Tumor renal con trombo en la vena cava inferior. Manejo quirúrgico y pronóstico

ObjectivesThe aim of this study was to evaluate strategies used for surgical management of renal cell carcinoma with tumoral thrombus extension in the inferior vena cava (IVC) and evaluate patient’s prognosis.MetodsFifteen patients with renal tumor and IVC thrombus, underwent radical nephrectomy and thrombectomy, and were retrospectively evaluated. Patients were followed for 0 to 36 months (mean of 9.5 months). Computed tomography (CT) scan with three-dimensional reconstruction was used to define IVC thrombus level.ResultsThe mean age was 54 years, range from 16 to 79. The thrombus was classified as level I - 13.5%, level II – 40%, level III – 26.5% and level IV – 20%. Surgery was performed with cardiopulmonary bypass (CPB) in six (40%) cases, three (50%) without sternotomy. There was one (13%) death during the intraoperative period; this patient presented extensive metastatic tumor, with the thrombus reaching the right atrium. Patients with lymph node or metastatic disease at initial presentation had poorer overall survival in Kaplan-Meier curve. Both, tumor stage (p = 0.380), and thrombus extension (p = 0.174) were not related to survival.ConclusionsDespite its morbidity and mortality, radical nephrectomy with thrombectomy should be performed in case of renal cell carcinoma with tumoral thrombus, because it can offers the possibility of local control. Patients with lymph node and distant metastatic disease have poor prognoses.     

Prospective and randomized comparison of electrical stimulation of the posterior tibial nerve versus oxybutynin versus their combination for treatment of women with overactive bladder syndrome

Objective

To verify whether the combination of transcutaneous electrical neural stimulation (TENS) with oxybutynin in the treatment of women with overactive bladder (OAB) would be more effective than isolated treatments.

Methods

We randomized 75 women with OAB, in three groups: GI—30 min TENS, twice a week; GII—daily slow release 10 mg oxybutynin; and GIII—TENS + oxybutynin (multimodal); all for 12 weeks. Patients were evaluated with validated questionnaires International Consultation on Incontinence-Short Form (ICIQ-SF), International Consultation on Incontinence-OAB (ICIQ-OAB), Symptom bother, and 3-day Voiding diary at weeks 0, 12, and 24.

Results

The groups were similar before treatment. After treatment, all groups significantly improved in OAB symptoms and quality of life (QoL). At week 12, ICIQ-OAB scores were 5.9, 4.6, and 2.9, in groups I, II, and III, respectively, p = 0.01. At week 24, GI and GIII kept the scores of the end of treatment (week 12), while GII increased ICIQ-OAB from 4.6 to 9.2, p = 0.0001, ICIQ-SF from 9.8 to 13.3, p = 0.0006, and Symptom bother score from 3.4 to 7.0, p = 0.0001.

Conclusions

The multimodal treatment was more effective and TENS alone or in association presented longer lasting results for improvement of clinical symptoms of OAB and QoL.     

Good response of low-fat/high-protein diet in a patient with chyluria

Chyluria is an inappropriate urinary excretion of chyle that turns the urine milky. A nutritional approach based on low-fat/high-protein content diet associated or not with medium-chain triglyceride (MCT) showed to be an efficient conservative treatment to improve the milky urine appearance in a patient with chyluria. Case report: A 30-year-old female patient was admitted with chyluria of unknown etiology. An ureteropyeloscopy revealed a single lesion in each kidney, both with linear aspect and measuring 5?mm in extension. These lesions were located close to the renal papillae and were leaking a cloudy and milky fluid. Both lesions were laser cauterized followed by improvement of the milky urine. However, the chyluria relapsed after few months and a low-fat/high-protein content diet with 10?g of soybean oil to meet the requirements essential fatty acids (EFA) and with MCT from coconut oil as alternative to prepare foods was started. Few weeks later the patient returned reporting consistent improvement of the milky urine appearance related with the use of the diet. However since the diet was tasteless and time consuming to prepare, she reported low compliance to diet with MCT and the milky urine relapsed. The MCT was discontinued and the diet with EFA source was maintained with better compliance. Since then the chyluria remains in remission. In conclusion, the dramatic improvement of the milky urine with low-fat/high-protein diet with EFA source observed in our patient demonstrates that this nutritional approach is efficient with fast results to treat chyluria during long term.     

Florid cemento-osseous dysplasia: a report of three cases

Florid cemento-osseous dysplasia (FCOD) is a non-neoplastic condition of the jaws that is not associated with inflammation of the pulp or periodontal tissue. This article reports on three cases that were diagnosed as FCOD, demonstrating the importance of both clinical and radiographic diagnosis and the clinical management of these lesions.     

Long-term follow-up of an 8-year-old boy with insulinoma as the first manifestation of a familial form of multiple endocrine neoplasia type 1

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant hereditary cancer syndrome characterized mostly by parathyroid, enteropancreatic, and anterior pituitary tumors. We present a case of an 8-year-old boy referred because of hypoglycemic attacks. His diagnosis was pancreatic insulinoma. Paternal grandmother died due to repeated gastroduodenal ulcerations and a paternal aunt presented similar manifestations. At a first evaluation, the father presented only gastric ulceration but subsequently developed hyperparathyroidism and lung carcinoid tumor. During almost 15 years of follow-up, three brothers and the index case presented hyperparathyroidism and hyperprolactinemia. Molecular study showed a G to A substitution in intron 4, at nine nucleotides upstream of the splicing acceptor site, causing a splicing mutation. All affected members of the family have the same mutation. Paternal grandmother and aunt were not studied and the mother does not carry any mutation. MEN1 is a rare condition that requires permanent medical assistance. Early clinical and genetic identification of affected individuals is essential for their own surveillance and also for genetic counseling.     

Primary small cell carcinoma of the cecum

Cecal extrapulmonary small cell carcinoma (cESC) is extremely rare, with only single previous report of occurrence in a child. We report a 76-year-old man admitted for evaluation of a cecal mass seen in colonoscopy. Histology revealed small cell carcinoma with classic immunohistochemical profile similar to those seen in the colon. Further clinical survey documented absence of any other masses or abnormality. To the best of our knowledge, this is the first case of primary cESC occurring in an adult. Awareness of the pathologist and clinician of the cecum as a potential site of cESC may help to prevent misdiagnosis as poorly differentiated adenocarcinoma. This is crucial because extrapulmonary small cell carcinomas usually have worse prognosis.     

In vitro activity of diphenyl diselenide and ebselen alone and in combination with antifungal agents against Trichosporon asahii

This study evaluated the in vitro susceptibility of Trichosporon asahii strains to diphenyl diselenide (DPDS) and ebselen (EBS) alone and in combination with amphotericin B (AMB), fluconazole (FCZ), itraconazole (ITZ) and caspofungin (CAS) using the microdilution method. EBS showed in vitro activity against T asahii strains with minimal inhibitory concentration (MIC) ranged from 0.25 to 8.0 μg/mL. For DPDS, the MIC ranged from 8.0 to 64 μg/mL. The combinations demonstrating the greatest synergism rate against fluconazole‐resistant T asahii strains were the following: CAS + DPDS (96.67%), AMB + DPDS (93.33%), FCZ + DPDS (86.67%) and ITZ + DPDS (83.33%). The combinations AMB + DPDS and AMB + EBS exhibited the highest synergism rate against the fluconazole‐susceptible (FS) T asahii strains (90%). Antagonism was observed in the following combinations: FCZ + EBS (80%) and FCZ + DPDS (13.33%) against the FS strains, and ITZ + EBS (20%) against the FR strains. Our findings suggest that the antimicrobial activity of DPDS and EBS against T. asahii and its use as an adjuvant therapy with antifungal agents warrant in vivo experimental investigation.     

Extra-anatomical transobturator bypass graft for femoral artery involvement by metastatic carcinoma of the penis: report of five patients

Objectives  Squamous cell carcinoma (SCC) of the penis with inguinal lymph node involvement aggravates prognosis and can cause femoral artery bleeding, hemorrhagic shock and even death. The objective of this study is to describe the use of extra-anatomical transobturator bypass graft for femoral artery involvement by metastatic carcinoma of the penis. Casuistic and method  Five patients with SCC and inguinal lymphatic metastasis involving the femoral vessels, who underwent extra-anatomical arterial bypass through obturator foramen between 1999 and 2007, were reviewed. The surgical technique and the postoperative outcome were described. Results  After extra-anatomical transobturator bypass, all patients presented distal pulses. The mean time of surgery was 6 h. In four patients, a knitted Dacron tube was used; and in one, the contralateral devalvulated greater saphenous vein was used. Concomitantly, two patients underwent mass resection and one patient underwent node dissection 2 weeks after bypass. Two patients chose not to undergo inguinal resection, opting for palliative chemotherapy after the vascular procedure. The average follow-up period was 12 months and four patients have died—three due to pulmonary metastasis, and one due to acute myocardial infarct. No prosthetic complication was identified and no patient presented femoral bleeding. Conclusions  The use of the transobturator bypass can benefit patients presenting with penile SCC and inguinal lymph nodes metastasis involving the femoral vessels, allowing resection of extensive tumor lesions, as well as avoidance of local complications.     

Leisure and mental health in people with hypertension: convergence in health education

People with hypertension constantly deal with issues related to mental health due to the psychosocial determinants of this illness, and leisure is an important control strategy. The objective of this study was to promote health education to a group of hypertensive patients, through research-action, based on critical-social pedagogy, and taking into consideration the participants' perception of leisure. Educational activities were conducted and, following, an evaluation was performed regarding the subjects' opinion about the impact of leisure on their lives and mental health. The group perceived leisure as a coping strategy for loneliness and also as a late development of independence; it was also regarded as a means of socialization and as a promotion of mental health. These perceptions revealed two themes: aging, leisure, and chronic disease; and knowledge and leisure experiences. Educational actions, such as group dynamics and discussions, were planned considering these themes with the purpose of providing the necessary conditions for socializing and exchanging experiences.