Individualized multidisciplinary therapy for vulvodynia.

OBJECTIVE: The main objective of this review was to develop strategies for individualizing multidisciplinary therapy for vulvodynia. METHODS: We conducted two literature searches; the first one focused on clinical trials assessing vulvodynia treatments published after the recommendations of the expert committee of the Fourth International Consultation on Sexual Medicine. The second search targeted studies identifying predictive factors and mediators of vulvodynia treatments, published from the earliest date to October 2022. RESULTS: Based on data from 55 relevant studies, we developed models of individualized multidisciplinary therapy targeting groups of women less responsive to multidisciplinary therapy (characterized by women with higher vulvar pain intensity, impaired sexual functioning, and vulvodynia secondary subtype) and to physical therapy, as an isolated treatment (characterized by women with increased pelvic floor muscle tone and vulvodynia primary subtype). Each individualized multidisciplinary therapy model comprises three components: psychotherapy, medical care, and physical therapy. These components provide distinct therapeutic modalities for distinct subgroups of women with vulvodynia; the women subgroups were identified according to the characteristics of women, the disease, partners, and relationships. Additionally, for women with provoked vestibulodynia who exhibit less benefits from vestibulectomy (such as those with higher levels of erotophobia, greater vulvar pain intensity, and the primary subtype) and encounter resistance to individualized multidisciplinary therapy, we suggest additional conservative treatments before performing vestibulectomy. CONCLUSION: Our study is a pioneer in the development of models that allow the individualization of multidisciplinary therapy for vulvodynia and represents a significant advance in the clinical practice of gynecologists, physiotherapists, and psychologists.

Long Term Follow-up Results of Surgical Management of Chronic Pancreatitis.

Background: Chronic pancreatitis is a progressive loss of exocrine and endocrine pancreatic function. Surgical procedures are required in cases of intractable pain, biliary obstruction or intestinal obstruction, complications from pseudocysts, or pancreatic fistulae. Objective: To assess the outcomes after surgical management of chronic pancreatitis, in a long-term follow-up. Methods: Patients that underwent surgical management of chronic pancreatitis,from 2006 to 2017, were reviewed. Demographics and complications of the procedures were recorded. Visual analogue pain scale was used for pain control evaluation. The 12-Item Short-Form Health Survey questionnaire was used for quality of life assessment. Results: Sixty-five patients were included in the study. Mean follow-up was 60.26 months. Twenty patients underwent lateral pancreatojejunostomy, 22 to Roux-en-Y cystojejunostomy, 7 to transgastric cyst-gastrostomy,1 to Frey procedure, 4 to hepaticojejunostomy, 1 to Frey procedure and hepaticojejunostomy, 1 to lateral pancreatojejunostomy and cyst-gastrostomy, 7 to lateral pancreatojejunostomy and hepaticojejunostomy and 2 to cystojejunostomy and hepaticojejunostomy. No cases of perioperative deaths were recorded. A Pancreatic fistula was found in 5 cases, and all of them followed non-operative management. Of the 65 patients included in the study, 39 answered the questionnaires. Mean scores on SF-12, physical and mental scales were respectively 42.72 +- 10.76 and 49.84 +- 11.75. Conclusion: Surgical management of chronic pancreatitis is safe, with low mortality and morbidity rates. These procedures are effective in assuaging pain and in providing good quality of life.

Prognostic significance of epidermal growth factor receptor overexpression in pancreas cancer and nodal metastasis.

BACKGROUND: Identification of molecular markers in pancreatic adenocarcinoma (PA) has the potential to guide targeted therapy. The objective of this study is to determine the prognostic significance of epidermal growth factor receptor (EGFR) expression (membrane and cytoplasmic) in resected PA and its correlation with lymph node metastasis and survival. METHODS: EGFR overexpression was determined by immunohistochemistry, and the pattern of expression was compared between the primary tumour, adjacent normal pancreas and involved lymph nodes. RESULTS: A total of 88 patients had curative resection. No difference was found in mEGFR overexpression between tumoural and metastatic nodal tissues (P = 0.28). Median overall survival time was 22.9 months. Overall cumulative 1-, 3- and 5-year survival was 48%, 20% and 18%, respectively. In positive mEGFR tumour expression, survival was 46% at 1 year, 8% at 3 years and 0% at 5 years (P < 0.05). Univariate analysis showed that male gender, portal vein (PV) resection, perineural, lymphovascular and peri-pancreatic invasion, positive margins and positive mEGFR expression in tumour tissue had worse survival. Multivariate analysis showed that male gender, PV resection, vascular and perineural invasion remained independent predictors of poor survival. CONCLUSION: Positive mEGFR overexpression is associated with decreased survival; however, it is not an independent prognostic factor.

Lymph node involvement and not the histophatologic subtype is correlated with outcome after resection of adenocarcinoma of the ampulla of vater.

BACKGROUND: Intestinal and pancreaticobiliary types of Vater's ampulla adenocarcinoma have been considered as having different biologic behavior and prognosis. The aim of the present study was to determine the best immunohistochemical panel for tumor classification and to analyze the survival of patients having these histological types of adenocarcinoma. METHOD: Ninety-seven resected ampullary adenocarcinomas were histologically classified, and the prognosis factors were analyzed. The expression of MUC1, MUC2, MUC5AC, MUC6, CK7, CK17, CK20, CD10, and CDX2 was evaluated by using immunohistochemistry. RESULTS: Forty-three Vater's ampulla carcinomas were histologically classified as intestinal type, 47 as pancreaticobiliary, and seven as other types. The intestinal type had a significantly higher expression of MUC2 (74.4% vs. 23.4%), CK20 (76.7% vs. 29.8%), CDX2 (86% vs. 21.3%), and CD10 (81.4% vs. 51.1%), while MUC1 (53.5% vs. 82.9%) and CK7 (79.1% vs. 95.7%) were higher in pancreatobiliary adenocarcinomas. The most accurate markers for immunohistochemical classification were CDX2, MUC1, and MUC2. Survival was significantly affected by pancreaticobiliary type (p = 0.021), but only lymph node metastasis, lymphatic invasion, and stage were independent risk factors for survival in a multivariate analysis. CONCLUSION: The immunohistochemical expression of CDX2, MUC1, and MUC2 allows a reproducible classification of ampullary carcinomas. Although carcinomas of the intestinal type showed better survival in the univariate analysis, neither histological classification nor immunohistochemistry were independent predictors of poor prognosis.

Efeitos do valerato de estradiol associado ao acetato de ciproterona em alguns parâmetros clínicos e da sexualidade em mulheres na pós-menopausa / Effects of estradiol valerate associated with cyproterone acetate on some clinical and sexuality-related aspects in postmenopausal women

Objetivo: Avaliar os efeitos clínicos da terapia estro-progestogênica em pacientes na pós–menopausa, com ênfase nos sintomas de climatério e sexualidade. Métodos: Estudo prospectivo, cego, randomizado, unicêntrico, cruzado e controlado com placebo, com duração de 12 meses consecutivos, feito com 40 mulheres na pós-menopausa (idade média de 52,2 anos) sem nenhuma contra-indicação para terapia hormonal e com útero íntegro, que foram divididas em dois grupos: nos primeiros seis meses de seguimento de estudo, um grupo recebeu valerato de estradiol 2 mg/dia por 21 dias/mês associado com acetato de ciproterona 1 mg/dia nos últimos dez dias (Climene®). O outro grupo recebeu um comprimido por dia, 21 dias/mês de placebo por seis meses. Os tratamentos foram então invertidos e as pacientes foram seguidas por mais seis meses. Para análise estatística o grupo que recebeu terapia hormonal foi referido como Grupo A e o grupo placebo como Grupo B. Avaliou-se a sintomatologia climatérica e a sexualidade. Aplicou-se a análise de variância (ANOVA, crossover) e o teste de McNemar. Rresultados: Nas pacientes do Grupo A, verificou-se redução significativa das ondas de calor e da insônia. No grupo que recebeu terapia hormonal, melhora significativa foi também detectada com respeito ao interesse sexual, na comunicação com o parceiro e na capacidade de obter orgasmo durante a penetração. Para as demais questões não foram detectadas diferenças estatisticamente significativas. Cconclusões: A melhora nos sintomas climatéricos e na sexualidade foram significativas nas mulheres do grupo com terapia hormonal.

Unusual clinical presentation of annular pancreas in the adult.

Annular pancreas (AP) is a rare congenital anomaly, usually present in childhood, with symptoms due to duodenal obstruction; however, this condition can manifest in adulthood with abdominal pain, pancreatitis and pancreatic head mass. The authors present a case of AP observed in a 22-year-old patient that presented an unusual dual-phase clinical manifestation of duodenal obstruction in infancy that was treated by a duodenojejunostomy, and abdominal pain due to chronic pancreatitis in the adult age. MRI with cholangiopancreatography played a decisive role in achieving the correct diagnosis. The patient was treated by a pylorus-preserving Whipple procedure, with resection of the previous duodenojejunostomy. Pancreatic changes characteristic of chronic pancreatitis were demonstrated both in the AP and in the resected pancreatic segment. A marked biliopancreatic ductal anomaly not previously described in the literature was demonstrated by radiologic examination of the surgical specimen. The pathogenesis of AP, the importance of its association with benign and malignant pancreatic disease and the treatment alternatives are discussed by the authors.

Avaliação da capacidade orgástica em mulheres na pós-menopausa / Assessment of orgasmic capacity of postmenopausal women

OBJETIVO: Correlacionar a capacidade orgástica (durante a relação sexual e/ou a masturbação solitária) de mulheres pós-menopausadas, saudáveis e sem tratamento hormonal com fatores climatéricos, psicossociais, comportamentais, hormonais e interpessoais. MÉTODOS: De um total de 999 mulheres avaliadas com idade entre 41 e 60 anos, selecionaram-se 60 mulheres saudáveis, sexualmente ativas, com pelo menos um ano de amenorréia, útero íntegro, relacionamento estável com parceiro capacitado ao coito e não usuárias de terapia hormonal. Elaborou-se um modelo estatístico de regressão logística que avaliou a capacidade de orgasmo (variável dependente) em função de 17 variáveis independentes, que representavam fatores psicossociais, comportamentais, interpessoais, climatéricos e hormonais. RESULTADOS: A capacidade orgástica está significativamente correlacionada à prática da masturbação (p=0,000), ao gostar de abraçar e acariciar o corpo do parceiro (p= 0,036) e à presença de secura vaginal (p=0,021). CONCLUSÕES: Nas mulheres pós-menopausadas avaliadas, a capacidade orgástica relacionou-se positivamente com o relacionamento mais afetivo com o companheiro e com a prática da masturbação. Mulheres que apresentam secura vaginal, mas que praticam a masturbação e mantêm relacionamento afetivo com o parceiro, conseguem obter o mesmo número ou um número maior de orgasmos se comparados à freqüência do coito.

Androgênios e sexualidade no climatério / Androgenic drugs and sexuality on climateric period

As influências do climatério na sexualidade são devidas a alterações orgânicas, psicossociais, interpessoais, culturais e situacionais e os problemas sexuais mais relacionados com essa fase da vida incluem declínio do desejo sexual, surgimento de dispaurenia e de secura vaginal e redução da frequencia sexual...

[Assessment of orgasmic capacity of postmenopausal women]. / Avaliação da capacidade orgástica em mulheres na pós-menopausa.

OBJECTIVE: To correlate the capacity of healthy postmenopausal women to have orgasms (during intercourse or by solitary masturbation) with psychosocial, behavioral, climacteric, hormonal and interpersonal factors. METHODS: Nine hundred and ninety-nine women (aged from 41 to 60 years) underwent physical and supplementary tests and answered questionnaires regarding sexual behaviour. Sixty healthy women, sexually active, with one or more years of amenorrhea, without hormone therapy and with a partner capable of intercourse were chosen from this group. A Logistic Regression Model with one dependent variable -- orgasmic capacity -- and seventeen independent variables -- psychosocial, behavioral, interpersonal, climacteric and hormonal factors -- was developed. RESULTS: The orgasmic capacity correlated significantly with the practice of masturbation (p=0.000), with pleasure in embracing and caressing the partner's body (p=0.036) and with the presence of vaginal dryness (p=0.021). CONCLUSIONS: This study shows that the most important factors were interpersonal and behavioral and that the other parameters considered were not statistically significant. Women with vaginal dryness, who however engage in masturbation and maintain an affective relationship with their partner, obtain an equal or a greater number of orgasms when compared to the frequency of sexual intercourse.

Comportamento sexual mulheres na pós-menopausa / Sexual behavior of menopaused women

Objetivo: analisar o comportamento sexual de mulheres menopausadas atendidas no Ambulatório de Ginecologia Endócrina e Climatério do Hospital das Clínicas da FMUSP.Pacientes e métodos: foram estudadas 79 mulheres saudáveis, na pós-menopausa, não usuárias da terapia dormonal ou de outros medicamnetos que pudessem interferir na sexualidade...

Terapia hormonal e sexualidade em mulheres na pós-menopausa / Hormone therapy and sexuality in postmenopausal women

Avaliação dos efeitos da terapia estro-progestacional isolada ou associada à metiltestosterona, na sexualidade e nos sintomas climatéricos, em mulheres saudáveis na pós-menopausa. Realizou-se estudo de coorte progressiva, duplo-cego, randomizado, com duração de 12 meses, utilizando estrogênios conjugados 0,625 mg e acetato de medroxiprogesterona 2,5 mg associados a metiltestosterona 2 mg (n=31) ou a placebo (n=29). Ambos os tratamentos aumentaram o desejo sexual vinculado, exclusivamente, às atividades desenvolvidas com o parceiro, a excitação, a capacidade orgástica e a freqüência sexual e reduziram a secura vaginal, a dispareunia e os sintomas climatéricos. A associação da metiltestosterona resultou em maior interesse sexual não vinculado, exclusivamente, às atividades com o parceiro e em aumento dos índices de Castelli I e II. /An analysis was conducted of the effects of estrogen-progesterone therapy, prescribed singly or associated with methyltestosterone, on sexuality and climacteric symptoms in healthy postmenopausal women. A progressive, double-blind, randomized cohort series over a 12 month period was realized, employing conjugated estrogens 0,625mg and medroxyprogesterone acetate 2,5mg together with methyltestosterone 2mg (n=31) or placebo (n=29). Both treatments increased sexual desire – linked exclusively to activities developed with the partner – excitation, orgasmic capacity and sexual frequency and they reduced vaginal dryness, dyspareunia and climacteric symptoms. Association of methyltestosterone resulted in major sexual interest, not linked exclusively to activities with the partner, and an increase in Castelli I and II indexes...

Incidência e resultado do tratamento das lesões da via biliar em colescistectomia por laparotomia / Biliary lesions in open cholecystectomy: incidence and treatment

Racional - As lesões da via biliar são complicações graves tanto na era atual da videolaparoscopia como na cirurgia por via aberta ou por laparotomia. Objetivo - Estabelecer a frequência de lesões iatrogênicas da via biliar em um hospital de ensino no Brasil, e analisar os resultados imediatos e tardios do seu tratamento...

Serous oligocystic adenoma of the pancreas.

Cystic neoplasms of the pancreas are uncommon lesions but are becoming increasingly prevalent. Herein we report a case of an oligolocular cystic lesion in the head of the pancreas in a young female that had undergone a cystenteroanastomosis 10 years ago. She underwent a duodenopancreatectomy with an uneventful recovery. The histology showed a serous oligocystic adenoma of the pancreas and the immunohistochemistry study confirmed the diagnosis. There is no sign of recurrence after the surgery. The role of pre-operative diagnosis based on tomographic, echoendoscopy and fine needle aspiration are discussed.

Alternative treatment for gallbladder stones in portal venous thrombosis.

BACKGROUND/AIMS: Cholecystectomy for treatment of gallbladder stones in patients with portal vein thrombosis can be a hazardous procedure. Dissection into an area of thin-walled collateral vessels can trigger troublesome bleeding and consequent blood coagulation disorders. METHODOLOGY: In order to avoid dissection, cholecysto-jejunostomy was used as the treatment of choice in three patients with symptomatic gallbladder stones and portal vein thrombosis. RESULTS: Surgical procedure was uneventful, blood or plasma transfusions were not required either at surgery or afterwards. Pre- and postoperative hematocrit evaluations showed no difference, as well as liver function tests. The procedure was well tolerated and patients were discharged from day 5 to 7. Follow-up ranged from 2 to 3 years, no biliary complications were found during this period. CONCLUSIONS: Choleysto-jejunostomy is a safe procedure and can be used as an effective treatment of symptomatic gallbladder stones in patients with portal vein thrombosis.

Effects of octreotide pretreatment in experimental acute pancreatitis.

BACKGROUND: Severity of systemic lesions and mortality of experimental acute pancreatitis (AP) are reduced after pancreatic enzyme content reduction induced by cerulein administration. Octreotide has been used both prophylatically and therapeutically in AP. The possible effects of octreotide on pancreatic enzyme content and its influence on pulmonary lesions of experimental AP were assessed in this study. METHODS: Wistar male rats were divided in two branches: BRANCH I - Animals divided into three groups: Group Sa (n = 10) intravenous saline infusion; Group Ce (n = 10) intravenous cerulein infusion, (0.133 micro g/kg(-1).h(-1)) and Group Oc (n = 10) SC octreotide (10 micro g/kg(-1)). Trypsin, elastase and amylase pancreatic contents as well as serum amylase were determined thereafter in all three groups; BRANCH II - Rats treated as in branch I, were submitted to sodium taurocholate AP (Groups Sa+AP, Ce+AP and Oc+AP). Two hours thereafter amylase and TAP assays were performed in serum, ascites and pancreatic tissue in eight animals of each group. Pulmonary histology was studied by morphometry 24 h after AP in the remaining animals. RESULTS: Increased serum amylase and pancreatic enzyme contents were observed in octreotide-treated animals when compared to animals receiving saline or cerulein. After AP increases of serum and ascitic fluid amylase and of pancreatic TAP were observed in octreotide pre-treated animals when compared to saline and cerulein groups. Pulmonary interstitial and alveolar edema after AP was significantly increased in rats receiving octreotide as compared to the cerulein group. CONCLUSION: Octreotide administration acutely increases the enzymatic content of the pancreas and thus may have a potential deleterious influence in the evolution of AP.

Pylorus-preserving pancreatoduodenectomy associated with longitudinal pancreatojejunostomy for treatment of chronic pancreatitis.

Patients with chronic pancreatitis presenting with lesions at the head of the pancreas and in the uncinate process associated with duct dilatation at the body and tail of the gland are inadequately treated by partial pancreatic head resection or by standard pancreatic drainage procedures. A new technique for the surgical treatment of this form of chronic pancreatitis, based on the performance of a pylorus-preserving pancreaticoduodenectomy associated with a longitudinal pancreatojejunostomy, is proposed herein. Nine patients with chronic pancreatitis were operated on according to this technique with no postoperative complications or mortality. Complete symptom control was achieved in all patients. Follow-up periods varied from one month to five years.

Pratica sexual em mulheres menopausadas / Sexual practice in women during menopause

Apesar do auto-erotismo constituir a forma de atividade sexual mais eficaz para produzir orgasmos em mulheres e dos esforcos de terapeutas sexuais no sentido de encoraja-las a se responsabilizarem por sua propria sexualidade, os poucos estudos existentes mostram...

Sexualidade na menopausa / Sexuality in menopause

A sexualidade e determinada pela anatomia, fisiologia, psicologia, cultura, pelos relacionamentos e experiencias acumuladas durante a vida. Ela inclui todos os...

Detection of K-ras point mutation at codon 12 in pancreatic diseases: a study in a Brazilian casuistic.

OBJECTIVE: To clarify the sensitivity and the validity of K-ras point mutational analysis at codon 12 in Brazilian patients with pancreatic diseases, and the possible correlation between the presence of the mutation and the histopathological findings. PATIENTS: Ninety-seven Brazilian patients with pancreatic ductal adenocarcinoma, pancreatic neuroendocrine tumors and chronic pancreatitis were enrolled in this study. Forty-five patients (46%) were female and 52 patients (54%) were male, having an average age of 60.2+/-9.2 years for adenocarcinoma (n=52), 45.1+/-19.4 years for pancreatic neuroendocrine tumors (n=20), and 46.4+/-11.2 years for chronic pancreatitis (n=25). DNA extracted from 11 normal human peripheric lymphocytes was utilized as a control. RESULTS: The sensitivity of K-ras mutational analysis was 83.3% (25/30) in paraffin-embedded samples and 72.7% (16/22) in surgically resected specimens of the malignancy. On the other hand, no mutations were found in pancreatic neuroendocrine tumors or in chronic pancreatitis. Regarding the histopathological grading, the higher positivity rate was found in poorly-differentiated adenocarcinoma (100%), and progressively decreased in moderately-differentiated adenocarcinoma (72.2%), and well-differentiated adenocarcinoma (66.6%). The positivity rate in non-classified adenocarcinoma was 81.8%. CONCLUSION: K-ras point mutation, in our study, is notably prevalent in malignancies and is absent in chronic pancreatitis and pancreatic neuroendocrine tumors. These results encourage us to consider the possibility of treatment strategies for this oncogene in the future.

A new biliary access technique for the long-term endoscopic management of intrahepatic stones.

Intrahepatic stone disease poses a difficult postoperative management problem due to frequent stone recurrence. Most of the methods proposed for long-term access to the intrahepatic biliary tree require multiple sessions of additional, usually invasive, procedures. An alternative method for endoscopic long-term access to the intrahepatic ducts, represented by a side-to-side anastomosis between the isolated Roux-en-Y jejunal limb of the bilioenteric bypass and the duodenum (duodenojejunostomy), was used in eight patients with retained and/or recurrent stones after surgical treatment of intrahepatic stone disease. There were no short- or long-term complications or mortality associated with the duodenojejunostomy. Postoperative endoscopic access to the intrahepatic ducts was successfully achieved in five of six patients: one with stone recurrence, one with a left hepatic duct stricture and stone recurrence and one with known retained postoperative stones. In two patients, no stones were found at endoscopy. Side-to-side duodenojejunostomy may be useful in the long-term endoscopic management of recurrent intrahepatic biliary stone disease and should be indicated whenever a bilioenteric anastomosis is performed for the treatment of bilateral intrahepatic stone disease.