang et al. found this combination to be significantly superior to the comparative placebo group (N=15)
(P < 0.001) (15). However, another study conducted by
Chang et al. did not show significant emesis reduction
compared to the placebo group (N=8) (16). Levitt et al.
compared patient preference for oral THC versus inhaled
marihuana. Nine of 20 patients had no preference (17).
Sample size in these studies was small and, as such, this
information cannot be extrapolated to the general population. The NCI's PDQ cancer information summary
states that inhaled cannabis sativa has not been compared with other antiemetic medications (12).
One study used vaporized cannabis combined with opioids in cancer patients (25). The authors came to the conclusion that cannabis increased opioid analgesic effect
and could be used for opioid dose reduction. This study
was conducted in 21 patients and the author highlights
that more studies are needed to confirm this information.
Appetite
In a randomized, double blind, placebo-controlled, pilot study enrolling 46 patients, oral cannabinoids were
shown to improve chemosensory perception (sense of
smell and taste), quality of sleep, and relaxation in cancer patients (30). Twenty-four of the 46 enrolled patients
received dronabinol while 22 received placebo.
Anorexia, weight loss, and cachexia are symptoms experienced by cancer patients. Currently, dronabinol is approved by the FDA as an appetite stimulant in AIDS patients due to its proven efficacy in these types of patients.
In two studies in which the use of oral cannabinoid in
cancer patients was evaluated, it was not shown to increase appetite (18-19). One of these studies randomized
469 patients to oral THC, megestrol or a combination
of both. Seventy-five (75%) percent patients reported increased appetite with the use of megestrol versus 49%
with the use of dronabinol (P= 0.0001). The combination
of both treatments did not show significant difference
compared with the group being treated with megestrol
(18). Currently, the drug of choice for increasing appetite in cancer patients is megestrol because it has shown
greater effectiveness in this scenario. Another randomized, Phase III study compared oral cannabis extract,
THC, and placebo. An increase in appetite of 73%, 58%,
and 69%, respectively, was reported but no statistical
difference was shown between study groups (19).
Two studies conducted in healthy subjects showed increased food intake with the use of inhaled cannabis sativa (N=9, N=6) (20-21). However, the NCI's PDQ cancer
information summary states that no studies have been
conducted with inhaled cannabis in cancer patients (12).
Pain
Opioids are widely used in the management of pain in
cancer patients. These patients can develop opioid resistance with severe pain. Several studies (22-24) that have
been conducted in cancer patients show the potential use
of oral cannabinoids in patients who get no relief from
the use of opioids. Two placebo-controlled studies have
shown pain relief in patients using oral cannabinoids
who had not obtained adequate analgesia with the use of
opioids (N=360, 269 treated) (N=177, 118 treated) (2223). An observational study found a reduction in the use
of other pain medications, including opioids, NSAIDs,
In non-cancer patients, neuropathic-type pain has been
reduced with the use of smoked cannabis and vaporized
cannabis (26-29). However, the NCI's PDQ cancer information summary states there are no studies in cancer
patients that evaluate cannabinoid effects on neuropathic
pain caused by chemotherapy (12).
Chemosensory Perception
Adverse Effects
The side effects of cannabis and cannabinoids include
tachycardia, hypotension, conjunctival redness, bronchodilation, muscle relaxation, reduced gastrointestinal
motility, euphoria, memory loss, difficulty completing
tasks, changed perception in time and space, and inability to concentrate (31,32). Death does not result from
marihuana overdose because, contrary to opioids, no
respiratory depression has been observed; its receptors
are not found in areas of the brain that control breathing.
Symptoms of overdose include paranoia, hallucinations,
disconnection from reality, altered heart rate (can precipitate myocardial infarction in patients at risk), somnolence, reduced blood pressure among others (31). Withdrawal symptoms include irritability, insomnia, flushing,
and nervousness. The NCI's PDQ cancer information
summary states that its addictive potential and withdrawal symptoms are fewer than for other substances used
for medicinal or recreational use, such as opioids (12).
While cannabis cigarettes contain more carcinogens than
tobacco cigarettes, there is great concern about other
possible effects (1). Some studies suggest that continued use of cannabis cigarettes could be associated with
the development of lung, mouth, and throat cancer, atrial
fibrillation, myocardial infarction, stroke, immunosuppression, (which could be detrimental in cancer patients)
and chronic bronchitis among others (1,31). Because of
the central nervous result from the use of cannabis, cancer patients who use oral cannabinoids receive education
and are advised as to not driving, operating machinery,
or participating in risky activities until it is known how
one reacts to the medication. Also, these patients should
be supervised by another responsible adult.
Opinion and Positions of Recognized Professional
Organizations
The position of the American Cancer Society is (2013)
(13):
“The IOM’s report suggests that there may be a benefit
to cancer patients from the chemicals, or cannabinoids,
contained within marihuana. These studies appear to
show that cannabinoids will help alleviate the nausea,
vomiting, wasting, and muscle spasms caused by chemotherapy in some patients”.
“The ACS is supportive of more research into the benefits of cannabinoids. Better and more effective treatments are needed to overcome the side effects of cancer
and its treatment”.
“The ACS does not advocate the use of inhaled marihuana or the legalization of marihuana”.
NCI's PDQ cancer information summary states (12):
“At present, there is insufficient evidence to recommend
inhaling Cannabis as a treatment for cancer-related
symptoms or cancer treatment-related side effects”.
NCCN Treatment Guidelines (33):
The use of marihuana is not recommended and is not part
of the NCCN Guidelines in the management of nausea
and vomiting in cancer patients receiving chemotherapy.
ASCO Treatment Guidelines (34):
The use of marihuana is not recommended and is not part
of the ASCO Guidelines in the management of nausea
and vomiting in cancer patients receiving chemotherapy.
CONCLUSIONS
There is scientific evidence showing that FDA approved
oral cannabinoids are effective in the management of
nausea and vomiting as rescue therapy but not in the
management of other symptoms in cancer patients. Currently, there is insufficient scientific evidence supporting the use of Cannabis sativa in cancer patients. Some
studies suggest that Cannabis sativa may be used in the
management of other symptoms such as anorexia, pain,
insomnia, and depression (14,31). This information
needs to be confirmed along with the possibility of using
Cannabis sativa and oral cannabinoids with the purpose
of reducing polypharmacy. Studies in rats suggest that
Cannabis sativa may have antitumor effects while other studies indicate that it may induce the proliferation
of cancer cells (35). Because cannabis contains a wide
variety of substances, the possibility of interaction with
other medications and its side effects in cancer patients
should be further studied.
Evidence-based medicine is the conscious, explicit, and
judicious use of the best, updated scientific evidence and
is essential when making decisions regarding the care of
our patients. Recommending the use of these substances
to patients for non-approved uses and in the absence of robust scientific evidence is not consistent with the practice
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 57
of evidence-based medicine. In its 1999 report, the IOM
issued specific recommendations on the design of these
studies. The American Medical Association and the
American College of Physicians have joined the IOM
claim of increasing the number of studies on this subject
(36). These entities recommend reclassifying marihuana as a Schedule II substance, instead of Schedule I, in
order to facilitate clinical research. Puerto Rico’s controlled substances act establishes the following (37):
Schedule I:
The drug or other substance has a high abuse potential.
The drug or other substance has no medicinal use approved in the United States.
Absence of accepted safety conditions for its use under
medical supervision.
Schedule II:
The drug or other substance has a high abuse potential.
The drug or other substance has approved medicinal use
in the United States, or approved medicinal use with severe restrictions.
The abuse of the drug or other substance may result in a
serious psychological or physical dependence.
Furthermore, the societal impact of marihuana medicalization and mechanisms to counteract the possibility
of abuse and undue profit are other areas that should be
studied.
REFERENCES
1. Todaro B. Cannabinoids in the treatment of chemotherapy-induced
nausea and vomiting. J Natl Compr Canc Netw. 2012; 10:487-492.
2. Gonzales v. Raich, 125 S. Ct. 2195.
3. Memorandum for Selected United States Attorneys [Department of
Justice Web site]. October 19, 2009. Available at: http://www.justice.gov/
opa/pr/2009/October/09-ag-1119.html . Accessed September 27, 2013.
4. Cerdá M, Wall M, Keyes KM, Galea S, Hasin D. Medical marihuana
laws in 50 states: investigating the relationship between state legalization
of medical marihuana and marihuana use, abuse and dependence. Drug
Alcohol Depend. 2012; 120:22-27.
5. Wall MM, Poh E, Cerdá M, Keyes KM, Galea S, Hasin DS. Adolescent marihuana use from 2002 to 2008: higher in states with medical
marihuana laws, cause still unclear. Ann Epidemiol. 2011; 21:714-716.
6. Harper S, Strumpf EC, Kaufman JS. Do medical marihuana laws increase marihuana use? Replication study and extension. Ann Epidemiol.
2012; 22:207-212.
7. Salomonsen-Sautel S, Sakai JT, Thurstone C, Corley R, Hopfer C.
Medical marihuana use among adolescents in substance abuse treatment.
J Am Acad Child Adolesc Psychiatry. 2012; 51:694-702.
8. Nussbaum AM, Boyer JA, Kondrad EC. "But my doctor recommended pot": medical marihuana and the patient-physician relationship. J Gen
Intern Med. 2011; 26:1364-1367.
9. Senado De Puerto Rico. P. del S. 517 [Microjuris Web site]. April
16, 2013. Available at: http://noticiasmicrojuris.files.wordpress.
com/2013/04/ps517.pdf. Accessed September 27, 2013.
10. Cámara de Representantes. P. del C. 1362 [Microjuris Web site]. September 4, 2013. Available at: http://noticiasmicrojuris.files.wordpress.
com/2013/04/pc1362.pdf. Accessed September 27, 2013.
11. Joy JE, Watson SJ, Benson JA. “Marihuana & Medicine: Assessing
the Science Base” [National Academies Press Web Site]. Institute of
Medicine. Washington DC, 1999. National Academy Press. Available at:
www.nap.edu.
12. National Cancer Institute: PDQ® Cannabis and Cannabinoids [Internet]. Bethesda, MD: National Cancer Institute. [updated 2014 Mar 25; cited 2014 Apr 14]. Available at: http://www.
cancer.gov/cancertopics/pdq/cam/cannabis/healthprofessional.
58 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
13. Medical Use of Marihuana: ACS Position [Internet]. Atlanta, Ga:
American Cancer Society. [updated 2013 Apr 10; cited 2013 Sep 1].
Available at: http://documents.cancer.org/acs/groups/cid/documents/
webcontent/001976-pdf.pdf.
14. Turcotte D, Le Dorze JA, Esfahani F, Frost E, Gomori A, Namaka
M. Examining the roles of cannabinoids in pain and other therapeutic
indications: a review. Expert Opin Pharmacother. 2010; 11:17-31.
15. Chang AE, Shiling DJ, Stillman RC, et al.: Delta-9-tetrahydrocannabinol as an antiemetic in cancer patients receiving high-dose
methotrexate. A prospective, randomized evaluation. Ann Intern
Med. 1979; 91:819-824.
16. Chang AE, Shiling DJ, Stillman RC, et al.: A prospective evaluation of delta-9-tetrahydrocannabinol as an antiemetic in patients
receiving adriamycin and cytoxan chemotherapy. Cancer. 1981;
47:1746-1751.
17. Levitt M, Faiman C, Hawks R, Wilson A. Randomized double
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3:91. [Abstract ]
18. Jatoi A, Windschitl HE, Loprinzi CL, et al. Dronabinol versus
megestrol acetate versus combination therapy for cancer-associated
anorexia: a North Central Cancer Treatment Group study.J Clin Oncol. 2002; 20:567-573.
19. Strasser F, Luftner D, Possinger K, et al. Comparison of orally
administered cannabis extract and delta-9-tetrahydrocannabinol in
treating patients with cancer-related anorexia-cachexia syndrome: a
multicenter, phase III, randomized, double-blind, placebo-controlled
clinical trial from the Cannabis-In-Cachexia-Study-Group. J Clin
Oncol. 2006; 24:3394-3400.
20. Foltin RW, Brady JV, Fischman MW. Behavioral analysis of marihuana effects on food intake in humans. Pharmacol Biochem Behav. 1986; 25:577-582.
21. Foltin RW, Fischman MW, Byrne MF. Effects of smoked marihuana on food intake and body weight of humans living in a residential laboratory. Appetite. 1988; 11:1-14.
22. Portenoy RK, Ganae-Motan ED, Allende S, et al. Nabiximols for
opioid-treated cancer patients with poorly-controlled chronic pain:
a randomized, placebo-controlled, graded-dose trial. J Pain. 2012;
13:438-449.
23. Johnson JR, Burnell-Nugent M, Lossignol D, Ganae-Motan
ED, Potts R, Fallon MT. Multicenter, double-blind, randomized,
placebo-controlled, parallel-group study of the efficacy, safety, and
tolerability of THC:CBD extract and THC extract in patients with
intractable cancer-related pain. J Pain Symptom Manage. 2010;
39:167-179.
24. Maida V, Ennis M, Irani S, Corbo M, Dolzhykov M. Adjunctive
nabilone in cancer pain and symptom management: a prospective observational study using propensity scoring. J Support Oncol. 2008;
6:119-124.
25. Abrams DI, Couey P, Shade SB, Kelly ME, Benowitz NL. Clin
Pharmacol Ther. 2011; 90:844-851.
26. Abrams DI, Jay CA, Shade SB, et al. Cannabis in painful HIV-associated sensory neuropathy: a randomized placebo-controlled trial.
Neurology. 2007; 68: 515-521. 27. Wilsey B, Marcotte T, Deutsch R, Gouaux B, Sakai S, Donaghe
H. Low-dose vaporized cannabis significantly improves neuropathic
pain. J Pain. 2013; 14:136-148. 28. Ellis RJ, Toperoff W, Vaida F, et al. Smoked medicinal cannabis
for neuropathic pain in HIV: a randomized, crossover clinical trial.
Neuropsychopharmacology. 2009; 34: 672-680. 29. Wilsey B, Marcotte T, Tsodikov A, et al. A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic
pain. J Pain. 2008; 9:506-521. 30. Brisbois TD, de Kock IH, Watanabe SM, et al. Delta-9-tetrahydrocannabinol may palliate altered chemosensory perception in
cancer patients: results of a randomized, double-blind, placebo-controlled pilot trial. Ann Oncol. 2011; 22:2086-2093.
31. Marihuana. American Cancer Society [Internet]. Atlanta, Ga:
American Cancer Society. [updated 2012 Jul 13; cited 2013 Sep 27].
Available at: http://www.cancer.org.
32. Lexi-Comp, Inc. (Lexi-Drugs). Lexi-Comp, Inc.; October 1,
2013.
33. Antiemesis v.1.2014. NCCN Clinical Practice Guideline in Oncology [Internet]. NCCN, 2014. Available at: http://www.nccn.org.
Accessed 2013 Oct 18.
34. Kris MG, Hesketh PJ, Somerfield MR et al. American Society o
f Clinical Oncology Guideline for Antiemetics in Oncology: Update
2011. J Clin Oncol 29:4189-4198.
35. de Jong FA, Engels FK, Mathijssen RH, Zuylen L, Verweij J.
Medicinal cannabis in oncology practice: still a bridge too far? J Clin
Oncol. 2005; 23:2886-2891.
36. Hoffmann DE, Weber E. Medical Marihuana and the Law. N Engl
J Med. 2010; 362:1453-1457.
37. Ley de Sustancias Controladas de Puerto Rico. [Microjuris Web
site]. June 23, 1971 amended to August 1, 2002. Available at: http://
www.lexjuris.com/lexlex/lexotras/lexdroga.htm. Accessed September 27, 2013.
Acknowledgment
We thank Rafaela Mena, R.Ph., MA, for translation and editorial
assistance.
RESUMEN
Reportes y estudios clínicos sugieren que la marihuana (Cannabis sativa) es efectiva para tratar glaucoma,
migraña, dolor, espasticidad en esclerosis múltiple,
anorexia, insomnio, depresión, náuseas y vómitos entre otros. Una de las enfermedades que más se le ha
adjudicado el beneficio de la marihuana es cáncer. En
veintiun estados de los Estados Unidos y el Distrito
de Columbia se ha aprobado el uso de marihuana para
cáncer y otras condiciones médicas. En Puerto Rico,
el debate público sobre la despenalización y la medicalización de la marihuana se ha intensificado. Para
los profesionales de la salud es esencial disponer de
evidencia científica contundente sobre la efectividad
y seguridad de los medicamentos o sustancias que
recomiendan para tratar diferentes condiciones. Este
artículo discute la evidencia científica que existe sobre la efectividad y seguridad de la marihuana y sus
derivados en pacientes de cáncer.
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 59
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Recete actividad fisica
The “STEMI code”- INTERVENTIONS TO
REDUCE TIME TO REPERFUSION
THERAPY: A novel Approach and
Review of the Literature
Gerald Marín García MSa*, Fernando L. Soto Torres MDb
UPR School of Medicine, Puerto Rico Health Science Center, San Juan, Puerto Rico.
Emergency Medicine Residency Program, UPR School of Medicine, Puerto Rico Health Science Center, San Juan, Puerto Rico.
*Corresponding author: Gerald Marín García MS - 4289 Ave. Constancia Villa del Carmen Ponce, PR 00716. E-mail: [email protected]
a
b
ABSTRACT
ST-elevation myocardial infarction (STEMI) is a common presentation in the Emergency Room. Proper treatment requires precision and time saving procedures. Hospitals around the world are currently developing
STEMI protocols to optimize this process since mortality and morbidity increase with time without treatment.
These protocols may involve Percutaneous Interventions (PCI), fibrinolytics or both, to optimize outcomes.
Protocols utilize different methods and techniques to improve Door-to-Balloon time. It is well established
that PCI provides improved mortality with a lower complication rate when compared to fibrinolytic therapy,
lack of availability being its biggest obstacle. Only a few PCI capable facilities are available and networking
protocols are required to improve STEMI management in Puerto Rico- an area that needs vast improvement.
Strategies that seek to reduce the intervention times are being evaluated and implemented throughout the
world. We present an approach implemented at a local hospital called "STEMI Code".
Index words: stemi, code, intervention, reduce, reperfusion, therap
H
INTRODUCTION
STEMI: A race against time
Heart disease is the leading cause of death in the United States (US), accounting for 28.5% of deaths in 2012
(1). One of the most common and deadly presentations
of heart disease is acute myocardial infarction (AMI). It
accounted for approximately 800,000 visits to the emergency room (ER) last year of with an approximate mortality of 27% (1). ST elevation myocardial infarction
(STEMI) is complete occlusion of a coronary artery
leading to transmural ischemia of the tissue. Damage
by the occlusion is irreversible after thirty minutes. It is
a tenet in the field that time is essential to improve patient survival and decrease complication rates; therefore
current guidelines for STEMI management are based
on elapsed time since initiation of symptoms.
Emergent STEMI management consists on prompt
reperfusion in conjunction with antithrombotic and
anticoagulant therapy. Primary percutaneous coronary
intervention (PCI) is the optimal reperfusion therapy if
the period between first medical contact (FMC)-to-balloon time is less than 90 minutes. Current guidelines
suggest an even more dramatic reduction in mortality
if adjuvant antithrombotic therapy is started before the
primary PCI with loading doses of 162-325mg of aspirin PO and clopidogrel 600mg PO and if anticoagulation is initiated at the time of the procedure starting with
an IV bolus of 70-100 U/kg of unfractionated heparin if
no GP IIb/IIIa receptor antagonist will be administered.
If GP IIb/IIIa antagonist is on schedule, the UFH should
be lowered to 50-70 U/kg in order to reach therapeutic
levels (4).
Around five million patients visited the emergency department in the US last year due to chest pain (1). When
a patient walks in with such complaint, an ECG must be
performed within the initial ten minutes. If the patient
is brought in by ambulance, a pre-hospital ECG is a priority. This intervention alone reduces management time
by twenty-three minutes when compared to no pre-hospital ECG. These results were reproduced by Diercks,
et al. where median management time was fourteen
minutes shorter (3).
60 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
Even though PCI has shown a marked reduction in
mortality, getting the patient into the catheterization
laboratory is still a challenge. Out of the approximately
5000 acute care hospitals available in the United States,
less than 25% have PCI capabilities (5). Therefore, the
STEMI patient is relying on interhospital transfers, further delaying appropriate management. In over 27,000
patients treated for STEMI with primary PCI in the US,
the average time from symptom onset to PCI was 5.5
hours, which is almost triples the 2 hour goal for ideal
rescue (6). When PCI is not readily available, and in the
absence of contraindications, administration of thrombolytics is in order if less than 12 hours have elapsed
since the onset of symptoms. As it is the case with PCI,
guidelines establish that adjunctive therapy with anticoagulation and antithrombotic is initiated even before
thrombolytics.
After the administration of the thrombolytics the patient
needs to be assessed for complications or non-revascularization. The abrupt relief of chest pain in addition to
ST elevation resolution is a trustable sign of revascularization. Less than 70% ST resolution at 90 minutes, had
a tenfold increase in mortality when compared to those
with complete (≥70%) ST resolution (7). If there is less
than 50% change in the ST elevation in the worst lead
by the first 90 minutes, transfer to a PCI capable facility
has to be considered immediately. During the assessment
there are two indications for rescue PCI after chemical
reperfusion: cardiogenic shock or severe acute heart failure. When the PCI is indeed taking place, it should occur
ideally within 24 hours but not in the first 2-3 hours after
administration of fibrinolytics (4).
What is being done to win the race?
Over the last couple of years STEMI protocols have been
established to reach the national standards of care. Parkin
et al., demonstrated a 38 minute reduction in door-to-balloon time when patients with STEMI presentation were
managed with a protocol were compared to retrospective
controls (8). Some involve PCI, others fibrinolytics, it
all depends on the hospital capabilities. Most protocols
involve a one call multi-activating system that engages
the catheterization lab, radiology department and nursing staff. This starts a chain reaction of collaboration and
teamwork between and within the units, which promotes
an efficient management of the acute patient.
The main objective for PCI capable hospitals is to activate the catheterization laboratory even before the
patient arrives. This is achieved by interpretation of a
pre-hospital ECG, which activates the protocol. This has
been shown to reduce door to balloon time on average
by 57 minutes p < 0.001 (9). This intervention has not
come without its disadvantages, as pre-hospital ECG
interpretation has led to a higher rate of false positive
activations and cancellations (10). Some protocols even
bypass ER admission and go directly to either the CCU
or the "catheterization lab" further reducing the FMC-toballoon time by 24 minutes (11).
The Mayo Clinic STEMI protocol is a fine model to pursue. It was implemented in 2004 with the idea of regionalizing and integrating a pharmaco-invasive approach.
Twenty-eight regional hospitals located up to 150 miles
away from Saint Mary’s Hospital were selected to participate. The selection criteria were based in the total transfer time, less than 90 minutes, and absence of a closer
PCI capable facility. Presentation time determined management. Symptoms lasting more than three hours were
transferred to Saint Mary’s Hospital for primary PCI. If
symptoms developed within three hours, the patient was
started on fibrinolytics unless they had a contraindication
for chemical therapy or were considered to be at high
clinical risk, such as those presenting with cardiogenic
shock or acute heart failure. After fibrinolysis, patients
were transferred to Saint Mary’s Hospital, where they
received another evaluation upon arrival. Patients underwent early rescue PCI for suspected failure to improve
or where scheduled for routine elective catheterization
after 24 to 48 hours if it was felt reperfusion had been
successful after fibrinolysis (12).
The local challenge
Puerto Rico’s PCI capabilities may not be sufficient to
fulfill our needs. In 2008, out of the 51 acute care hospitals available in Puerto Rico, only 8 hospitals had PCI
capabilities, well under the 25% reported in the United
States (13). We also need to take into consideration that
even hospitals that are capable of performing PCI, are
not able to provide around the clock staffing in case of
emergency presentations (13). Time to needle and/or
medication at those institutions mirror the lack of availability and irregular access that plagues the US with less
than half of the patients reaching the goal (5,13). For
improvement, a networking system between pre-hospital fibrinolytics and transportation to an appropriate
hospital needs to be addressed. This approach will give
the patient enough time receive an adequate invasive intervention. Dudek et al., demonstrated that when delays
are expected ( > 90 minutes) in transfer to a PCI capable
hospital, a combination of reduce dose fibrinolytics and
full dose GP Iib/IIIa antagonist reduces the frequency of
cardiac adverse events at 30 days and 12 month comparable to primary PCI (14, 15).
As of August 2013 an emergency room physician activated “STEMI Code” protocol was implemented at the
University of Puerto Rico Hospital Emergency Department - Dr. Federico Trilla. Our goal was to administer
tenecteplase within 30 minutes of the activation of the
protocol. An ECG is performed to any patient presenting
with chest pain within 10 minutes of arrival. It is promptly evaluated by the ER attending physician who, in the
presence of a STEMI, activates the protocol for the ER
personnel through the internal speaker. The emergency
department clerk contacts the Radiology Department notifying the need for a portable chest X-ray which is performed and evaluated promptly. Trained nurses will have
divided their responsibilities a priori and will handle the
code simultaneously. Nurse A places the heart monitor,
in-dwelling urinary catheter, two peripheral intravenous lines and obtains blood samples. Nurse B gets the
“STEMI Code” kit located in the medication room; administers medications following the doctor's indications
and stays with the patient through the administration of
the tenecteplase. She also completes post-medication assessment for the following two hours and documents the
chart. Nurse C supervises that all documentation is properly completed and assists in any other needs. During
this time the physician checks for any contraindications
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 61
to therapy, talks to the patient and family and examines
the patient in order to provide recommendations. If no
contraindications are found, the medication is administered and the patient is continuously monitored for any
deterioration.
There are two “STEMI Code” kits ready at all times in
the medication room. The Pharmacy department is in
charge of verifying and supplying the kit on a daily basis.
Inside, the medications are separated in different compartments, which are labeled on top with the name and
dosage to avoid possible confusions.
Figure 1 shows a more descriptive representation.
Figure 1. Picture of the actual STEMI code kit.
Two of them will attend any code activation. Once it is
unlocked, proper documentation needs to be prepared
including:
a) Tenecteplase 50mg (weight-based dose)
b)
Nitroglycerin sublingual 0.4 mg tablet
c)
Nitroglycerin Intravenous vial. 50mg/250ml
D5W
d)
Metoprolol 50mg
e)
Aspirin 325mg in 4 chewable 81mg tablets
f)
Clopidogrel 300mg tablet
g)
Enoxaparin 30, 60, 80 and 100mg single use injectable vials
CONCLUSION
In summary, STEMI management guidelines are well established. Following the time requirements for primary
PCI is still a challenge that hospitals with these capabilities face. The development of protocols that integrate different strategies to improve reperfusion times are taking
us one step closer to overcoming the obstacles in prompt
and effective STEMI interventions. Treatment of these
cardiovascular emergencies is an area that needs vast improvement in Puerto Rico. Future research will focus in
how these interventions improve the door-to-medication
time in STEMI patients. With these algorithms we hope
to provide the most effective care to our acute STEMI
presentations and provide optimal windows for transfer
to PCI-capable facilities, while maintaining the outflow
of patients in the unit, because after all, the ER must
keep running as efficiently as possible.
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Acute St-elevetation Myocardial Infarction." Boletin- Asociacion De Medicos De
Puerto Rico 104.3 (2012): 4-9.
6.Smalling, R., G. Giesler, V. Julapalli, A. Denktas, S. Sdringola, M. Vooletich, J. Mccarthy, R. Bradley, D. Persse, and B. Richter. Pre-Hospital Reduced-Dose Fibrinolysis
Coupled With Urgent Percutaneous Coronary Intervention Reduces Time to Reperfusion and Improves Angiographic Perfusion Score Compared With Prehospital Fibrinolysis Alone or Primary Percutaneous Coronary InterventionResults of the PATCAR
Pilot Trial. Journal of the American College of Cardiology. 2007; 50.16: 1612-614.
7 De Lemos, J. A., Braunwald, E. ST Segment Resolution as a Tool for Assessing
the Efficacy of Reperfusion Therapy. Journal of the American College of Cardiology.
2001; 38.5: 1283-294
8.Parikh, R., R. Faillace, and A. Hamdan. "An Emergency Physician Activated Protocol , "Code STEMI" Reduces Door-to-ballon Time and Length of Stay of Patient
Presenting with Acute ST-elevation Myoardial Infarction." Int J Clin Pract (2009); 63:
398-406.
9.Brown, J. P., E. Mahmud, J. V. Kunford, and O. Ben-Yehuda. "Effect of Prehospital
12 Lead Electrocardiogram on Activation of the Cardiac Catheterization Laboratory and Door-to-ballon Time in ST-segement Elevation Myocardial Infarction." J Am
Cardiol (2008); 101: 158-61.
10.Rodriguez-Vila, Orlando, MD,MMS, and Miguel A. Campos-Esteve, MD. Setting
Up a Population-Based Program to Optimize ST-Segment Elevation Myocardial Infarction Care. Interventional Cardiology Clinics 2012; 1.4: 583-97.
11.Amit, G., C. C. Gilutz, and I. R. Zahger. "Benefit of Direct Ambulance to Coronary
Care Unit Admission of Acute Myocardial Infarction Patients Undergoing Primary
Percutaneous Intervention." Int J Cardiol (2007); 119: 355-58.
12. Holmes, D. R., M. R. Bell, and B. J. Gersh. "System of Care to Improve Timeliness of Reperfusion Therapy for ST-segment Elevation Myocardial Infarction during
off Hours: The Mayo Clinic STEMI Protocol." JACC: Cardiovascular Interventions
(2008); 1.1: 88-96.
13. Escabi-Mendoza, Jose. "Reperfusion Therapy in ST-segment Elevation Myocardial Infarction In The Veteran Administration Hospital Healthcare System; Search for
Improvement." Boletin- Asociacion De Medicos De Puerto Rico (2008); 100.4: 5-17.
14.Dudek, D., A. Dziewierz, and Z. Siudak. "Transportation with Very Long Transfer
Delays (90 Min) for Facilitated PCI with Reduce-dose Fibrinolysis in Patients with
ST-segment Elevation Myocardial Infarction: The Krakow Network." Int J Cardiol
139 (2010): 218-27.
15 Peterson, Michael C., Tyler Syndergaard, Josh Bowler, and Richmond Doxey. A
Systematic Review of Factors Predicting Door to Ballon Time in ST-segment Elevation Myocardial Infarction Treated with Percutaneous Intervation. International
Journal of Cardiology. 2012; 157: 8-23
RESUMEN
El Infarto al miocardio con elevaciones del segmento ST,
(STEMI, por sus siglas en inglés) es una de las presentaciones más comunes en las salas de emergencias. El tratamiento adecuado requiere procedimientos que agilicen el
proceso ya que la mortalidad y potenciales complicaciones
aumentan con el tiempo. Mundialmente se han desarrollando protocolos con el fin de optimizar el manejo de STEMI.
Estos pueden incluir arreglos con la sala de cateterismo,
trombolíticos o ambos, dependiendo de la accesibilidad y
el tiempo de presentación del paciente. En cada protocolo
se utilizan técnicas y métodos diferentes para mejorar el
tiempo " "puerta-cateterismo" o "puerta-medicamento". En
la literatura se ha descrito que el cateterismo cardíaco es superior en cuanto a la mortalidad con menos complicaciones
en comparación a los trombolíticos, pero la inaccesibilidad
a éste es su mayor debilidad. Existen pocos hospitales con
capacidad de cateterismo en Puerto Rico, por lo tanto, se
necesitan mejorar el área de desarrollo de protocolos que
envuelvan redes interhospitalarias con el propósito de canalizar el paciente de la manera mas efectiva posible. Algunas estrategias están siendo consideradas para reducir el
tiempo a terapia alrededor del mundo. Aquí traemos a discusión un "código STEMI" que fuera implementado en un
hospital local con miras a mejorar esos tiempos.
62 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
LA ENSEÑANZA DE LOS ASPECTOS
LEGALES DE LA PRÁCTICA MÉDICA A
LOS ESTUDIANTES DE MEDICINA EN
PUERTO RICO
Luis J. Lugo Vélez MD JDa*
Escuela de Derecho Pontificia Universidad Católica de Puerto Rico, Ponce, Puerto Rico
*Correspondencia: Lcdo. Luis J. Lugo Velez MD - P.O. Box 712 Mercedita, Puerto Rico 00715-0712. Email: [email protected]
a
RESUMEN
Los retos y cambios que enfrenta la medicina moderna hacen imprescindible que los médicos adquieran conocimientos sobre la estructura legal y reglamentaria de la práctica médica. A pesar de la importancia de este
asunto, los currículos en la mayoría de las escuelas de medicina no incluyen cursos que ofrezcan a los estudiantes de medicina la información necesaria sobre sus deberes legales al ejercer la medicina. Por tal motivo,
la tendencia debe ser a ofrecer dichos cursos en las escuelas de medicina y en los programas de residencias
médicas.
Palabras indíces: ensenanza, aspecto, legales, practica, medicina, estudiantes
L
La práctica de la medicina como la conocemos hoy enfrenta retos que demandan que los médicos y estudiantes de medicina adquieran conocimientos en bioética,
derecho de salud, profesionalismo y la economía de la
industria de la salud. La reforma de salud del Presidente
Obama (1) y los dramáticos cambios introducidos a la
medicina y la salud en general es un claro ejemplo de la
necesidad de adquirir dichos conocimientos.
La medicina es una profesión extensamente reglamentada, por lo que es esencial que los estudiantes de
medicina y los médicos se familiaricen y conozcan la
estructura legal y los procesos relevantes al ejercicio de
la misma. Durante el pasado año la clase médica de
Puerto Rico completó el proceso de recertificación de
sus licencias y de registro de profesionales para el trienio 2013-2016. Por primera vez la Junta de Licenciamiento y Disciplina Médica estableció como requisito
de dicho proceso que los médicos tomarán seis créditos
de educación médica continua en bioética y profesionalismo. (2) Ambos tópicos comprenden una diversidad
de temas que inciden en la toma de decisiones que hace
diariamente el médico en su práctica.
No obstante, el tema que siempre está latente en la mente del médico es la posibilidad de enfrentar una demanda por impericia profesional. El impacto de la impericia
profesional sobre el sistema de cuidado de salud es impresionante. Entre 1992 y 2006 se radicaron en Puerto
Rico 7,633 casos de impericia médica, esto es aproximadamente 508 casos por año. Las principales causas para
el aumento en los casos de demanda por impericia profesional son resultados no esperados de un tratamiento u hospitalización, una mala relación personal entre
el médico y el paciente y/o los familiares de este, y
falta de comunicación entre los médicos que atienden
al paciente. Mientras que el efecto de este incremento
es perdida de la confianza en el médico, miedo del
médico a ser demandado, práctica de una medicina defensiva, como por ejemplo la realización de pruebas
que no son necesarias, y un aumento en las primas de
los seguros de responsabilidad profesional.
La importancia y necesidad de ofrecer educación legal a
los estudiantes de medicina fue reconocida por primera
vez en 1952 por el Comité de Problemas Médico-Legales de la Asociación Médica Americana (AMA) cuando
en su Reporte Anual recomendaron que:
“no medical student should be permitted to receive his [medical] degree without instruction in
legal duties”. (3)
De igual manera recomendaron a las escuelas de medicina que incorporaran un curso obligatorio en medicina legal en sus currículos. (4) La AMA repitió su
llamado a favor de ofrecer educación legal para los estudiantes de medicina, nuevamente en el año 1968. (5)
Desafortunadamente estos llamados no tuvieron eco entre las facultades de medicina.
Para el año 1971 un estudio de Beresford encontró que el
47% de las escuelas de medicina en los Estados Unidos
BOLETIN Médico Científico de la Asociación Médica de Puerto Rico | 63
no tenían en sus currículos de enseñanza ningún curso
de medicina legal. (6) Más aún el estudio encontró que
cerca de la mitad de las escuelas de medicina que contestaron la encuesta no consideraban importante el ofrecimiento de dichos cursos a sus estudiantes. (7)
El estudio de Dornette, también del año 1971, confirmó
los hallazgos del estudio de Beresford y fue más lejos
al recomendar que los médicos residentes en los programas graduados de medicina recibieran instrucción
médico-legal como forma de subsanar la laguna causada
por las escuelas de medicina. (8) En el año 1977 el Colegio Americano de Medicina Legal también recomendó
que tanto los estudiantes de medicina como los médicos
residentes en programas de entrenamiento debían recibir
instrucción en medicina legal. (9) En el año 1997 Kollas
llevó a cabo el primer estudio con el propósito de examinar el grado de conocimiento de médicos residentes
sobre aspectos médico-legales. (10) Con los resultados
del estudio Kollas implementó para el año 1999 un currículo sobre aspectos médico-legales para residentes de
medicina interna. (11)
encargada de dicha función. (16) Sin embargo, es requisito
de ley adicional pertenecer de forma obligatoria al Colegio
de Médicos Cirujanos de Puerto Rico para poder ejercer
la medicina. (17) Múltiples agencias tanto estatales como
federales intervienen en la reglamentación de la práctica
médica. Por ejemplo, la Administración de Servicios contra
la Adicción y la Administración para el Control de Drogas
(DEA por sus siglas en inglés) son las agencias encargadas
de otorgar las licencias para la prescripción de sustancias
controladas. En el estado de Texas se requiere a los aspirantes a una licencia para la práctica de la medicina aprobar
un examen de jurisprudencia médica. (18)
La influencia del derecho en la medicina requiere que los
estudiantes de medicina, residentes y médicos en general
adquieran los conocimientos y destrezas necesarias para entender y manejar el complejo andamiaje reglamentario, ético
y económico de la práctica médica moderna.
Es por eso que la tendencia en las escuelas de medicina y
programas de residencias médicas en Puerto Rico debe estar
dirigida a incluir en los currículos de enseñanza y entrenamiento cursos sobre los aspectos legales no solo de la meYa para el año 2008 el treinta y siete por ciento (37%) dicina sino sobre el derecho de salud en general.
de las escuelas de medicina en los Estados Unidos ofrecían cursos formales a sus estudiantes sobre aspectos REFERENCIAS
legales o reglamentarios de la práctica de la medicina.
(12) Las escuelas de medicina de Puerto Rico enfocan 1. Pub. L. 111-148; 124 Stat. 119
Reglamento de la Junta de Licenciamiento y Disciplina Médica de
su atención en la enseñanza del profesionalismo y la 2.
Puerto Rico; Reglamento Núm. 7811 del Departamento de Estado; Art.
ética médica, con especial énfasis en la relación médi- 9.2 (C).
co-paciente. Sin embargo, un currículo en medicina 3. American Medical Association Committee on Medicolegal Problems,
legal debe establecer la enseñanza de tres principales Report of Committee on Medicolegal Problems, 150 J.A.M.A. 716 (1952).
áreas de interés: las leyes relativas a la práctica de la 4. Id.
American Medical Association Committee on Medicolegal Problems,
medicina, las relativas a la conducta ética y las relativas 5.
Teaching Medical Law, 205 J.A.M.A. 245, 246 (1968).
a la reglamentación. (13)
6. Beresford, The Teaching of Legal Medicine in Medical Schools in the
Las leyes relativas a la práctica de la medicina comprenden áreas como negligencia, impericia y estándares de
cuidado, además de los aspectos de la confidencialidad
y privacidad de la información médica de los pacientes.
(14) Estos temas son los más relevantes a la práctica
diaria de los médicos, y todos están estrechamente ligados a la relación médico-paciente donde los aspectos
legales de temas como el consentimiento informado y
el derecho del paciente a rehusarse a recibir tratamiento
deben ser discutidos con los estudiantes y residentes.
Por otro lado las leyes relativas a la conducta ética, más
allá de tocar aspectos relativos al comportamiento individual y entre colegas, se enfoca en el rol del médico
ante el debate ético de asuntos profundamente controversiales en la práctica diaria de la medicina. Por ejemplo, resulta difícil entender la actuación del médico ante
las situaciones que rodean la toma de decisiones con
respecto al cuidado al final de la vida de un paciente sin
primero entender las definiciones legales de la muerte,
muerte cerebral, suicidio asistido y futilidad. (15)
Por último la reglamentación de la práctica de la medicina
por el Estado va más allá de la otorgación de una licencia
para ejercerla. En Puerto Rico la Junta de Licenciamiento y Disciplina Médica es la agencia gubernamental
United States, 46 J. Med. Educ. 401 (1971).
7. Id.
8. Dornette, Interdisciplinary Education in Medicine and Law in American Medical Colleges, 46 J. Med. Educ. 389 (1971).
9. American College of Legal Medicine, Task Force on Medical-Legal
Curriculum, A Recommended Medical-Legal Curriculum, 5 J. Legal Med.
8EE (1977).
10. Kollas, CD., Exploring internal medicine chief residents’ medicolegal
knowledge, J. Legal Med., 18:1, 47-61; (1997).
11. Kollas CD, Frey CM. A medico-legal curriculum for internal medicine residents. J. Gen. Intern. Med. 1999;14:441–443.
12. Shah, Nirav D., The Teaching of Law in Medical Education; Am.
Med. Assoc. J. of Ethics; May 2008, Vol. 10, Num. 5: 332-337.
13. Id.
14. Id.
15. Id.
16. La Junta fue creada por la Ley Núm. 139 de 1 de agosto de 2008.
17. El Colegio fue creado por la Ley Núm. 77 de 13 de agosto de 1994.
18. Texas Code of Occupations Sec. 155.003
ABSTRACT
Cada vez son más nuestras
Estrellas de Calidad
Dr. Antolín Padilla Morales
Grupo Médico Geriatrico
Dr. Anselmo Fuentes Aponte
Island Medical Group
Dr. Randolfo Morales Schmidt
Island Medical Group
Dr. Jorge Rivera Torres
Southern Medical Alliance
Dr. José Pastrana Sierra
Grupo Médico Geriátrico
Dr. Aurelio Collado Pacheco
IPA Castellana Physician
Services SE
Dr. Carlos Pérez Berdeguer
Grupo Médico Geriátrico
Dr. Ernesto Laboy Figueroa
IPA Castellana Physician
Services NE
Dr. Domingo Acosta Albino
Solidarity Medical Group
Dr. José Ayala Berríos
Grupo Médico Geriátrico
Felicidades doctores.
Continúan uniéndose a los
proveedores que dan el
ejemplo de excelencia con
un nivel de 4 a 5 en sus
métricas de calidad.
Cada trimestre, MMM y PMC evalúan
el desempeño de los proveedores
basado en indicadores específicos de
calidad en una escala de uno a cinco.
El cumplimiento sobresaliente de
nuestros proveedores con estas
medidas nos ayuda a cumplir con el
Programa de Clasificación
5 Estrellas establecido a los
Medicare Advantage por los
Centros de Servicios de
Medicare y Medicaid.
Ya son sobre 322 médicos primarios
que oficialmente han alcanzado un nivel
entre 4 a 5. ¡Cada día se suman más!
Dr. Roberto Durand Rolón
IPA Castellana Physician
Services NE
Dr. Jorge Méndez Santiago
IPA Castellana Physician
Services NE
Dr. Carlos Robles Oramas
IPA Castellana Physician
Services MN
Dr. Jesús Sierra Díaz
Grupo Médico Geriátrico
Dr. Ariel Morciglio Almodóvar
IPA Castellana Physician
Services SE
Dr. José Peña Figueroa
East Coast Medical Group
Dr. Rafael Vázquez Pérez
Grupo Médico Geriátrico
Dr. Carlos Cidre Miranda
Médicos Selectos del Norte
Dra. Clara Acosta Azcona
IPA Castellana Physician
Services E
Dr. Ferdinand Marín Rivera
Advantage Medical Group
En el último periodo estos
20 médicos se destacan en los
primeros lugares, tomando en cuenta
la complejidad y volumen de sus
respectivos paneles de pacientes.
Sentimos orgullo del compromiso de
cada proveedor cuando trabaja junto
a nuestros afiliados para lograr el
mejor cuidado y el seguimiento
preventivo que necesitan.
Challenges and changes facing modern medicine make it
imperative that physicians acquire knowledge of the legal
and regulatory framework of medical practice. Despite the
importance of this issue, the curriculum in most medical
schools do not include courses that offer medical students
the necessary information about their legal duties to practice
medicine. The trend should be to offer such courses in medical schools and medical residency programs.
64 | BOLETIN Médico Científico de la Asociación Médica de Puerto Rico
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