Sergio Ralon

The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135–15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359–5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138–5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184–5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598–9.930; aOR 3.983), abdominal compartment...

In our days, the Arab Israeli conflict is increasingly every day
without  finding  a  way  to  move  forward.  The  latest
negotiations looking for two states that work side by side are
increasingly distant. On the one hand, the Israeli claims after
the failed Oslo agreements whereby giving autonomy to the
Palestinian authority only provoked more disputes between
Israelis and even between the so-called Palestinian Arabs
themselves. The popular election in the Gaza area made
Hamas become a dictatorship in that area and Abbas, leading
the Palestinian authority in the autonomous area of Judea
and Samaria, has never called for a new popular election
becoming a dictatorship as well. As in ancient Greco-Roman tragedies, Israel in trying to deal with this problem seems to
have formed a two-headed monster each trying to pull its
own body in a different direction . The point of this thesis is
the  claim  of  the  Arab  population called  since  1967 ,  "
Palestinian  "  to  be  called a  “Palestinian people  ”  or  “
Palestinian state  ”  and  what  is  the  archaeological ,
anthropological support that ancient history tells us to name
a Palestinian People existing since ancient times. What legal,
anthropological , historical, archaeological support exists for
us to say that throughout history the "Palestinian people "
exists ? Is there any archaeological evidence that supports
whether  throughout ancient  and  modern  history ,  the  "
Palestinian state" or the Palestinian kingdom really existed?

Se presenta el siguiente estudio retrospectivodescriptivo de pacientes que consultaron con diagnóstico de Tumor Filodes al departamento de Cirugía del Hospital General San Juan de Dios, en un lapso de 16 años. Todas las pacientes recibieron imagen y diagnóstico preoperatorio con Mamografía, Ultrasonido , biopsia con aguja gruesa y algunos casos con biopsia incisional o excisional. Todas fueron clasificadas según Azzopardi y Pyetruszka, determinando su grado de malignidad, borderline o benigno. A 12 de estas pacientes se les realizó Mamoplastia Excisional, teniendo recurrencia local en cuatro casos, en dos de los cuales fue necesario hacer mastectomía y a las dos restantes solamente una nueva reescisión. Los resultados demuestran que el concepto de Oncoplástica es aplicable a un segmento bien clasificado y seleccionado de este tipo de pacientes

Social and economic changes in Vietnam since the economic restructuring of the 1980s have caused a shift in norms about premarital sex. While expectations of female chastity remain, sex before marriage is becoming more common among young people. As the formative phase of a parent randomized controlled trial, the present study examined the normative context of sex in dating relationships from the perspectives of young women and men in Vietnam. Men (n = 12) and women (n = 9) studying at two universities in Hanoi participated in semi-structured interviews that explored perspectives on sexual relationships and sexual coercion among their peers. Thematic analysis synthesized participant narratives into broader themes. Our findings confirmed that, as social norms evolve in Vietnam, young women must navigate shifting, and often contradictory, expectations about sex and dating relationships. Women and men expressed the belief that competing sexual expectations often can limit young women’s ...

De mayo de 1998 a diciembre del 2010, se realizó un estudio prospectivo
para determinar la sensibilidad del linfático y ganglio centinela en el manejo de las pacientes con Cáncer de mama con el uso de colorante azul de Metileno. El total de pacientes que llenaron criterios de ingreso fue de 96, las cuales se encontraban en estadio T1N0M0/T2N0M0. En 87 de 96 casos fue posible identificar el ganglio centinela, en los casos restantes se realizó una disección axilar de rutina de los niveles 1 y II. En 80 de los 87 casos con ganglio centinela identificado, es el estatus del ganglio se correlaciona directamente con el estatus del resto de ganglios disecados. Teniendo una sensibilidad del 96%, un valor predictivo de196%, y una eficiencia de la prueba del 93%. Dos complicaciones se observaron, una paciente con necrosis leve de la piel en el sitio de inyección y un caso de recurrencia axilar con ganglio centinela negativo. Los resultados confirman que la prueba de mapeo linfático y ganglio centinela es un procedimiento seguro y confiable en el manejo de las pacientes con Cáncer de mama.

Purpose Mutations in hereditary breast cancer genes play an important role in the risk for cancer. Methods Cancer susceptibility genes were sequenced in 664 unselected breast cancer cases from Guatemala. Variants were annotated with ClinVar and VarSome. Results A total of 73 out of 664 subjects (11%) had a pathogenic variant in a high or moderate penetrance gene. The most frequently mutated genes were BRCA1 (37/664, 5.6%) followed by BRCA2 (15/664, 2.3%), PALB2 (5/664, 0.8%), and TP53 (5/664, 0.8%). Pathogenic variants were also detected in the moderate penetrance genes ATM, BARD1, CHEK2, and MSH6. The high ratio of BRCA1/BRCA2 mutations is due to two potential founder mutations: BRCA1 c.212 + 1G > A splice mutation (15 cases) and BRCA1 c.799delT (9 cases). Cases with pathogenic mutations had a significantly earlier age at diagnosis (45 vs 51 years, P 

BackgroundMutations in hereditary breast cancer genes play an important role in the risk for cancer, however, little is known of the type and frequency of mutations in Central American populations, including Guatemala.MethodsTwo separate panels of known cancer susceptibility genes were used to sequence blood DNA from 664 unselected breast cancer cases from two large hospitals in Guatemala. Variants were annotated with ClinVar and VarSome. Data from a structured questionnaire was used to compare mutation carriers of medium and high penetrance genes.ResultsA total of 73 out of 664 subjects (11%) had a variant classified as pathogenic in a gene with known high or medium penetrance for inherited breast cancer. The most frequently mutated genes were BRCA1 (37/664, 5.6%) followed by BRCA2 (15/664, 2.3%), PALB2 (5/664, 0.8%) and TP53 (5/664, 0.8%). Pathogenic variants were also detected in the moderate penetrance genes ATM, BARD1, CHEK2, and MSH6, and rare pathogenic variants detected in t...

PURPOSE Breast cancer is the most common form of cancer among women in Latin America. Limited health care access, late-stage diagnosis, and lack of knowledge on the mutation profile of cancer susceptibility genes in low- and middle-income country populations lead to higher mortality rates. To address this health disparity, this study analyzes the breast cancer mutation profile of women from Mexico and Guatemala. Results from this study can be used to improve breast cancer screenings in these countries and for Latin American women living in the United States. METHODS Genomic and clinical data of women with breast tumors were obtained at the Instituto Nacional de Salud Publica in Mexico and Instituto Nacional de Cancerologia in Guatemala. Mutations in known breast cancer susceptibility genes were identified using targeted sequencing and were validated by manual review in the Integrative Genomics Viewer and pathogenicity determined using online databases (ClinVar and Varsome). Finally,...

Based on high quality surgery and scientific data, scientists and surgeons are committed to protecting patients as well as healthcare staff and hereby provide this Guidance to address the special issues circumstances related to the exponential spread of the Coronavirus disease 2019 (COVID-19) during this pandemic. As a basis, the authors used the British Intercollegiate General Surgery Guidance as well as recommendations from the USA, Asia, and Italy. The aim is to take responsibility and to provide guidance for surgery during the COVID-19 crisis in a simplified way addressing the practice of surgery, healthcare staff and patient safety and care. It is the responsibility of scientists and the surgical team to specify what is needed for the protection of patients and the affiliated healthcare team. During crises, such as the COVID-19 pandemic, the responsibility and duty to provide the necessary resources such as filters, Personal Protective Equipment (PPE) consisting of gloves, flui...

El objetivo de este estudio fue evaluar el valor predictivo del mapeo linfático y la biopsia del ganglio centinela en pacientes sometidos a linfadenectomia D2 por cáncer gástrico invasivo. Entre enero de 1998 y junio 2013 tuvimos 180 pacientes con cáncer gástrico sometidos a laparotomía exploratoria, de éstos, un total de 58 pacientes con cáncer invasivo operable fueron categorizados en etapas quirúrgicas T2N0M0 / T3N0M0, los cuales fueron sometidos a mapeo linfático con azul de metileno , biopsia del ganglio centinela y disección linfática D2. El ganglio centinela fue identificado en 42 / 58. Los falsos negativos fueron del 16%. El ganglio centinela fue predictivo del estado linfático en el 85%, la sensibilidad fue del 85%, y la especificidad del 100%. Este procedimiento es una buena alternativa para evaluar la selectividad de la disección de los ganglios linfáticos y disminuir la morbilidad de la linfadenectomía en el cáncer gástrico.

In our country statistics have always been a problem, however there are reliable data sources, although we know that probably with some margin of sub registration that we have to consider. At the end of this work you will be able to consult the sources from where these data were extracted.

LYMPHATIC MAPPING IN BREAST CANCER


PURPOSE: To evaluate the use of Lymphatic mapping in the management of Breast Cáncer Between October 1998 to May 2001.

METHOD: We evaluated 25 patients with breast cáncer in clinical stages T1N0M0 and T2N0M0, we used blue dye 5 cc peri-tumoral inside the gland; 5 minutes later we initiated the procedure looking for the Sentinel Node, all the patients had an axillary dissection in levels I and II, and the results were correlated the status of the sentinel node
And the status of the axillary dissection.

RESULTS: In 22 patients was possible identified the sentinel node. In 3 patients the result of the sentinel node do not correlated with the status of the rest of the nodes in level I and II. The predictive value of the sentinel node biopsy is 90%.

CONCLUSION: The sentinel node biopsy allows accurate determination of axillary status and is a good alternative in the conservative management of the Breast Cáncer.

En relación al comentario editorial de mi trabajo " Valor Predictivo de la biopsia de ganglio centinela en Cáncer de mama " publicado en el Vol. 10, No. 3 de nuestra revista de la asociación me gustaría hacer tres comentarios para que nuestros lectores tengan mas clara la situación del mapeo linfático en cáncer de mama. 1. En el comentario se puede leer " probablemente esto se puede mejorar, y minimizar los fallos y falsos negativos, cambiando el azul de metileno por Verde de Indocianina (usado en la mayoría de los estudio publicados) ". En la presente fecha puede encontrarse en uno de los mayores motores de búsqueda de Internet 1360 estudios publicados de ganglio centinela donde se utiliza algún tipo de tinte Azul entre ellos Azul de Metileno, Azul Isosulfan (el mas usado en los Estados Unidos) y Azul patente. Así como se comento en la discusión del articulo el autor reconoce que tal como dicen la mayoría estudios el Isosulfan es superior al Azul de Metileno. Se utilizo Metileno por que es lo que existe en nuestro medio. El problema de este tipo de tinte es su gran difusión liposomal que presenta, por eso los resultado cuando se inyecta en el tejido celular subcutáneo no son los mejores a diferencia cuando es utilizado intra parenquimatoso (como se presenta en el trabajo). En ese mismo motor de búsqueda de Internet pueden encontrarse solamente 18 artículos que utilizan el verde de indocianina como mapeo linfático, siendo la mayoría de los estudios son de origen Japonés. 2. La utilización de Sestamibi Tecnecio 99 es una técnica para visualización preoperatoria de lesiones mamarias, no transoperatoria, conocida como scintimamografia la cual su problema es la baja sensibilidad para detección de lesiones tumorales dentro la mama. En el caso de lesión metastasica a ganglios esta técnica tiene una sensibilidad reportada del 67%. Para la localización de ganglio centinela antes y durante la cirugía utilizando un radio marcador se utiliza Tecnecio 99 sulfuro coloidal filtrado, técnica conocida como linfoscintillografia y se usa un contador geiger modificado(conocido como

Guatemala. Se estudiaron todos los casos que llenaron el criterio histológico de reacción granulomatosa. Todos fueron referidos a nuestro centro como sospechosas de Cáncer Mamario. Se describen su presentación clínica, radiológica, evaluación preoperatoria además del manejo medico y quirúrgico de todos los casos. La causa más frecuente fue Mastitis Granulomatosa Idiopática (MGI), seguido de Mastitis Oleogranulomatosa (MO) y de Mastitis de origen Tuberculoso (MT). Clínica y radiológicamente presentan las mismas características de Carcinoma Mamario, la evaluación con biopsia con aguja gruesa fue de utilidad en el diagnostico preoperatorio. Solamente dos casos necesitaron ser tratados con Mastectomía correspondiendo a los de origen Oleogranulomatoso. El drenaje y tratamiento medicamentoso es de utilidad en el manejo del resto de causas de Mastitis Granulomatosa PALABRAS CLAVE: MASTITIS GRANULOMATOS IDIOPATICA, MASTITIS TUBERCULOSA, MASTITIS OLEGRANULOMATOSA, CANCER MAMARIO

To understand our territorial conflict we have to come back through history to the Judean Kingdom creation. Part of the Hebrew population in the year 928 BC, the Jewish people, survived multiple invasions and conquests until the year 63 BC when the Romans arrived and established their political and military power. Two important Jewish uprisings are well known against Roman domination, Gamla, sad stories, with the Jewish community living in the Golan Heights and almost simultaneously the Masada uprising in the Death Sea around the year 70 AC. Another one in the year 135 AC led by Bar Koba, probably the most relevant historically, two famous Roman Legions leaded by Adriano were defeated, and the military casualties were high. (24) Regretfully for our History the Romans finally defeated Bar Koba and overpowered Beitar, the last Jewish rebellious City that lived almost three years as a free and independent Jewish state. According to Josephus, the Romans killed around one million Jews and slaved 97,000. When Adriano defeated the Jewish rebellious faction he wanted to set an important precedent to humiliate the Jewish population so he asked: Who had been the worst Hebrew enemy of all times? His historians told him that the Philistines coming from Philistine, people coming from the Aegean Sea that invaded the coast of the Judean Kingdom. He ordered to deleted the name of Roman Judean Province for Syria Paelistina and change the name of Jerusalem for Aelia Capitolina (25) prohibiting the entry of Jews to the holy City and the practice of Judaism, forcing the survivors and the remaining Jewish population to migrate to the Northern city of Safed and to the south to settlements in the Negev. The rest of the Jews were slaved and taken to Hispania as the Iberic peninsula was known at the time. After the Romans, the Muslims called it Al-Andalus, and today it's Spain, the region where most of the Jewish community grew during the " diaspora ". After the fall of the Roman Empire the Judea region was invaded and conquered by different civilizations, the most recognized was the Arab-Muslim invasion in the year 640 AC, then came the " pious " Christians crusades slaughtering Jews and Muslims alike in the year 1099 AC but they were finally defeated by the Muslims in the year 1291 AC leaving most of the region under Islamic domination. The population was forced to convert to Islamism, that´s why a big percentage of the actual Muslim population has its origin in the Jewish population of that time. In the year of 1516 the Turkish-Ottoman Empire seized the region of Palestine that included the actual Israel, Syria, Lebanon, and Jordan also known as the antique Levant. By then the Syria Palestine changed its name to Ottoman Syria for the next 600 years. (26) After the defeat in WWI, the Ottoman Empire gave up control of this region to the victorious allied countries. France took control of the administration of Lebanon and Syria and Great Britain from Egypt and Palestine. The British mandate in Palestine encompassed the West and East regions of the Jordan River, limited by the Mediterranean in the West, Irak to the East, Lebanon and Syria to the North and Egypt at the South.

Desde hace mucho tiempo ha existido la corriente
de clasificar a la enfermedad Benigna de la Mama bajo el
termino de " ENFERMEDAD FIBROQUISTICA " ; sin embargo esta
designación  es poco precisa, no especifica y no toma en
cuenta las transformaciones patofisiologicas que ocurren en la
Mama en el transcurso de la vida misma. Probablemente el
llamar a un proceso benigno de la Mama " Enfermedad
Fibroquistica " solo refleje la falta de conocimiento que
existe entre la comunidad Medica sobre la patología Mamaria
benigna.

Abstract.  The aim of this study was to evaluate the predictive value of sentinel node biopsy for invasive Gastric Cancer. Between January 1998 and June 2001 we had 45 patients with gastric cancer underwent exploratory laparatomy, from these 45 a total of 15 patients with invasive operable Gastric Cancer in surgical stages T2N0M0/ T3N0M0 underwent patent blue dye lymphatic mapping and sentinel node biopsy followed by D2 lymphatic dissection.  The sentinel node was identified in 12/15.The false –negative rate was 16%, the sentinel node was predictive of the lymphatic status in 85%, the sensitivity was 85%, and the specificity 100%. Sentinel node biopsy in Gastric Cancer seems a good alternative to enhancing the selectivity of Lymph node dissection and avoid the morbidity of the major lymphadenectomy in Gastric Cancer.

Who should operate a woman with breast problems?
what kind of specialist should I go if I have a breast disease?

Those two questions are often heard in the female population and  also in the medical community as well

Take for example the United States, undoubtedly this country has one of the best medical organizations worldwide. With over 300 million people and breast cancer being the leading cause of cancer in women.

The highest levels of success in the management of this disease as American doctors managed forming multidisciplinary teams including surgeons (General Surgeon), the clinical oncologist (chemotherapy) and Radiation therapists. Gynecologist's role is oriented to primary care that is early detection as the radiologists with the proper interpretation of imaging methods (mammography, ultrasound, MRI).

In Guatemala training programs include theoretical and practical knowledge in the surgical treatment of these diseases are general  surgery programs or Surgical oncologíst ,supported by the University of San Carlos.

Breast surgery is extremely complex that includes not only the management of the mammary gland but the draining lymph (lymphatic drainage) and surrounding vascular structures such as the axillary artery and vein and the nerve plexus axillary. They are also major thoracic structures and breast skin flaps.
Throughout the five years of training to receive a surgeon is exposed to the theory and practice of procedures to address these areas of the body every day. It is common and routine for a surgeon having to work in complex anatomical areas, damage to vascular structures injured by stab or firearms,  tumors and nodes attached to veins and arteries are a frequent problem that surgeons are in their daily practice, this means that when dealing with complex cases or routine breast disease, for the  surgeon is easier (and therefore also be for the patient) to solve these problems, the patient avoid painful, expensive and bad results medical and  aesthetic as well , and their can manage complications  properly and have associated with a good evolution of their illness.


Personally in my 20 years as a consultant surgeon in multiple hospitals in my country it has been more than once that I had to get  emergency operating room situation when a patient who was being operated by a one Physician not specialist in a surgery  has developed complications during surgical proceadure  because he/she  has surgical  problems  that  was not able to solve.

It is advisable for a woman when choosing a doctor to be operated by problems in your breasts (except the aesthetics issues,  since in that case you would have to go with a plastic surgeon who is also a specialist and he specialized in surgery general as well) is to choose a surgeon dedicated to treating breast disease (it is the same recommendation by the American Society of Breast Surgeons), scientifically it is well  demonstrated in breast cancer , than a woman who is treated  by a surgeon who routinely is engaged in this Disease have better survival compared with doctors who operate one or two patients a year, or those who occasionally do throughout their  career

In my country, Guatemala, large state hospitals are the only ones that have a high volume of patients and the specialists in charge of operating Surgeons breast cancer and breast disease patients in the departments of surgery are the ones with most experience.
So if you or someone in your family needs surgery for a problem of this Disease  , make your research and investigate which of these specialists can treat them equally in a state hospital as they can do it in a private hospital.

#bestbreastsurgeon

Dr Sergio Ralon
Head of the Breast Clinic
Department of Surgery
General hospital
25 years of surgical practice of breast diseases
Member of the American Society of Breast Surgeons
International Guest American Collegue of Surgeons
American Society of Surgical Oncology

Historia clásica de dolor postprandial en cuadrante superior derecho y epigastrio irradiado hacia la espalda y al hombro derecho, puede tener asociado nausea y vómitos. Diagnóstico: Ultrasonido es el método de elección para el diagnóstico de Litiasis vesicular. Debe evaluarse siempre las pruebas hepáticas y determinar si existe obstrucción de la vía biliar. Tratamiento: Colecistectomia laparoscópica electiva es el procedimiento de elección hoy en día COLECISTITIS AGUDA Causada por una obstrucción en el bacinete de la vesícula por un cálculo enclavado, evolucionando a Hidrocolecisto o Piocolecisto (más del 50% tienen bilis infectada). Historia clásica de dolor en Hipocondrio derecho. Dolor constante por debajo del reborde costal, Signo de Murphy positivo (dolor exacerbado a la palpación del HD en el momento de la inspiración provocando que el/la paciente detenga la respiración y le cause dolor) Diagnóstico : El ultrasonido es el método de elección, determina la presencia de litiasis, hidrocolecisto, y grosor de las paredes vesiculares. La centellografia de excreción hepática (disida) tiene una alta sensibilidad en colecistitis aguda. Tratamiento: Colecistectomia debe de ser realizada en las primeras 72 horas de iniciado el cuadro de colecistis, Cobertura antimicrobiana debe darse para gram negativos y anaerobios VIA BILIAR ! 1

Historia clásica de dolor postprandial en cuadrante superior derecho y epigastrio irradiado hacia la espalda y al hombro derecho, puede tener asociado nausea y vómitos. Diagnóstico: Ultrasonido es el método de elección para el diagnóstico de Litiasis vesicular. Debe evaluarse siempre las pruebas hepáticas y determinar si existe obstrucción de la vía biliar. Tratamiento: Colecistectomia laparoscópica electiva es el procedimiento de elección hoy en día COLECISTITIS AGUDA Causada por una obstrucción en el bacinete de la vesícula por un cálculo enclavado, evolucionando a Hidrocolecisto o Piocolecisto (más del 50% tienen bilis infectada). Historia clásica de dolor en Hipocondrio derecho. Dolor constante por debajo del reborde costal, Signo de Murphy positivo (dolor exacerbado a la palpación del HD en el momento de la inspiración provocando que el/la paciente detenga la respiración y le cause dolor) Diagnóstico : El ultrasonido es el método de elección, determina la presencia de litiasis, hidrocolecisto, y grosor de las paredes vesiculares. La centellografia de excreción hepática (disida) tiene una alta sensibilidad en colecistitis aguda. Tratamiento: Colecistectomia debe de ser realizada en las primeras 72 horas de iniciado el cuadro de colecistis, Cobertura antimicrobiana debe darse para gram negativos y anaerobios VIA BILIAR ! 1

In our days, the Arab Israeli conflict is increasingly every day
without finding a way to move forward.  The latest
negotiations looking for two states that work side by side are
increasingly distant. On the one hand, the Israeli claims after
the failed Oslo agreements whereby giving autonomy to the
Palestinian authority only provoked more disputes between
Israelis and even between the so-called Palestinian Arabs
themselves. The popular election in the Gaza area made
Hamas become a dictatorship in that area and Abbas, leading
the Palestinian authority in the autonomous area of Judea
and Samaria, has never called for a new popular election
becoming a dictatorship as well. As in ancient Greco-Roman tragedies, Israel in trying to deal with this problem seems to
have formed a two-headed monster each trying to pull its
own body in a different direction . The point of this thesis is
the  claim  of  the  Arab  population called  since  1967 ,  "
Palestinian  "  to  be  called a  “Palestinian people  ”  or  “
Palestinian state  ”  and  what  is  the  archaeological ,
anthropological support that ancient history tells us to name
a Palestinian People existing since ancient times. What legal,
anthropological , historical, archaeological support exists for
us to say that throughout history the "Palestinian people "
exists? Is there any archaeological evidence that supports
whether throughout ancient and  modern history , the  "
Palestinian state" or the Palestinian kingdom really existed?