Metastasis of melanoma in non-sentinel nodes in patients with metastatic sentinel node. Can we avoid complementary lymphadenectomy?

BACKGROUND: Lymph mapping with sentinel node biopsy is the standard procedure for lymph node staging in patients with cutaneous melanoma with a tumor thickness of 1 mm or greater. Patients who have metastases in sentinel node must undergo complementary lymphadenectomy; however, it has not been shown to improve survival. OBJECTIVE: To know the prevalence in our setting of metastases in the product of complementary lymphadenectomy in patients with metastatic sentinel node. METHOD: Evaluation of a descriptive, retrospective, observational and analytical cohort of patients with metastatic sentinel node submitted to lymphadenectomy. Multivariate analysis of tumor thickness, neural invasion, location, sentinel node number, serum DHL level, lymph nodes dissected and extracapsular spread. RESULTS: 67 patients, 35 women and 32 men with a mean of 66 years, 22% had metastases in lymph nodes from complementary lymphadenectomy, 19% of them with extracapsular spread; no relationship with the Breslow level. Extracapsular spread in the sentinel node, lymphadenectomy time, and perineural invasion in the primary tumor were prognostic factors for non-sentinel node metastasis. CONCLUSIONS: In this series, 22% of the patients with a sentinel node-positive have metastases in the non-sentinel nodes, 19% of them with extracapsular spread, which justifies complementary lymphadenectomy.

ANTECEDENTES: El mapeo linfático con biopsia del ganglio centinela es el procedimiento estándar de estadificación ganglionar en pacientes con melanoma cutáneo con grosor tumoral de 1 mm o mayor. Los pacientes que tienen metástasis en él deben ser sometidos a linfadenectomía complementaria; sin embargo, esta no ha mostrado mejorar la superviviencia. OBJETIVO: Conocer la prevalencia en nuestro medio de metástasis en el producto de linfadenectomía complementaria en pacientes con ganglio centinela metastásico. MÉTODO: Evaluación de una cohorte descriptiva, retrospectiva, observacional y analítica de pacientes con ganglio centinela metastásico sometidos a linfadenectomía, con análisis multivariado de grosor tumoral, invasión neural, localización, número de ganglios centinela, concentración sérica de deshidrogenasa láctica, ganglios disecados en linfadenectomía y ruptura capsular. RESULTADOS: Hubo 67 pacientes (35 mujeres y 32 hombres), con una media de 66 años de edad, en el 22% hubo metástasis en ganglios de linfadenectomía complementaria y en el 19% ruptura capsular; sin relación con el nivel de Breslow. La ruptura capsular en el ganglio centinela, el tiempo de linfadenectomía y la invasión perineural fueron factores pronóstico de metástasis en ganglios no centinela. CONCLUSIONES: En esta serie, el 22% de los pacientes tuvieron metástasis en ganglios no centinela, el 19% de ellos con ruptura capsular, lo cual justifica la linfadenectomía complementaria.

[Organizational climate in management teams and its relationship with health care outcomes]. / Clima organizacional de equipos directivos y su relación con los resultados en la atención a la salud.

OBJECTIVE: To identify the relationship between organizational climate of management teams and the performance of health services. MATERIALS AND METHODS: A transversal and analytical study was designed. The Organizational Climate Scale (OCS) was utilized and performance was assessed by the achievement indicators through correlation analysis and multiple regression. Thirty four medical benefits services headquarters (JSPM) were measured of the Mexican Social Security Institute. RESULTS: Of 862 participating, 238 (27.6%) evaluated the climate of their organizations with a high level; the maximal score was 56%. Average performance value was 0.79 ± 0.07 (minimal: 0.65; maximal: 0.92). A positive correlation was demonstrated between organizational climate level and performance (r=0.4; p=0.008). CONCLUSIONS: The organizational climate of the health services managers (JSPM) is directly related with performance in health care.

Clima organizacional de equipos directivos y su relación con los resultados en la atención a la salud / Organizational climate in management teams and its relationship with health care outcomes

Objetivo. Identificar la relación entre el clima organizacional de los equipos directivos y el desempeño de los servicios de salud. Material y métodos. Estudio transversal y analítico. Se utilizó la Escala de Clima Organizacional (EDCO). El desempeño se valoró por el logro de indicadores a través de correlación y regresión múltiple. Se evaluaron 34 jefaturas de servicios de prestaciones médicas del Instituto Mexicano del Seguro Social. Resultados. De 862 participantes, 238 (27.6%) evaluaron el clima de sus organizaciones con nivel alto. El promedio de desempeño fue 0.79±0.07 (mínimo: 0.65; máximo: 0.92). Se muestra una correlación positiva entre clima organizacional y desempeño (r=0.4; p=0.008). Conclusiones. El clima organizacional de las jefaturas de servicios de prestaciones médicas se relaciona con el desempeño en la atención a la salud.

Objective. To identify the relationship between organizational climate of management teams and the performance of health services. Materials and methods. A transversal and analytical study was designed. The Organizational Climate Scale (OCS) was utilized and performance was assessed by the achievement indicators through correlation analysis and multiple regression. Thirty four medical benefits services headquarters (JSPM) were measured of the Mexican Social Security Institute. Results. Of 862 participating, 238 (27.6%) evaluated the climate of their organizations with a high level; the maximal score was 56%. Average performance value was 0.79 ± 0.07 (minimal: 0.65; maximal: 0.92). A positive correlation was demonstrated between organizational climate level and performance (r=0.4; p=0.008). Conclusions. The organizational climate of the health services managers (JSPM) is directly related with performance in health care.

[Frequency of cervical epithelial lesions reported in the Regional Laboratory of Exfoliative Cytology in Jalisco]. / Frecuencia de lesiones epiteliales cervicales reportadas en el Laboratorio Regional de Citología Exfoliativa de Jalisco.

BACKGROUND: The Official Mexican Norm for the prevention, treatment and control of Cervical Cancer (CC) indicates that the Papanicolau (Pap) is the procedure for the detection of this neoplasia; therefore, it is of interest to know the prevalence of suspected cases by this technique in Mexican population. In this study, we show the diagnosed cases in the State of Jalisco, México. METHODS: A retrospective study was made to the samples that arrived for their analysis to the Laboratorio Regional de Citología Exfoliativa (LARCE), of the Instituto Mexicano del Seguro Social (IMSS) in Guadalajara, Jalisco. We considered all cases from January 2010 to December 2012. RESULTS: We analyzed 188 095 cases, from which 5.3 % had a diagnosis of low dysplasia, 0.18 % of moderated dysplasia and 0.05 % of high dysplasia. Microinvasive and invasive cancer showed a low frequency (0.03 %). CONCLUSIONS: The frequency of abnormal findings identified by vaginal cervical cytology is relatively low. The number of inadequate and limited samples for cytological assessment is high; there is a high proportion of women attending for the first time in life to cytology evaluation in older age groups.

Introducción: La Norma Oficial Mexicana para la prevención, tratamiento y control del Cáncer Cérvico Uterino (CaCU) indica que el Papanicolaou (Pap) es el procedimiento de elección para la detección oportuna de esta neoplasia, por lo que es de interés conocer la prevalencia de casos tamizados mediante esta técnica en la población mexicana. En la presente investigación se muestran los casos que se identificaron como sospecha para CaCU por tamizaje en el estado de Jalisco, México. Métodos: se realizó un estudio retrospectivo de las muestras que llegaron para su análisis al Laboratorio Regional de Citología Exfoliativa (LARCE) del Instituto Mexicano del Seguro Social (IMSS) en Guadalajara, Jalisco. Se consideraron todos los casos de enero de 2010 a diciembre de 2012. Resultados: se analizaron 188 095 casos, de los cuales el 5.3 % se reportaron con sospecha de displasia leve, el 0.18 % de displasia moderada y el 0.05 % de displasia grave. En cáncer microinvasor e invasor se observó una baja frecuencia (0.03 %). Conclusiones: la frecuencia de hallazgos anormales identificados por citología cervicovaginal es relativamente baja. El número de muestras inadecuadas más limitadas para valoración citológica es alto; existe una elevada proporción de mujeres que asisten por primera vez en la vida a estudio citológico en grupos de edad avanzados.

[Epidemiological overview of uterine cervical cancer]. / Panorama epidemiológico del cáncer cervicouterino.

The World Health Organization (WHO) reported more than 6 million cases of cancer worldwide in women during 2008; 57.2 % of those cases occurred in less developed countries. Cervical cancer (CC) ranks third in the world in all cancers affecting women, with an estimated of 530 000 new cases. CC has multiple causes and it arises by the association of various risk factors. The main factor is related to the human papillomavirus infection (HPV), which acts as a necessary but not sufficient cause. Also, the interaction with other cofactors has an impact on the development and severity of this neoplasm. Survival is related to the timeliness of care and, therefore, to more access to health services. CC is a neoplasm considered a preventable cancer; thus, it is possible to save more than 150 000 lives by 2030 if control measures are applied with opportunity. The aim of this work is to review the CC in different geographical areas and to make an analysis of risk factors related to this neoplasm.

La Organización Mundial de la Salud (OMS) reportó en 2008 más de 6 millones de casos de cáncer en mujeres; el 57.2 % de esos casos ocurrió en países menos desarrollados. El cáncer cervicouterino (CaCU) ocupa el tercer lugar de las neoplasias malignas que afectan a la mujer, con un número estimado de 530 000 casos nuevos. El CaCU es multicausal y obedece a la asociación de diferentes factores de riesgo. El principal de ellos es la infección por virus de papiloma humano (VPH), que actúa como una causa necesaria pero no suficiente. Asimismo, la interacción con otros cofactores incide en el desarrollo y la severidad de esta neoplasia. La sobrevida se encuentra relacionada con la oportunidad de atención y por lo tanto con mayor accesibilidad a los servicios de salud. El CaCU es una neoplasia considerada como un cáncer prevenible, así que es factible salvar más de 150 mil vidas para 2030 si las medidas de control se aplican con oportunidad. El objetivo de este trabajo es revisar el comportamiento del CaCU en diferentes ámbitos geográficos, así como realizar un análisis de los factores de riesgo relacionados con esta neoplasia.

An educational strategy for improving knowledge about breast and cervical cancer prevention among Mexican middle school students.

INTRODUCTION: Prevention programs have not achieved the expected results in preventing mortality from breast and cervical cancer in Mexico. Therefore, we propose a complementary strategy. METHODOLOGY: An educational strategy for high school students in Mexico (2011-2013) was designed (longitudinal design, two measurements and a single intervention). The postintervention assessment included: 1) knowledge acquired by students about cancer prevention and 2) The performance of the student as a health promoter in their household. The strategy was based on analysis of cases and developed in three sessions. An assessment tool was designed and validated (Test-Retest). The levels of knowledge according to the qualifications expected by chance were determined. Wilcoxon test compared results before and after intervention. RESULTS: An assessment instrument with 0.80 reliability was obtained. 831 high school students were analyzed. Wilcoxon rank-sum test showed a significant learning after the intervention (Z = - 2.64, p = 0.008) with improvement of levels of knowledge in a 154.5%. 49% of students had a good performance as health promoters. CONCLUSIONS: The learning in preventive measures is important to sensitize individuals to prevention campaigns against cancer. This strategy proved to improve the level of knowledge of students in an easy and affordable way.

[Drainage time in patients submitted to radical neck dissection. Influence of peri-operative intravenous liquid perfusion]. / Tiempo de drenaje en pacientes sometidos a disección radical de cuello. La influencia de la perfusión de líquidos en el periodo perioperatorio.

INTRODUCTION: Drainage after radical neck dissection (RND) is routine and several factors impact the postoperative drainage number of days (PODND). OBJECTIVE: to determine the impact of trans-operative intravenous fluid management (TOFM) in in PODND. METHODS: Retrospective analysis of patients subjected to some type of radical neck dissection. Variables analyzed: blood loss volume, radical neck dissection type, surgical time, anesthesia time, and trans-operative intravenous fluid management volume. RESULTS: 120 patients included: average age 58.3 years; 60 males and 60 females. Radical neck dissection most frequent indications: thyroid cancer (36.6%), laryngeal cancer (15.8%) and tongue cancer (7.5%). Radical neck dissection most frequent types: 47 modified radical (39.2%), 22 lateral (18.3%) and 16 supra-omohyoid (13.3%). Median surgical time 3.55 hours, median anesthesia time 4.3 hours, median blood loss 278 ml, related to transoperative intravenous fluid management. Classical radical neck dissection was performed in 13 patients in whom postoperative drainage number of days was greater than in the other types (p = 0.08). No difference in postoperative drainage number of days among the different types of radical neck dissection. An apparent association was found between trans-operative intravenous fluid management volume and postoperative drainage number of days: the greater the quantity of fluids, the greater the number of days (p = 0.001). Patients who had drain removed during the first seven days had an average of 1,500 ml infused. Patients who had an average of 3,000 ml of fluid had drainage of 10 days. Perfusion > 3,500 ml = postoperative drainage number of days ≥ 10 días. CONCLUSIONS: In the present series a statistically significant relationship was found between the TOFM and PODND. A meticulous surgical technique and an anesthesia procedure that carefully assesses fluid balance could decrease PODND.

Polymorphism in exon 4 of TP53 gene associated to HPV 16 and 18 in Mexican women with cervical cancer.

Cervical cancer (CC) is the second most common cancer in Mexican women. Human papillomavirus (HPV) infection is necessary but not sufficient for CC development. Furthermore, genetic factors as polymorphisms could be important susceptibility factors. Controversial results regarding TP53 polymorphisms specifically in codon 72 of CC have been reported. In the present work, the exon 4 sequence of TP53 gene in CC and healthy Mexican-mestizo women were analyzed. A group of 111 women with CC and 126 healthy women (control) were included. Peripheral blood cells for polymorphism analysis and cervical scrape for HPV detection were used. PCR of exon 4 of TP53 were subjected to denaturing high-performance liquid chromatography (DHPLC) analysis and sequencing. HPV detection was subjected to PCR and sequencing. The statistical analysis was carried out using the Arlequin software. Codon 72 Arg/Arg was the most common SNP detected, and Hardy-Weinberg analysis showed equilibrium in control and CC samples (P>0.05). Wild type sequence of TP53 exon 4 was detected in 66 and 57% in control and CC samples, respectively. For codon 72 Arg/Arg, differences between control and CC women were found (P=0.043). An association between HPV 16/18 infection and 72 Arg/Arg in woman with CC was found (P=0.026). Haplotype GC (codon 36 and 72) was statistically significantly associated with CC (P=0.011). HPV 16 was the most common viral type. Codon 72 Arg/Arg is the most common polymorphism in the Mexican population and could be associated to HPV 16 and/or HPV 18 infection in CC.

Human papilloma virus in patients with epidermoid head and neck carcinoma: a prognostic factor?

BACKGROUND: The three most important prognostic factors in patients with head and neck squamous cell carcinoma (HNSCC) are tumor size, nodular histological condition and tumor origin. Recently, human papilloma virus (HPV), particularly HPV-16, has been acknowledged as a prognostic factor. HPV+ patients have better survival than HPV-. This has created a controversy because other factors may influence the prognosis. The objective of this study was to investigate whether HPV has prognostic value in patients with HNSCC. METHODS: We carried out a retrospective evaluation of patients with HNSCC and the following variables were analyzed: survival, tumor location, stage, general condition according to Eastern Cooperative Oncology Group (ECOG) status, treatment and HPV association identified by PCR. We used a descriptive analysis of simple frequencies and central tendency and dispersion measures according to the type of variables. We used descriptive analysis for overall survival with Kaplan- Meier and Cox regression with 95% confidence interval. RESULTS: There were 179 patients included: 119 (66.5%) were male. Average age of patients was 64 years; 34% of the tumors were located in the oral cavity and 33% were located in the larynx. Factors associated with survival were ECOG (RR = 11.3; 2.6-48), clinical stage (RR = 7.8; 1.7-34), age >70 years (RR = 3.5, 1.4-8.5) and nonsurgical treatment (RR = 2.3; 1.4-3.8). Average overall survival for patients with HPV16 was 22 months vs. 28 months in those with other types of viruses. HPV infection was not associated with the prognosis in this series. CONCLUSIONS: ECOG at the time of the diagnosis and clinical stage were the most significant prognostic factors in this series. HPV did not show any prognostic value.

The role of macrophages and mast cells in lymphangiogenesis and angiogenesis in cervical carcinogenesis.

During carcinogenesis it is known that growth factors and cytokines from stromal and inflammatory cells from the microenvironment promote angiogenesis and lymphangiogenesis. However, the participation of macrophages and mast cells in these processes is not well understood. The aim of this study was to evaluate the relationship between mast cell and macrophage density with blood and lymphatic vessels in various stages of carcinoma of the uterine cervix. Tissue sections from archival paraffin-embedded samples from cases with cervical intraepithelial neoplasias (CIN) 1, 2, 3, carcinoma in situ, and invasive carcinoma were used. Immunohistochemical staining was done using the following antibodies: anti-LYVE-1; anti-CD31; anti-CD68, and anti-tryptase. Our results showed a significant increase in the number of macrophages in carcinoma in situ, a correlation between lymphatic vessels and macrophages in premalignant lesions CIN 2, and a correlation between mast cells and blood vessels in both CIN 2 and carcinoma in situ. In conclusion, our data underscore the importance of the recruitment of macrophages and mast cells in the development of tumor-associated blood and lymphatic capillaries.

El virus del papiloma humano como factor pronóstico en pacientes con carcinoma epidermoide de cabeza y cuello / Human papilloma virus in patients with epidermoid head and neck carcinoma: a prognostic factor

Introducción: Los tres principales factores pronóstico en pacientes con carcinoma epidermoide de cabeza y cuello (CECyC) son tamaño del tumor, estado histológico ganglionar y origen del tumor. Se ha reconocido al virus del papiloma humano, sobre todo la variedad 16 (VPH-16), como factor pronóstico, sin embargo, resulta controversial que los pacientes VPH+ tengan mejor supervivencia que los VPH−. El objetivo del presente es conocer si la infección por VPH tiene valor pronóstico en pacientes con CECyC. Material y métodos: Evaluación retrospectiva de pacientes con CECyC. Se analizó supervivencia, localización tumoral, estado general (ECOG), tipo de tratamiento y asociación a VPH identificado por PCR en tejido tumoral. Análisis descriptivo de frecuencias simples, medidas de tendencia central y dispersión, de acuerdo con el tipo de variables. Análisis descriptivo para supervivencia con Kaplan-Meier y regresión de Cox, con intervalo de confianza de 95%. Resultados: Se incluyeron 179 pacientes, 119 (66.5%) hombres; promedio de edad de 64 años; 34% de los tumores se localizó en cavidad oral y 33% en laringe. Factores asociados con supervivencia: ECOG (RR = 11.3, 2.6-48), estadio clínico (RR = 7.8, 1.7-34), edad mayor a 70 años (RR = 3.5, 1.4-8.5) y tratamiento no quirúrgico (RR = 2.3, 1.4-3.8). La mediana de supervivencia para pacientes con VPH-16 fue de 22 meses versus 28 meses de quienes tuvieron otros tipos virales. La infección por VPH no se asoció con el pronóstico. Conclusiones: El ECOG en el momento del diagnóstico y la etapa clínica fueron los factores pronóstico más importantes en esta serie; el VPH no mostró valor pronóstico.

BACKGROUND: The three most important prognostic factors in patients with head and neck squamous cell carcinoma (HNSCC) are tumor size, nodular histological condition and tumor origin. Recently, human papilloma virus (HPV), particularly HPV-16, has been acknowledged as a prognostic factor. HPV+ patients have better survival than HPV-. This has created a controversy because other factors may influence the prognosis. The objective of this study was to investigate whether HPV has prognostic value in patients with HNSCC. METHODS: We carried out a retrospective evaluation of patients with HNSCC and the following variables were analyzed: survival, tumor location, stage, general condition according to Eastern Cooperative Oncology Group (ECOG) status, treatment and HPV association identified by PCR. We used a descriptive analysis of simple frequencies and central tendency and dispersion measures according to the type of variables. We used descriptive analysis for overall survival with Kaplan- Meier and Cox regression with 95% confidence interval. RESULTS: There were 179 patients included: 119 (66.5%) were male. Average age of patients was 64 years; 34% of the tumors were located in the oral cavity and 33% were located in the larynx. Factors associated with survival were ECOG (RR = 11.3; 2.6-48), clinical stage (RR = 7.8; 1.7-34), age >70 years (RR = 3.5, 1.4-8.5) and nonsurgical treatment (RR = 2.3; 1.4-3.8). Average overall survival for patients with HPV16 was 22 months vs. 28 months in those with other types of viruses. HPV infection was not associated with the prognosis in this series. CONCLUSIONS: ECOG at the time of the diagnosis and clinical stage were the most significant prognostic factors in this series. HPV did not show any prognostic value.

[Quality indicators in the early detection of cervicouterine-cancer in primary health care units]. / Indicadores de calidad en la detección oportuna de cáncer cervicouterino en unidades de primer nivel de atención.

BACKGROUND: to determine the quality of a prompt cervical cancer detection program (TDC CC) according to the indicators for prevention and diagnosis. METHODS: cross-sectional and comparative study conducted in four primary care units. We selected 400 patients who attended preventive services to participate in the study of cervical cytology (Pap). The evaluation of the Program of TDC CC was obtained by the degree of fulfillment of quality and productivity outlined by an institutional program. The seven indicators were measured by the same scale. A descriptive statistics, adjusted kappa, and chi square with a level of significance of 95 % confidence interval was used. RESULTS: the average age was 40 ± 12.6 years. Most women (92.5 %) had information about the Pap screening method in CC, even thought only 25.3 % had this test done in the last three years. The inter-observer agreement was scored low by three cytotechnologists. The degree of compliance according to indicators of the 4 units was 35.7 %, and was rated as moderate. The best indicators were great productivity among cytotechnologists, the number and proportion of re-examined cytologies. CONCLUSIONS: most indicators were below the expected values.

[The first Mexican consensus of endometrial cancer. Grupo de Investigación en Cáncer de Ovario y Tumores Ginecológicos de México]. / Primer consenso Mexicano de cancer de endometrio.

INTRODUCTION: Endometrial cancer (EC) is the second most common gynecologic malignancy worldwide in the peri and postmenopausal period. Most often for the endometrioid variety. In early clinical stages long-term survival is greater than 80%, while in advanced stages it is less than 50%. In our country there is not a standard management between institutions. GICOM collaborative group under the auspice of different institutions have made the following consensus in order to make recommendations for the management of patients with this type of neoplasm. MATERIAL AND METHODS: The following recommendations were made by independent professionals in the field of Gynecologic Oncology, questions and statements were based on a comprehensive and systematic review of literature. It took place in the context of a meeting of four days in which a debate was held. These statements are the conclusions reached by agreement of the participant members. RESULTS: Screening should be performed women at high risk (diabetics, family history of inherited colon cancer, Lynch S. type II). Endometrial thickness in postmenopausal patients is best evaluated by transvaginal US, a thickness greater than or equal to 5 mm must be evaluated. Women taking tamoxifen should be monitored using this method. Abnormal bleeding in the usual main symptom, all post menopausal women with vaginal bleeding should be evaluated. Diagnosis is made by histerescopy-guided biopsy. Magnetic resonance is the best image method as preoperative evaluation. Frozen section evaluates histologic grade, myometrial invasion, cervical and adnexal involvement. Total abdominal hysterectomy, bilateral salpingo oophorectomy, pelvic and para-aortic lymphadenectomy should be performed except in endometrial histology grades 1 and 2, less than 50% invasion of the myometrium without evidence of disease out of the uterus. Omentectomy should be done in histologies other than endometriod. Surgery should be always performed by a Gynecologic Oncologist or Surgical Oncologist, laparoscopy is an alternative, especially in patients with hypertension and diabetes for being less morbid. Adjuvant treatment after surgery includes radiation therapy to the pelvis, brachytherapy, and chemotherapy. Patients with Stages III and IV should have surgery with intention to achieve optimal cytoreduction because of the impact on survival (51 m vs. 14 m), the treatment of recurrence can be with surgery depending on the pattern of relapse, systemic chemotherapy or hormonal therapy. Follow-up of patients is basically clinical in a regular basis. CONCLUSIONS: Screening programme is only for high risk patients. Multidisciplinary treatment impacts on survival and local control of the disease, including surgery, radiation therapy and chemotherapy, hormonal treatment is reserved to selected cases of recurrence. This is the first attempt of a Mexican Collaborative Group in Gynecology to give recommendations is a special type of neoplasm.

[Value of (99m)Tc tetrofosmin scan in well-differentiated thyroid cancer].

BACKGROUND: Patients with cold thyroid nodules without ultrasound malignant suspicion and with benign/undetermined cytology may be subjected to follow-up surveillance. 99mTc-tetrofosmin scan (99mTc-TS) may identify patients where this observation can be performed with more certainty. Absence of uptake never occurs in carcinoma patients. Our objective was to determine the 99mTc-TS negative predictive value (NPV) in patients with cold thyroid nodules. METHODS: An evaluation with 99mTc-TS was conducted prior to surgery in patients with thyroid gland tumor who were candidates for surgery. All patients underwent thyroidectomy according to histology; NPV and test sensitivity were evaluated when compared with the histopathological result. Then, 296-370 MBq (8-10 mCi) of 99mTc-tetrofosmin was administered, and scan images were evaluated after 120 min. Scan result was reported as a) with increased metabolic activity (IMA) or b) without increased metabolic activity (WIMA). RESULTS: Included in the study were 86 consecutive patients. In 60 patients the scan showed IMA, 20/60 (33%) with carcinoma, 67% with benign nodule. In 26 (30.2%) the scan was WIMA. In this group, 3/26 (11.5%) had carcinoma and (88.4%) had a benign neoplasia. Sensitivity = 91.43 (95% CI = 80.73-100), specificity = 45.10 (95% CI = 30.46-59.73), positive predictive value = 53.33 (95% CI = 39.8-66.79) and NPV = 88.46 (95% CI 74.26-100). Negative probability ratio = 0.19. CONCLUSIONS: IMA-99mTc-TS is less specific in thyroid cancer; nevertheless, in WIMA patients the possibility of carcinoma is 13%. Most patients (70%) showed IMA, 33% with carcinoma. WIMA-NPV = 30%. 99mTc-TS may be useful in the therapeutic decision of patients with thyroid nodule with concerns about surgery. Its usefulness lies in the NPV.

Human leukocyte antigens I and II haplotypes associated with human papillomavirus 16-positive invasive cervical cancer in Mexican women.

Infection with human papillomavirus (HPV), mainly HPV type 16, is the major etiologic factor associated with cervical cancer (CC), but HPV infection alone is not sufficient for progression of precursor lesions. Host genetic susceptibility may lead to abnormal immune response resulting from virus persistence. Several studies have suggested a possible association with specific human leukocyte antigen (HLA) class I and II alleles and CC, but results are not consistent. The association of genetic HLA class I (A and B) and HLA class II (DR*B1 and DQ*B1) haplotypes with HPV16-positive CC (n = 104) and base population controls (n = 104) was evaluated in this Mexican population study. Sequence-specific primer HLA genes were determined by polymerase chain reaction (PCR)-based methods in peripheral blood cell counts (PCR sequence-specific oligonucleotides). The cervical swabs of 208 women were tested for HPV16 by Hybrid Capture II. Allele and haplotype HLA frequencies, Hardy-Weinberg tests, and a haplotype homogeneity test were estimated using the Arlequin software v. 3.01. Odds ratio (OR) was calculated to compare cases and control women. Consistent associations across other studies in women with CC and infected by HPV16 were observed for HLA-DRB1*15 (OR, 3.9; 95% CI, 1.6-10.2) and the haplotype DRB1*15 DQB1*0602 (OR, 4.1; 95% CI, 1.4-12.7) compared with control women. The HLA-A2-B44-DR4-DQ*0302, HLA-A24-B35-DR16-DQ*0301, and HLA-A2-B40-DR4-DQ*0302 haplotypes showed a positive association with CC (OR, >1), whereas HLA-A2-B39-DR4-DQ*0302, HLA-A24-B35-DR4-DQ*0302, and HLA-A68-B40-DR4-DQ*0302 showed a negative association (OR, <1). These results support the hypothesis that some HLA class I and II haplotypes could be involved with susceptibility for developing CC.

Valor de la gammagrafía con Tc-99m-tetrofosmín en el diagnóstico del cáncer bien diferenciado de tiroides / Value of (99m)Tc tetrofosmin scan in well-differentiated thyroid cancer

Introducción: Los pacientes con nódulos tiroideos hipocaptantes sin sospecha ultrasonográfica y con citología benigna o indeterminada pueden ser vigilados. El gammagrama con Tc- 99m-tetrofosmín (Tc-99m-TS) identifica pacientes en los que la vigilancia es más segura. La ausencia de captación nunca ocurre en pacientes con carcinoma. El objetivo de este estudio fue conocer el valor predictivo negativo del Tc-99m-TS en pacientes con nódulo tiroideo. Material y métodos: Evaluación preoperatoria con Tc-99m-TS de pacientes con nódulo tiroideo candidatos a cirugía. Tiroidectomía de acuerdo con el diagnóstico en todos. Evaluación de valor predictivo negativo y sensibilidad al comparar con el resultado histopatológico. Se administraron 296-370 MBq (8-10 mCi) de Tc-99m-TS; evaluación de imágenes a los 120 minutos. Resultado reportado con actividad metabólica aumentada (AMA) o sin actividad metabólica aumentada (SAMA). Resultados: Se incluyeron 86 pacientes consecutivos. Sesenta (69.7 %) tuvieron AMA, 20/60 con carcinoma (33 %), en 67 % el diagnóstico fue de nódulo benigno. En 26 (30.2 %) SAMA, 11.5 % tuvo carcinoma y 88.4 % neoplasia benigna. Sensibilidad de 91.43 % (IC 95 % = 80.73-100 %), especificidad de 45.10 % (IC 95 % = 30.46-59.73), valor predictivo positivo de 53.33 % (IC 95 % = 39.8-66.79), valor predictivo negativo de 88.46 % (IC 95 % = 74.26-100). Razón de verosimilitud negativa = 0.19. Conclusiones: Tc-99m-TS con AMA es poco específico en cáncer tiroideo; en pacientes SAMA 13 % tiene carcinoma. La mayoría de los pacientes (70 %) mostró AMA, 33 % con carcinoma. Valor predictivo negativo en grupo SAMA = 88 %. Tc-99m-TS podría ser útil en la decisión terapéutica de pacientes con nódulo tiroideo en los que existe duda de cirugía; su utilidad radica en el valor predictivo negativo.

BACKGROUND: Patients with cold thyroid nodules without ultrasound malignant suspicion and with benign/undetermined cytology may be subjected to follow-up surveillance. 99mTc-tetrofosmin scan (99mTc-TS) may identify patients where this observation can be performed with more certainty. Absence of uptake never occurs in carcinoma patients. Our objective was to determine the 99mTc-TS negative predictive value (NPV) in patients with cold thyroid nodules. METHODS: An evaluation with 99mTc-TS was conducted prior to surgery in patients with thyroid gland tumor who were candidates for surgery. All patients underwent thyroidectomy according to histology; NPV and test sensitivity were evaluated when compared with the histopathological result. Then, 296-370 MBq (8-10 mCi) of 99mTc-tetrofosmin was administered, and scan images were evaluated after 120 min. Scan result was reported as a) with increased metabolic activity (IMA) or b) without increased metabolic activity (WIMA). RESULTS: Included in the study were 86 consecutive patients. In 60 patients the scan showed IMA, 20/60 (33%) with carcinoma, 67% with benign nodule. In 26 (30.2%) the scan was WIMA. In this group, 3/26 (11.5%) had carcinoma and (88.4%) had a benign neoplasia. Sensitivity = 91.43 (95% CI = 80.73-100), specificity = 45.10 (95% CI = 30.46-59.73), positive predictive value = 53.33 (95% CI = 39.8-66.79) and NPV = 88.46 (95% CI 74.26-100). Negative probability ratio = 0.19. CONCLUSIONS: IMA-99mTc-TS is less specific in thyroid cancer; nevertheless, in WIMA patients the possibility of carcinoma is 13%. Most patients (70%) showed IMA, 33% with carcinoma. WIMA-NPV = 30%. 99mTc-TS may be useful in the therapeutic decision of patients with thyroid nodule with concerns about surgery. Its usefulness lies in the NPV.

The hospital appropriateness evaluation protocol in elderly patients: a technique to evaluate admission and hospital stay.

BACKGROUND: Aging of the population represents one of the main challenges for health systems because of the increase in the demand for hospital services. To be able to count on tools that allow an objective evaluation of hospital-resource use becomes indispensable for health systems. OBJECTIVE: To evaluate the reliability and validity of the Appropriateness Evaluation Protocol (AEP) regarding the appropriateness of admissions and hospital stays in elderly patients. In a scenario of scarce resources, to have a valid instrument will make it possible to evaluate the process of care in our growing elderly population in a standardized way. METHODS: We carried out a retrospective study of 144 randomly chosen elderly patients admitted to the hospital with 394 even-numbered hospital-stay days. For the reliability analysis between the pair of nurses with the AEP and the pair of specialists, the details of the hospital admissions and the stay days were obtained from the clinical files. Criteria validity was conducted by pairs of physicians, including two internists, two general surgeons and two geriatricians. Only the agreements were compared with agreements of the AEP-trained nurses. Disagreements were excluded from the final analysis. RESULTS: Inter-rater (inter-reviewer) agreement of hospital admissions and days spent by the patient presented a kappa coefficient of >0.70, while these admissions and hospital-stay days was >0.70. Sensitivity and positive predictor value to detect inappropriate admissions were not calculated because no agreement existed on inappropriate admissions. Specificity and negative predictive value to detect appropriate admission was >94.0% and >98.0%. Sensitivity and positive predictor value to detect inappropriate hospital-stay days was >44.0% and >10.0%, while specificity and negative predictor value for detecting appropriate hospital-stay days was >79.0% and >88.0%. CONCLUSIONS: AEP's high-reliability and moderate-validity results with regard to clinical judgement positions it as a useful instrument for appropriate hospitalization screening in elderly patients.

[Associated factors for women's non-compliance for cervical cancer screening]. / Factores asociados con incumplimiento para tamizaje en cáncer de cérvix.

OBJECTIVE: To identify the associated factors for non-compliance among women for the cervical cancer screening program. METHODS: A case-control study was carried out in which cases were women who were just diagnosed with cervical cancer (confirmed with pathological study); controls were women not having cervical cancer (negative pathological study). Cases and controls had the same age, lived in the same geographical area and were selected from the primary care facilities. Lack of compliance for cervical cancer screening was defined as the time since the last cytology (no previous Pap test or > or =3 years since last Pap test). A logistic regression analysis served to identify the associated factors to the lack of compliance. RESULTS: There were 279 cases and 392 controls included in the study. The rate of non-compliance among cases was 76.7% and among controls was 29.6%. Among cases 45.5% had never undergone Pap test compared with 9.9% of controls. Main risk factors for non-compliance to attend to cervical cancer screening were age > 65 years (aOR = 2.9, 95% CI 1.6-5-3); illiteracy (aOR = 3.8, 95% CI 1.7-6); use of public transportation to attend to the preventive service (aOR = 2.3, 95% CI 1.2-6.4); more than five pregnancies (aOR = 3.0, 95% CI 1.6-5.3) and lack of knowledge about cervical cancer (aOR = 4.2, 95% CI 3.6-7.2). CONCLUSION: The rate of non-compliance close to 30% was high; social and cultural risk factors were the most relevant.

[Human papillomavirus: association with head and neck cancer]. / Virus del papiloma humano asociado a cáncer de cabeza y cuello.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) is the 6th most common cancer worldwide. In 2005, 400,000 cases of HNSCC were diagnosed worldwide. The most frequently affected site is the oral cavity. Alcohol/tobacco consumption is the most important risk factor for this neoplasia; nevertheless, since 1983 it has been suggested that human papilloma viruses (HPV) have a role in HNSCC, mainly in the oropharynx (level 1 evidence). We undertook this study to determine HPV prevalence and types in patients with HNSCC. METHODS: Presence of HPV was determined by polymerase chain reaction and staged by in situ hybridization. We analyzed stage, tumor site of origin, sexual practices, and alcohol/tobacco consumption. Fisher's exact test and Student's t-test were used for statistical analysis. We performed a multiple regression analysis for adjustment of variables. RESULTS: There were 118 patients were HPV positive and oropharyngeal and laryngeal cancer patients were the most frequently affected (55% and 50%, respectively). HPV-16 was most frequently isolated (70%). Laryngeal cancer patients suffered the highest ratio of HPV-16 infection (68.7%). Factors associated with HPV (univariate analysis) were age >50 years, tobacco/alcohol consumption and male gender. In multivariate analysis, none of the variables showed importance (p >0.5); HPV infection was more frequent in patients with history of alcohol/tobacco consumption (p = 0.6). CONCLUSIONS: There was HPV presence in 42% of HNSCC patients, HPV-16 in 70%, with the oropharynx and larynx being the most affected sites. No variables are associated with the virus presence. HPV is a co-factor in HNSCC etiology.

The risk of developing cervical cancer in Mexican women is associated to CYP1A1 MspI polymorphism.

The aim of the study was to evaluate the association of two CYP1A1 polymorphisms (Msp1 and exon 7) with cervical cancer in Mexican women considering their smoking habit. The polymorphisms were determined in 310 individuals (155 with cervical cancer and 155 healthy controls). Women with MspI T/C or C/C showed increased risk of developing cervical cancer (3.7- and 8.3-fold increase, respectively) compared to women with T/T genotype. When smoking habit was considered, the risk for non-smokers with T/C and C/C genotypes was similar (5.2 and 4.1, respectively), whereas smoking women with C/C genotype showed a 19.4-fold increase of cervical cancer. Number of child births, number of sexual partners and marital status were strong risk factors for developing cervical cancer in women with T/T genotype; however, in women with T/C genotype, only the number of child births and sexual partners had a significant influence. These results suggest an important role of the CYP1A1 MspI polymorphism in the risk of developing cervical cancer.