Pregnancy associated breast cancer

Pregnancy associated breast cancer (PABC) defined as breast cancer occurring during pregnancy or within the first 1‐2 years postpartum. Delay in diagnosis is common. Treatment is timed around gestational age. Surgery and chemotherapy are considered safe after the first trimester. Radiation, anti–her‐2, and endocrine therapy are delayed until after delivery due to adverse fetal effects. Iatrogenic prematurity likely causes most long‐term fetal sequelae. Multi‐disciplinary care and social support are critical for patients and families with PABC.     

Reacreditación o recertificación de los cirujanos generales en España: esa es la cuestión. Resultados de una encuesta nacional

IntroductionThe Law for the Regulation of Health Professions (LOPS) indicates that health professionals will carry out continuous training throughout their professional life, and will regularly prove their professional competence. The objective of the study was to carry out a national survey to find out the opinion of Spanish surgeons and thus be able to prepare a recertification project by the Spanish Association of Surgeons (AEC).MethodsCross-sectional observational study carried out in June-July 2020, through a survey sent to the members of the AEC.ResultsThe survey had a total of 1230 visits and an overall completion rate of 784 responses (67.3%). 69.6% were unaware of the LOPS forecasts and 83.4% were unaware of similar initiatives in other specialties and 95.5% agreed to demand adequate information. 71.4% believed it necessary but only 57% believed that it should be mandatory. 82.9% would agree that it should be regulated through an objective and predictable official procedure.ConclusionsThe concept of re-accreditation is not well known in our specialty and in view of the results obtained, adequate and reliable information seems necessary. Therefore, it would be pertinent to propose by the AEC a specific project to assess activities and skills.     

Effect of cyclosporin therapy in controlling the rejection of ileal versus jejunal allografts*

Abstract. Experimental evidence suggests that jejunal allografts are rejected as rapidly as are ileal grafts, despite their lesser content of lymphoid tissue as an immunologic stimulus. However, it may be possible to postpone the rejection of jejunal grafts more readily than that of ileal grafts by means of immunosuppressive therapy with cyclosporin (CyA). To test this, we used the rat model (BN-LEW) of orthotopic small-bowel transplantation. The proximal third of the small-bowel with one-third of the mesenteric lymph nodes (n= 20), or the distal ileal third with all of the mesenteric lymph nodes (n= 22), or the entire small-bowel (n= 23) was interposed after resection of an equivalent type and length of recipient bowel. CyA (15 mg/kg) was given to all of these rats for 5 days. Three additional control groups were not given CyA. The difference in graft/recipient survival among the groups receiving CyA and among those not on CyA therapy was not statistically significant. Antidonor hemagglutinin titers, the mixed lymphocyte culture (MLC) assay, and histologic examination of the allograft failed to show a mitigated rejection reaction for the recipients of jejunal grafts. The data show that short-term treatment with CyA prolongs graft survival. Equal doses of CyA, however, did not lead to prolonged survival of jejunal grafts or alter the course of rejection in comparison with that for ileal or whole-bowel transplants.     

Whole body MRI for systemic staging of breast cancer in pregnant women

When breast cancer is diagnosed during pregnancy, treatment should be as close; as possible to what is used in non-pregnant patients. This requires accurate local and systemic staging: ultrasound (US) is used for local staging and allows adequate evaluation of the liver and pelvis, but chest and bones cannot be explored and imaging techniques involving exposure to ionizing radiation would be needed. However, since imaging techniques involving ionizing radiation and the use of radionuclides should be limited, whole body magnetic resonance imaging (WB-MRI) without administration of contrast agent represents a very interesting alternative, but limited data is available. In this paper we describe the obstetrical and oncological outcome of 14 patients in whom breast cancer was diagnosed during the second or third trimester of pregnancy and that were staged using WB-MRI. Median age of the patient at diagnosis was 35 years (range 20–36), median gestational age at MRI was 30 weeks (range 13–32) and median age at delivery was 38 weeks (range 32–38). At birth, one new-born presented respiratory distress syndrome and one jaundice. We conclude that diffusion-weighted MRI is feasible accurate and safe for the mother and for the foetus. It may represent the staging technique of choice in pregnant women diagnosed with breast cancer after the first trimester of pregnancy.     

Anesthesia for liver transplantation in patients with arterial hypoxemia

Abstract. Arterial oxygenation during anesthesia and time of postoperative mechanical ventilation were investigated in 17 patients with chronic liver disease who underwent liver transplantation. Six patients had arterial hypoxemia (PaO₂ 64 3 mm Hg) and the other 11 patients had normal PaO₂ (105 5 mm Hg) before transplantation. None of the patients were smokers and all had normal preoperative pulmonary X-ray and spirometry. During transplantation, PaO₂ increased in both groups, but PaO₂ was still approximately 20% lower and PA-aO₂ was 40%-60% higher in the hypoxemic group than in the normoxemic patients ( P < 0. 05). The median postoperative time on mechanical ventilation was three times longer in the hypoxemic group (56 h) than in the normoxemic patients (18 h; P = NS). Number or severity of postoperative complications and outcome did not differ between the two groups. It is therefore suggested that patients with arterial hypoxemia without overt lung disease should also be accepted for liver transplantation.     

Relation between Asymmetric Dimethylarginine (ADMA) and Hearing Loss in Patients with Renal Impairment

Background. Hearing loss is common in patients with CRF. The exact etiology of this complication is not known, and little can be done to ameliorate the disorder. ADMA is found to be high in CRF patients. We studied the relation between ADMA and hearing loss in patients with CRF under conservative treatment. Methods. The study was carried out on 40 patients with renal impairment under conservative treatment (group 1) and 30 normal control subjects (group 2). For both groups' medical history and examination, biochemical tests, otological examination, pure tone audiometry, high sensitivity CRP, and asymmetric dimethylarginine (ADMA) were completed. Results. High-frequency hearing impairment was the predominant auditory dysfunction in CRF patients who showed worse high-tone hearing level on pure tone audiometry as compared with the controls (p < .001). Multiple regression analysis for hearing level at high frequency in group 1 shows that significant determinants of hearing level are ADMA (p = 0.002), high sensitivity CRP (p = 0.02), duration of renal disease (p = 0.01), diabetes mellitus (p < 0.001), and serum creatinine (p = 0.008). No correlation was found between hearing loss with age, gender, smoking, hematocrit, or lipid parameters. Conclusion. Patients with CRF under conservative treatment often experience a significant frequency hearing loss. Such a hearing disorder is mainly affected by duration and degree of renal disease, presence of DM, and level of hsCRP and ADMA. There is a close correlation between ADMA and hearing loss. Thus, ADMA could be an important factor causing hearing loss in those patients. Modifying this factor can be of value to ameliorate this common complication.     

Organ transplantation in Japan - present status and problems

Abstract. Kidney transplantation was first performed in Japan in 1956. Liver, heart, and pancreas transplantation began in 1964, 1968, and 1984, respectively. From 1964 until the end of 1987, 5328 kidney transplantations were performed in 122 facilities. A total of 75. 7% of the grafts came from living related donors and 24. 3% from cadavers. Although there were 80553 patients on dialysis at the end of 1987, only 572 renal transplants were performed that year. No liver or heart transplantations have been performed since 1968. In this review, data from the Japanese National Registry on Dialysis and Transplantation are presented. In addition, the social problems and public attitude towards brain death legislation and organ transplantation are discussed.     

Organ transplantation in Japan — present status and problems

Kidney transplantation was first performed in Japan in 1956. Liver, heart, and pancreas transplantation began in 1964, 1968, and 1984, respectively. From 1964 until the end of 1987, 5328 kidney transplantations were performed in 122 facilities. A total of 75.7% of the grafts came from living related donors and 24.3% from cadavers. Although there were 80553 patients on dialysis at the end of 1987, only 572 renal transplants were performed that year. No liver or heart transplantations have been performed since 1968. In this review, data from the Japanese National Registry on Dialysis and Transplantation are presented. In addition, the social problems and public attitude towards brain death legislation and organ transplantation are discussed.     

Symptomatic cytomegalovirus (CMV) infections identified by image cytometry and other parameters for CMV infection

Abstract. Thirty-eight renal transplant recipients were followed during the first 3 months after transplantation. Once weekly, cultures of urine and buffy coat for cytomegalovirus (CMV) were taken and an immunocytochemical assay for immediate early antigens of CMV (IEA assay) was performed. Thirty patients had evidence of a CMV infection and 11 had a symptomatic CMV infection. All symptomatic patients had one or more positive urine cultures or a positive IEA assay. However, 15 patients with positive urine cultures and 12 patients with a positive IEA assay lacked any signs of symptomatic CMV disease. Moreover, 6 out of 15 patients with positive buffy coat cultures for CMV did not have symptomatic CMV disease. Using a computerized system to quantify IEA-positive granulocytes, we show that the absolute number of positive cells per million correlates very well with the occurrence of symptomatic CMV disease.     

Validation of impedance cardiography measurements of cardiac output during limited exercise in heart transplant recipients

Twenty-one patients were studied at rest and during exercise after heart transplantation to compare cardiac output measured by thermodilution and impedance cardiography. Exercise was performed on a bicycle ergometer over a limited range of work load (25 and 50 watt) whilst metabolic gas exchange was recorded. One patient was studied at rest whilst his circulation was maintained by a Jarvik-7 artificial heart. The values of cardiac output measured by impedance cardiography corresponded closely with the flow rate from the artificial heart. There was also close agreement between the impedance and thermodilution measurements of cardiac output at rest and during exercise. Both measurements followed the changes in heart rate and oxygen consumption. Both thermodilution and impedance cardiography methods elicited good reproducibility of cardiac output measurements at rest and during exercise. These observations suggest that the noninvasive and continuous record of cardiac output obtained by impedance cardiography can be used for the postoperative monitoring of heart transplant recipients.     

Hepatic adenoma during pregnancy and anesthetic management

We report the case of a 24-year-old woman with a large hepatic adenoma diagnosed in the third trimester of pregnancy. The adenoma was at risk of rupture. She underwent scheduled preterm cesarean delivery under combined spinal-epidural anesthesia, followed by transarterial embolization on post-partum day six. Definitive resection of the adenoma took place two months postpartum.     

Vascular lesions after percutaneous biopsies of renal allografts

On the basis of two arteriovenous fistulas, one arteriocaliceal fistula, and the literature concerning these complications, clinical symptoms, diagnostic measures, and therapeutic strategies are discussed. Decreased renal function, severe hypertension, and a bruit over the transplant site —particularly after core biopsy — are said to be indicative of an arteriovenous fistula, while persisting hematuria is seen as evidence of an arteriocaliceal fistula. In both cases, angiographic evaluation is indicated. Therapeutic possibilities include selective angiographic embolization and surgical repair. Large intraparenchymal fistulas may require wedge resection.     

Renal allograft immunosuppression: II. A randomized trial of withdrawal of one drug in triple drug immunosuppression

Abstract. A prospective randomized study was conducted to evaluate the impact of four different conversion protocols on graft outcome in long-term follow-up. Between January 1986 and May 1987, 128 patients with first cadaveric kidney allografts were randomized at the time of transplantation to four treatment groups of 32 patients each, to be assigned 10 weeks post-transplantation. During the first 10 weeks, all patients received triple therapy with low-dose azathioprine (Aza), cyclosporin (CyA), and methylprednisolone (MP). After 10 weeks, one group continued with triple therapy (group A) while the three other groups received different combinations of two drugs, namely, Aza and CyA (group B), Aza and MP (group C), or CyA and MP (group D). Withdrawal of MP (group B) or especially of CyA (group C) was associated with 4/29 (14%) and 10/28 (36%) acute rejection episodes, respectively, for 60 days after conversion. All rejections were mild and reversible. There were no rejections after Aza withdrawal or in the group that continued on triple therapy during the corresponding time period. The most common reason for dropping out after withdrawal, for those patients who could not continue on the originally randomized medication, was azathioprine intolerance (n= 12). Five patients were switched back to triple therapy after CyA withdrawal due to rejection. Steroid intolerance was rare and CyA in low doses was very well tolerated. At 1 year there were no statistically significant differences in graft survival between groups A, B, C, and D-81 %, 88%, 88%, and 88%, respectively-or in patient survival-88%, 88%, 88%, and 97%, respectively. For those patients continuing with the originally randomized treatment protocol, there were no differences in patient or graft survival either, the means being 91% and 89%, respectively. The most common cause of death after withdrawal was cardiovascular in nature, and there were no more fatal infections under triple drug treatment than with double drug regimens. There were no statistically significant differences in mean serum creatinine values at 1 year. The median serum creatinine values for groups A, B, C, and D were 112, 132, 133, and 133 μmol/l, respectively. At 1 year the mean CyA dose in the groups that continued with CyA was 3. 5–4. 2 mg/kg per day and CyA concentrations were equal.     

Early experience with laparoscopic appendectomy in women

Summary Experience and the surgical technique of laparoscopic appendectomy in 70 female patients over a period of more than three years is described. Three women were pregnant. Complications occurred in one case.     

Aplicación de la medicina regenerativa y la bioimpresión 3D en urología

In the last two decades, a new purpose has collected great efforts from scientists in all branches of medicine. It is about the possibility to make the body regenerate ill tissues and organs by itself with de right artificial stimuli or the construction of new functional organs to replace the damaged ones. This process comprises various interdisciplinary approaches to healthcare, such as tissue engineering, molecular medicine, biotechnology, and three-dimensional printing. Urologists have been remarkably active in this field of medicine called Regenerative Medicine. The searching of the different requirements like suitable and compatible biomaterials, versatile cells, adequate techniques to construct tissues, available biomolecules, and the knowledge of all these minimizing risks, are some of the aims and the approximations until now. Despite many obstacles, in vitro and in vivo studies are already showing encouraging options. We will review the advances related to the bladder, urethra, ureter, and kidneys. Difficulties such as ethical issues, time investment and high costs, have been some of the drawbacks encountered. Further studies are still required for its clinical application in daily life.     

Effect of cyclosporin therapy in controlling the rejection of ileal versus jejunal allografts

Experimental evidence suggests that jejunal allografts are rejected as rapidly as are ileal grafts, despite their lesser content of lymphoid tissue as an immunologic stimulus. However, it may be possible to postpone the rejection of jejunal grafts more readily than that of ileal grafts by means of immunosuppressive therapy with cyclosporin (CyA). To test this, we used the rat model (BN-LEW) of orthotopic small-bowel transplantation. The proximal third of the small-bowel with one-third of the mesenteric lymph nodes (n=20), or the distal ileal third with all of the mesenteric lymph nodes (n=22), or the entire small-bowel (n=23) was interposed after resection of an equivalent type and length of recipient bowel. CyA (15 mg/kg) was given to all of these rats for 5 days. Three additional control groups were not given CyA. The difference in graft/recipient survival among the groups receiving CyA and among those not on CyA therapy was not statistically significant. Antidonor hemagglutinin titers, the mixed lymphocyte culture (MLC) assay, and histologic examination of the allograft failed to show a mitigated rejection reaction for the recipients of jejunal grafts. The data show that short-term treatment with CyA prolongs graft survival. Equal doses of CyA, however, did not lead to prolonged survival of jejunal grafts or alter the course of rejection in comparison with that for ileal or whole-bowel transplants.Presented at the 1988 Tripartite Meeting of the Society of University Surgeons (SUS), the Surgical Research Society of Great Britain (SRS), and the European Society for Surgical Research (ESSR) Bristol, UK     

A comparative study on changes in hemostasis in orthotopic and auxiliary liver transplantation in pigs

We compared blood loss and hemostasis in pigs which had undergone either orthotopic liver transplantation (OLT) (group A, n=12) or auxiliary heterotopic partial liver transplantation (APLT) (group B, n=11). Blood samples were taken at regular intervals during and after the operations. In both groups, nine animals survived longer than 24 h and data from these animals were used for analysis. Median (range) intraoperative blood loss was 825 ml (250–1500 ml) in OLT and 425 ml (300–750) in APLT (P<0.01). Routine clotting times, as the activated partial thromboplastin time, prothrombin time and thrombin time, showed no major intraoperative changes in either group. Fibrinogen levels decreased in both groups, but no significant difference was found between the two groups. The only significant difference between group A and B was a more sustained increase in fibrinolytic activity after graft recirculation in group A. Post-operatively, restoration of fibrinogen, antithrombin-III and ₂-antiplasmin levels was slightly faster in group B, resulting in significantly higher levels during the first day. We conclude that, in this animal model, APLT is associated with significantly lower blood loss and less severe fibrinolytic activity, than OLT. This difference might result from the lack of an anhepatic period and the reduced surgical trauma in auxiliary heterotopic liver transplantation.     

A technique of pancreas transplantation in the rat securing pancreatic juice for monitoring

Abstract. In order to study exocrine pancreas graft function and cytological findings, a technique of vascularized pancreas transplantation with special reference to a pancreatic juice collecting system has been developed in the rat model. For this purpose, a catheter is introduced into the common bile duct, which is ligated close to the duodenum, thus covering all pancreatic ducts. This catheter is connected to a reservoir implanted subcutaneously, from which pancreatic juice can easily be aspirated. The amount of 0. 7–1. 2 cc of juice produced over a 24-h period has proven to be sufficient for various analyses and cytological examination.