Fibrolamellar Carcinoma: A Rare Liver Neoplasm.

Fibrolamellar carcinoma is a rare liver tumor, with most cases arising in people younger than 40 years of age. We present a case series of five patients with histological confirmation of fibrolamellar carcinoma who had liver resection as the primary treatment. The median age of diagnosis was 24 years with nonspecific clinical manifestations in otherwise healthy patients. Alpha-fetoprotein levels were widely variable. Patients had classical imaging, macroscopic, and microscopic findings. Most of our patients underwent a hemihepatectomy and 60% recurred after the first year.

Endoscopic ultrasound-guided celiac plexus neurolysis in pancreatic cancer-associated pain: different technical approaches in three challenging cases

Abdominal pain is severe in the vast majority of patients with pancreatic cancer. In some cases, chronic use of analgesics markedly reduces quality of life due to side effects. Endoscopic ultrasound-guided celiac plexus neurolysis is a procedure that controls cancerassociated pain in this population and consists of injecting a neurolytic agent around or within the celiac plexus. In this report, we present three cases with different technical approaches for celiac plexus neurolysis.

El cáncer de páncreas se puede presentar con dolor abdominal intenso, siendo necesario el uso de analgésicos a largo plazo en muchos de los pacientes. Sin embargo, estos medicamentos pueden tener efectos adversos que finalmente reducen la calidad de vida de los pacientes. La neurólisis del plexo celíaco guiada por ecoendoscopia es un procedimiento que controla el dolor asociado a este tipo de neoplasia y consiste en inyectar un agente neurolítico en o alrededor del plexo celíaco. Presentamos tres casos en los cuales se realizan diferentes técnicas de abordaje terapéutico.

[Gastric cancer in octogenarians. Is a curative surgery viable?] / C áncer g ástrico en octogenarios ¿Es viable una cirugía con intención curativa?

The objective was to evaluate the association between octogenarian age and the rate of postoperative morbidity and mortality and 5-year survival in older adults at the National Institute of Neoplastic Diseases (INEN) during the period 2000-2013. We developed an observational, retrospective, analytical, paired cohort study. It includes patients with gastric adenocarcinoma as diagnosis, treated by R0 D2 gastrectomy at INEN during the period 2000 to 2013. One group included all octogenarian patients who met the inclusion criteria (92) and the other group made up of non-octogenarian patients, aged between 50 to 70 years because it is the age peak for this pathology (276). In a 1:3 ratio, paired according to sex, tumor stage, and type of gastrectomy, which are the main factors that could influence survival in this population. Octogenarians had lower albumin level (p < 0.002), lower preoperative hemoglobin (p<0.001) and higher ASA classification (p<0.001). 30 days mortality rate was higher in octogenarians but not statistically significant (4.1% vs 1.4%; p=0.099). The 5-year cumulative survival probability was 56% for octogenarians and 58% for non- octogenarians (p=0.763). Clinical stage >= III and postoperative complication grade >= 3 by Clavien Dindo scale were predictors of survival. In conclusion, octogenarians have a higher rate of postoperative morbidity, mainly for respiratory causes. Postoperative mortality and overall survival rates do not differ between octogenarians and non-octogenarians with stomach cancer treated by R0 D2 gastrectomy.

Such a fun-guy! Is this Candida or Histoplasma?

Histoplasmosis is a neglected mycosis with high mortality in immunocompromised individuals. The diagnosis can be delayed due to nonspecific clinical manifestations and similar morphology with other organisms. A high index of suspicion is required.

Cáncer gástrico en octogenarios ¿Es viable una cirugía con intención curativa?

El objetivo de la presente investigación es evaluar la asociación entre la edad octogenaria y la tasa de morbimortalidad posoperatoria y supervivencia a los 5 años en adultos mayores tratados mediante gastrectomía R0 D2 en el Instituto Nacional de Enfermedades Neoplásicas (INEN) durante el periodo 2000-2013. Se realizó un estudio observacional, retrospectivo, analítico de cohorte pareado, que incluye pacientes con diagnóstico de adenocarcinoma gástrico tratados mediante gastrectomía R0 D2 en el INEN durante los años 2000 a 2013. Un grupo compuesto por todos los pacientes octogenarios que cumplieron los criterios de inclusión (92) y otro grupo compuesto por pacientes no octogenarios, con edades entre 50 a 70 años por ser el pico de presentación para esta patología (276). En una proporción 1:3, pareados según sexo, estadio tumoral y tipo de gastrectomía, los cuales constituyen los principales factores que podrían influir en la sobrevida de esta población. Los octogenarios presentaron menor albúmina (p<0,002), menor hemoglobina preoperatoria (p<0,001) y mayor clase ASA (p<0,001). La tasa de mortalidad a 30 días fue mayor en los octogenarios, pero no estadísticamente significativa (4,1% vs 1,4%; p=0,099). La probabilidad acumulada de supervivencia a 5 años fue 56% para octogenarios y 58% para los controles (p=0,763). El estadio clínico ≥ III y complicación posoperatoria grado ≥3 por Clavien Dindo fueron factores asociados de supervivencia. En conclusión, los octogenarios presentan mayor tasa de morbilidad posoperatoria, principalmente de causa respiratoria. Las tasas de mortalidad posoperatoria y supervivencia global no difieren entre octogenarios y no octogenarios con cáncer de estómago tratados mediante gastrectomía R0 D2.

The objective was to evaluate the association between octogenarian age and the rate of postoperative morbidity and mortality and 5-year survival in older adults at the National Institute of Neoplastic Diseases (INEN) during the period 2000-2013. We developed an observational, retrospective, analytical, paired cohort study. It includes patients with gastric adenocarcinoma as diagnosis, treated by R0 D2 gastrectomy at INEN during the period 2000 to 2013. One group included all octogenarian patients who met the inclusion criteria (92) and the other group made up of non-octogenarian patients, aged between 50 to 70 years because it is the age peak for this pathology (276). In a 1:3 ratio, paired according to sex, tumor stage, and type of gastrectomy, which are the main factors that could influence survival in this population. Octogenarians had lower albumin level (p<0.002), lower preoperative hemoglobin (p<0.001) and higher ASA classification (p<0.001). 30 days mortality rate was higher in octogenarians but not statistically significant (4.1% vs 1.4%; p=0.099). The 5-year cumulative survival probability was 56% for octogenarians and 58% for non- octogenarians (p=0.763). Clinical stage ≥ III and postoperative complication grade ≥ 3 by Clavien Dindo scale were predictors of survival. In conclusion, octogenarians have a higher rate of postoperative morbidity, mainly for respiratory causes. Postoperative mortality and overall survival rates do not differ between octogenarians and non-octogenarians with stomach cancer treated by R0 D2 gastrectomy.

Endoscopic ultrasound-guided celiac plexus neurolysis in pancreatic cancer-associated pain: different technical approaches in three challenging cases.

Abdominal pain is severe in the vast majority of patients with pancreatic cancer. In some cases, chronic use of analgesics markedly reduces quality of life due to side effects. Endoscopic ultrasound-guided celiac plexus neurolysis is a procedure that controls cancer-associated pain in this population and consists of injecting a neurolytic agent around or within the celiac plexus. In this report, we present three cases with different technical approaches for celiac plexus neurolysis.

The hardest pill to swallow: A freak of nature.

Not required.

Analysis of medical appointments for patients with overweight and obesity in a public hospital of Lima, Peru: a cross-sectional study of audio-recorded consultations.

OBJECTIVE: To describe the content of overweight and obesity counseling performed in a public Peruvian hospital. METHODS: We audio-recorded 40 visits of patients with overweight or obesity from the internal medicine, cardiology, endocrinology, and family medicine services at Cayetano Heredia Hospital. Fragments of the recordings in which counseling was performed were transcribed and codified. We established a checklist to score each counseling session and performed descriptive analyses. RESULTS: Complete counseling (including weight, nutrition, and physical activity) was performed in 32.5% of consultations. The average time spent in counseling was 1.72 minutes. Counseling on weight loss was performed in 65% of consultations, nutrition in 65%, and physical activity in 35%. On average, 8 of 26 checklist items were fulfilled per appointment. Weight loss goals were established in 15% of visits. The most frequent diet recommendations were eating more fruits and vegetables (32.5%) and eating fewer carbohydrates (30.0%). Suggested physical activities were walking (10.0%), running (7.5%), and playing any sport (7.5%). CONCLUSIONS: Complete counseling was only addressed in one-third of the appointments, and most counseling was superficial without considering therapeutic goals. This suggests the need to include lifestyle counseling in consultations, regardless of the medical specialty or patient's background condition.

Is air an issue? A severe case of subcutaneous emphysema in an immunocompromised patient.

Abdominal crepitus and air in the subcutaneous tissue should be recognized early, as the most common etiologies for subcutaneous emphysema are fatal if not treated acutely. We present the case of a patient who developed subcutaneous emphysema as a consequence of the dehiscence of a previously closed gastrocutaneous fistula.

Development, implementation and outcomes of a quality assurance system for the provision of continuous renal replacement therapy in the intensive care unit.

Critically ill patients with requirement of continuous renal replacement therapy (CRRT) represent a growing intensive care unit (ICU) population. Optimal CRRT delivery demands continuous communication between stakeholders, iterative adjustment of therapy, and quality assurance systems. This Quality Improvement (QI) study reports the development, implementation and outcomes of a quality assurance system to support the provision of CRRT in the ICU. This study was carried out at the University of Kentucky Medical Center between September 2016 and June 2019. We implemented a quality assurance system using a step-wise approach based on the (a) assembly of a multidisciplinary team, (b) standardization of the CRRT protocol, (c) creation of electronic CRRT flowsheets, (d) selection, monitoring and reporting of quality metrics of CRRT deliverables, and (e) enhancement of education. We examined 34-month data comprising 1185 adult patients on CRRT (~ 7420 patient-days of CRRT) and tracked selected QI outcomes/metrics of CRRT delivery. As a result of the QI interventions, we increased the number of multidisciplinary experts in the CRRT team and ensured a continuum of education to health care professionals. We maximized to 100% the use of continuous veno-venous hemodiafiltration and doubled the percentage of patients using regional citrate anticoagulation. The delivered CRRT effluent dose (~ 30 ml/kg/h) and the delivered/prescribed effluent dose ratio (~ 0.89) remained stable within the study period. The average filter life increased from 26 to 31 h (p = 0.020), reducing the mean utilization of filters per patient from 3.56 to 2.67 (p = 0.054) despite similar CRRT duration and mortality rates. The number of CRRT access alarms per treatment day was reduced by 43%. The improvement in filter utilization translated into ~ 20,000 USD gross savings in filter cost per 100-patient receiving CRRT. We satisfactorily developed and implemented a quality assurance system for the provision of CRRT in the ICU that enabled sustainable tracking of CRRT deliverables and reduced filter resource utilization at our institution.

Stress and a sedentary lifestyle are associated with irritable bowel syndrome in medical students from Peru: a cross-sectional study.

BACKGROUND: Previous studies suggest that medical students may have higher rates of irritable bowel syndrome as compared to the general population. We hypothesized lifestyle characteristics may be associated to irritable bowel syndrome. METHODS: A cross-sectional survey was conducted in 2015 among students in their fourth, fifth, sixth and seven years of a medical school in Peru. Volunteer participants responded to questions pertaining to demographics, surveys including the Rome III criteria and the Self-reported Stress questionnaire. Regression models were performed to establish variables independently associated with irritable bowel syndrome. RESULTS: Out of 452 students, 346 responded the survey (response rate: 76.5%; female rate: 47%; median age: 22 years). The irritable bowel syndrome prevalence in respondents was 9.5% (95% confidence interval: 6.7%-13.1%). On univariate analysis, being a senior medical student (odds ratio: 2.8; 95% confidence interval: 1.3-5.9; P < 0.01), mental illness (odds ratio: 3.3; 95% confidence interval: 1.6-6.8; P = 0.002), psychiatric medication use (odds ratio: 2.8; 95% confidence interval: 1.4-5.9; P = 0.005), sedentary lifestyle (odds ratio: 4.4; 95% confidence interval: 1.8-11; P = 0.001) and stress (odds ratio: 4.4; 95% confidence interval: 2.1-9.3; P < 0.001) were associated to irritable bowel syndrome. On a multivariate analysis, a sedentary lifestyle (odds ratio: 3.2; 95% confidence interval: 1.25-8.20; P = 0.01) and stress (odds ratio: 3.0; 95% confidence interval: 1.35-6.67; P < 0.01) were independently associated with irritable bowel syndrome. CONCLUSION: The prevalence of irritable bowel syndrome in medical students from Peru is slightly lower compared to the global prevalence of irritable bowel syndrome. Stress and a sedentary lifestyle were independent risk factors associated with irritable bowel syndrome. Our study suggests that lifestyle modifications and stress coping techniques could have an impact to reduce the rates of irritable bowel syndrome in medical students.

Strongyloides stercoralis hyperinfection syndrome: a deeper understanding of a neglected disease.

Strongyloides stercoralis hyperinfection syndrome (SHS) is a life-threatening condition that warrants early detection and management. We describe the pathogenesis, organ-specific clinical manifestations, and risk factors associated to this condition. A comprehensive review of the literature was conducted in PubMed, LILACS, EBSCO and SciELO by using the keywords: "hyperinfection syndrome"; "Strongyloides stercoralis"; "disseminated strongyloidiasis"; "systemic strongyloidiasis", "pathogenesis" and "pathophysiology". Relevant articles on this topic were evaluated and included by consensus. Also, a secondary search of the literature was performed. Articles in English and Spanish language were included. SHS has been described in tropical and sub-tropical regions. However, there is growing evidence of cases detected in developed countries favored by increasing migration and the advance in immunosuppressive therapies for oncologic and inflammatory diseases. SHS is characterized by massive multiplication of larvae, typically in immunocompromised hosts. Clinical manifestations vary according to the organ involved and include diarrhea, intestinal bleeding, alveolar hemorrhages, heart failure, jaundice, bacteremia among others. Despite advances in the understanding of this condition, fatality rates are near 90%. Clinicians should consider SHS in the differential diagnosis of acutely ill patients with multiple organ damage and epidemiological risk factors. Adverse outcomes are common, especially with delayed anti-parasitic treatment.

Strongyloides stercoralis infection after the use of emergency corticosteroids: a case report on hyperinfection syndrome.

BACKGROUND: In clinical practice, identification of a case of severe asthma exacerbation prompts initiation of corticosteroids. However, not all that wheezes is asthma. CASE PRESENTATION: A 61-year-old man from the Peruvian Amazon presented with progressive dyspnea, abdominal pain, and cough for the past week. His medical history was remarkable for asthma since childhood; he was treated with beta-agonists, ipratropium, and orally administered corticosteroids. On evaluation, he was febrile and ill-appearing. His chest examination revealed diffuse wheezing and bilateral crackles. He was diagnosed as having community-acquired pneumonia and asthma exacerbation and was started on empiric antibiotics, nebulized beta-agonists, and orally administered corticosteroids. His clinical status continued deteriorating and he became critically ill despite broad-spectrum antibiotics and antifungals. Considering the epidemiological background of our patient, bronchoalveolar and fecal samples were obtained to investigate soil-transmitted helminths. Larvae of Strongyloides stercoralis were found in both specimens. Ivermectin was initiated and corticosteroids were discontinued. He experienced remarkable improvement of clinical condition over the next weeks. The literature on this topic was reviewed. CONCLUSION: Cases of severe asthma exacerbation warrant careful evaluation before the initiation of corticosteroids, especially in patients at risk for parasitic infections. A high index of suspicion is critical. Alternative etiologies of respiratory decompensation should be considered in patients who fail to improve with broad-spectrum antibiotics and antifungals.

Fibromialgia, trayectoria y calidad de vida en un hospital de tercer nivel de Lima-Perú / Fibromyalgia, its progression and quality of life in a tertiary care hospital in Lima-Peru

Objetivo: Determinar la trayectoria, características clínicas y calidad de vida en pacientes con fibromialgia (FM) que se atienden en un hospital de tercer nivel, en Lima-Perú. Materiales y métodos: Se seleccionó a pacientes con diagnóstico validado por un médico reumatólogo; en quienes se recolecto información sociodemográfica, clínica, y se aplicaron las escalas de depresión y ansiedad hospitalaria (HADS, así como el cuestionario de Impacto de Fibromialgia en español (S-FIQ). Resultados: Se entrevistó a 75 pacientes mujeres, con una edad promedio de 54,9 años. Alrededor de 5,2 años tuvieron que pasar desde el inicio de los síntomas hasta que se hizo el diagnóstico. Setenta y uno pacientes (94,7%) reportaron que el dolor musculoesquelético era el síntoma principal y 60 pacientes (80%) presentaron un impacto moderado o grave en la calidad de vida. Seis pacientes tuvieron "depresión probable" y 22 fueron un "caso probable de ansiedad". Además, 55 pacientes (73,3%) reportaron haber sufrido algún tipo de violencia y 12 reportaron violencia sexual. Conclusión: Transcurren alrededor de cinco años desde la aparición de los síntomas hasta que se hace el diagnóstico de FM. Esta enfermedad causa un impacto severo en la calidad de vida, afectando la salud mental, el trabajo y los ingresos. Hasta dos tercios de las mujeres reportan algún tipo de violencia, con un porcentaje elevado de violencia sexual.

Objective: To determine the disease progression, its clinical characteristics, and its impact in patients diagnosed with fibromyalgia in a tertiary care hospital in Lima, Peru. Materials and methods: Patients with a diagnosis of fibromyalgia validated by a rheumatologist were selected. Sociodemographic and clinical information was collected, and both the Hospital Depression and Anxiety Scales (HADS) and the Fibromyalgia Impact Questionnaire in Spanish (S-FIQ) were administered. Results: Seventy-five female patients were interviewed, with an average age of 54.93 years. Approximately 5.24 years had to elapse since symptoms started until a diagnosis was made. Seventy-one patients (94.67%) reported musculoskeletal pain as their main symptom and 60 (80%) patients had a moderate or severe impact in their quality of life. Six patients had "likely depression" and 22 were described as a "likely anxiety case". Also, 55 patients (73.33%) reported suffering some type of violence, and 12 reported sexual violence. Conclusions: It takes about 5 years from fibromyalgia symptom onset until a diagnosis is made. This condition has a severe impact on quality of life, affecting mental health, work, and income. Up to two thirds of women reported having suffered some type of violence, with an elevated percentage of sexual violence.

Prostate cancer mortality rates in Peru and its geographical regions.

OBJECTIVE: To evaluate the mortality rates for prostate cancer according to geographical areas in Peru between 2005 and 2014. MATERIALS AND METHODS: Information was extracted from the Deceased Registry of the Peruvian Ministry of Health. We analysed age-standardised mortality rates (world population) per 100 000 men. Spatial autocorrelation was determined according to the Moran Index. In addition, we used Cluster Map to explore relations between regions. RESULTS: Mortality rates increased from 20.9 (2005-2009) to 24.1 (2010-2014) per 100 000 men, an increase of 15.2%. According to regions, during the period 2010-2014, the coast had the highest mortality rate (28.9 per 100 000), whilst the rainforest had the lowest (7.43 per 100 000). In addition, there was an increase in mortality in the coast and a decline in the rainforest over the period 2005-2014. The provinces with the highest mortality were Piura, Lambayeque, La Libertad, Callao, Lima, Ica, and Arequipa. Moreover, these provinces (except Arequipa) showed increasing trends during the years under study. The provinces with the lowest observed prostate cancer mortality rates were Loreto, Ucayali, and Madre de Dios. This study showed positive spatial autocorrelation (Moran's I: 0.30, P = 0.01). CONCLUSION: Mortality rates from prostate cancer in Peru continue to increase. These rates are higher in the coastal region compared to those in the highlands or rainforest.

Trends and geographic pattern of stomach cancer mortality in Peru.

BACKGROUND: Stomach cancer mortality rates in South America are among the highest in the world. In Peru, stomach cancer has the highest absolute number of cancer deaths in both sexes combined. We estimated mortality rates for stomach cancer in Peru by sex and geographical region between 2008 and 2015. METHODS: We obtained death data for stomach cancer from the Peruvian Ministry of Health database. We estimated the age-standardized mortality rate (ASMR) per 100,000 persons using the direct method and the world standard population. RESULTS: A total of 25,020 deaths from stomach cancer were identified in the study period. At national level, stomach cancer mortality rates (per 100,000 population) for men ranged from 9.8 in 2008 to 8.8 in 2015 with a percent change of -16%, and for women from 8.8 in 2008 to 7.7 in 2015 with a percent change of -16.8%. The highlands had the highest mortality rates overall, mainly in Huancavelica and Huánuco. The rainforest had the lowest rates and the highest decline in stomach cancer ASMRs. The coast displayed intermediate rates overall. CONCLUSIONS: Within the study period, mortality rates from stomach cancer in Peru declined by 16%. The highlands had the highest mortality rates as compared to those from the coast or rainforest region. These geographical differences in mortality could reflect a different distribution in stomach cancer risk factors as the prevalence of H. pylori, poor dietary habits, low socioeconomic background of the Andean population and the lack of a decentralized health system.

Motivation towards medical career choice and academic performance in Latin American medical students: A cross-sectional study.

INTRODUCTION: Motivation in medical students is positively associated with learning strategies. However, the evidence of a direct relationship between motivation and performance is vague. The objective of this study is to determine if the motivation that pushed students to choose the medical career is associated with their academic performance during their university years. METHODS: The study was conducted in 4,290 medical students from 10 countries in Latin America. The "Attribution Scale of General Achievement Motivation" was used to evaluate their general performance. The "Medical motivation Scale" test was used to measure social, altruist, economic, and prestige motivators. For statistical analyses, frequencies and percentages were described, and generalized linear models were used to establish statistical associations. RESULTS: Fifty percent of the students surveyed were females and the mean student age was 21 years old. This study showed that male students had a higher social/altruist motivation (PR:1.11,95%CI: 1.03-1.18; p<0,01) than females. Those who had familial pressure had a lower social/altruist motivation (PR:0.17,95%CI:0.08-0.36; p<0,001). The positive vocational test was associated with a higher social/altruist motivation (PR:1.85,95%CI:1.03-3.30; p<0,05). Moreover, good grades at school were related with a higher economical/prestige motivation (PR:1.39,95%CI:1.05-1.83; p<0,05), but lower social/altruist motivation (PR:0.85,95%CI:0.74-0.98; p<0,05) and academic performance (PR:0.63,95%CI:0.50-0.79; p<0,001). We found a higher frequency in the general motivation was associated to a lowest social/altruist motivation (PR: 0.57; CI95%: 0.46-0.70; p<0.001), and that it increased according to the year of study (PR: 1.15; CI95%: 1.03-1.28; p:0.013) and was higher when pressure by the family was present (PR: 1.36; CI95%: 1.17-1.59; p<0.001). CONCLUSION: This study indicated that male medical students and having a positive vocational test were associated with a higher social/altruist motivation. Conversely, those who had familial pressure and good grades at school had a lower social/altruist motivation. Is necessary to conduct further studies that assess other factors related to motivation as demographics, personality, and learning styles.