RESUMO
OBJECTIVES: The primary aim of this study was to compare the diagnostic accuracy of transvaginal sonography (TVS) with vs without bowel preparation (BP) in detecting the presence of rectosigmoid endometriosis. Secondary objectives were to compare the diagnostic accuracy of the two techniques in estimating infiltration of the submucosa, length of the largest rectosigmoid nodules, distance of the nodules from the anal verge and presence of multifocal disease. METHODS: This was a prospective study of patients with symptoms of pelvic pain for more than 6 months and/or suspicion of endometriosis referred to our institution between October 2016 and April 2018. Participants underwent a first TVS without BP followed by TVS with BP within a time interval of 1 week to 3 months. The examinations were performed independently and blindly by two sonographers. Only patients who underwent laparoscopy within the 6 months following the second ultrasound examination were included. Ultrasound results using the two techniques were compared with surgical and histological findings. RESULTS: Of the 262 patients included in the study, 118 had rectosigmoid endometriosis confirmed at surgery. There was no significant difference in accuracy between TVS with and that without BP in diagnosing the presence of rectosigmoid endometriosis (93.5% vs 92.3%; P = 0.453). No significant difference was observed in accuracy between TVS with and that without BP in diagnosing submucosal infiltration (88.8% vs 84.6%; P = 0.238) and multifocal disease (97.2% vs 95.2%; P = 0.727) in patients diagnosed sonographically with rectosigmoid endometriosis. The accuracy of TVS with BP was similar to that of TVS without BP in estimating the maximum diameter of the largest nodule (P = 0.644) and the distance between the more caudal rectosigmoid nodule and the anal verge (P = 0.162). CONCLUSION: BP does not improve the diagnostic performance of TVS in detecting rectosigmoid endometriosis and in assessing characteristics of endometriotic nodules. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
Assuntos
Colo Sigmoide/diagnóstico por imagem , Endometriose/diagnóstico por imagem , Reto/diagnóstico por imagem , Ultrassonografia/métodos , Vagina/diagnóstico por imagem , Adulto , Catárticos/administração & dosagem , Colo Sigmoide/patologia , Endometriose/patologia , Endometriose/cirurgia , Feminino , Humanos , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Dor Pélvica/diagnóstico , Dor Pélvica/etiologia , Gravidez , Estudos Prospectivos , Reto/patologia , Sensibilidade e Especificidade , Ultrassonografia/tendências , Vagina/patologiaRESUMO
OBJECTIVES: Several studies have investigated the correlation between endometriosis and adverse pregnancy and perinatal outcomes. However, the role of adenomyosis as a risk factor for adverse perinatal outcome in women with endometriosis has yet to be established. The aim of this study was to explore if fetal and maternal outcomes, in particular the incidence of a small-for-gestational-age (SGA) infant, are different in pregnant women with endometriosis only from in those with the concomitant presence of diffuse or focal adenomyosis. METHODS: This was a retrospective analysis of data collected prospectively during a 3-year period. We included 206 pregnant women with endometriosis: 148 (71.8%) with endometriosis only, 38 (18.4%) with focal adenomyosis and 20 (9.7%) with diffuse adenomyosis. Adenomyosis was diagnosed using ultrasonography and was classified as focal or diffuse. The study included patients who conceived spontaneously or by an assisted reproductive technique. Demographics, ultrasound variables and outcome were compared between women with endometriosis only and those with diffuse and those with focal adenomyosis. Logistic regression analysis was performed to assess the association of variables with SGA at birth in women with diffuse and those with focal adenomyosis. RESULTS: The three groups were similar in demographic characteristics (age, body mass index, mode of conception). Patients with diffuse adenomyosis compared with those with endometriosis only had significantly lower pregnancy-associated plasma protein A (0.61 vs 0.88 multiple of the median, P < 0.001), higher mean uterine artery pulsatility index in the first (2.23 vs 1.67, P < 0.001) and second (1.30 vs 0.94, P < 0.001) trimesters of pregnancy, and higher incidence of SGA (40% vs 10.8%, P < 0.001). No statistically significant differences were found in patients with focal adenomyosis compared with those with endometriosis only. Logistic regression analysis demonstrated that diffuse adenomyosis (odds ratio = 3.744; 95% CI, 1.158-12.099; P = 0.027) was the only independent risk factor for SGA. CONCLUSIONS: The presence of diffuse adenomyosis in pregnant women with endometriosis is strongly associated with delivery of a SGA infant. Women with diffuse adenomyosis should be treated as being at high risk of placental dysfunction, and these pregnancies might therefore need closer monitoring. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Assuntos
Adenomiose/diagnóstico por imagem , Endometriose/diagnóstico por imagem , Retardo do Crescimento Fetal/epidemiologia , Recém-Nascido Pequeno para a Idade Gestacional , Ultrassonografia Pré-Natal , Adulto , Feminino , Humanos , Incidência , Recém-Nascido , Itália/epidemiologia , Gravidez , Resultado da Gravidez , Estudos Prospectivos , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVES: To evaluate the impact of tertiary cytoreductive surgery (TCS) on survival in recurrent epithelial ovarian cancer (EOC), and to determine predictors of complete cytoreduction. METHODS: A multi-institutional retrospective study was conducted within the MITO Group on a 5-year observation period. RESULTS: A total of 103 EOC patients with a ≥6month treatment-free interval (TFI) undergoing TCS were included. Complete cytoreduction was achieved in 71 patients (68.9%), with severe post-operative complications in 9.7%, and no cases of mortality within 60days from surgery. Multivariate analysis identified the complete tertiary cytoreduction as the most potent predictor of survival followed by FIGO stage I-II at initial diagnosis, exclusive retroperitoneal recurrence, and TCS performed ≥3years after primary diagnosis. Patients with complete tertiary cytoreduction had a significantly longer overall survival (median OS: 43months, 95% CI 31-58) compared to those with residual tumor (median OS: 33months, 95% CI 28-46; p<0.001). After multivariate adjustment the presence of a single lesion and good (ECOG 0) performance status were the only significant predictors of complete surgical cytoreduction. CONCLUSIONS: This is the only large multicentre study published so far on TCS in EOC with ≥6month TFI. The achievement of postoperative no residual disease is confirmed as the primary objective also in a TCS setting, with significant survival benefit and acceptable morbidity. Accurate patient selection is of utmost importance to have the best chance of complete cytoreduction.
Assuntos
Procedimentos Cirúrgicos de Citorredução/métodos , Recidiva Local de Neoplasia/cirurgia , Neoplasias Epiteliais e Glandulares/cirurgia , Neoplasias Ovarianas/cirurgia , Adulto , Idoso , Carcinoma Epitelial do Ovário , Feminino , Humanos , Pessoa de Meia-Idade , Análise Multivariada , Recidiva Local de Neoplasia/patologia , Neoplasias Epiteliais e Glandulares/mortalidade , Neoplasias Ovarianas/mortalidade , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
OBJECTIVE: To compare the accuracy of magnetic resonance enema (MR-e) and rectal water-contrast transvaginal sonography (RWC-TVS) in the diagnosis of rectosigmoid endometriosis. METHODS: This prospective study included 286 patients of reproductive age with clinical suspicion of rectosigmoid endometriosis. Patients underwent MR-e and RWC-TVS before laparoscopic excision of endometriotic lesions. The findings of MR-e and RWC-TVS were compared with surgical and histological results. RESULTS: Of the 286 patients included in the study, 151 (52.8%) had rectosigmoid endometriosis. MR-e and RWC-TVS had similar accuracy in the diagnosis of rectosigmoid endometriosis (P = 0.063). In the diagnosis of rectosigmoid endometriosis with MR-e, the sensitivity was 95.4% (95% CI, 90.7-99.1%), specificity was 97.8% (95% CI, 93.6-99.5%), positive predictive value (PPV) was 98.0% (95% CI, 94.1-99.6%), negative predictive value (NPV) was 95.0% (95% CI, 89.9-97.9%), positive likelihood ratio (LR+) was 42.91 (95% CI, 14.01-131.46) and negative likelihood ratio (LR-) was 0.05 (95% CI, 0.02-0.10). For diagnosis with RWC-TVS, sensitivity was 92.7% (95% CI, 87.3-96.3%), specificity was 97.0% (95% CI, 92.6-99.2%), PPV was 97.2% (95% CI, 93.0-99.2%), NPV was 92.3% (95% CI, 86.6-96.1%), LR+ was 31.29 (95% CI, 11.90-82.25) and LR- was 0.08 (95% CI, 0.04-0.13). MR-e and RWC-TVS underestimated the size of the endometriotic nodules; for both imaging techniques the underestimation was greater for nodules with a diameter ≥ 30 mm. There was no significant difference in the mean intensity of pain experienced by the patients during the two examinations. CONCLUSIONS: RWC-TVS should be the first-line investigation in patients with clinical suspicion of rectosigmoid endometriosis and physicians should be trained in performing this examination. Considering that MR-e is more expensive than RWC-TVS, it should be used only when the findings of RWC-TVS are unclear. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Assuntos
Endometriose/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Ultrassonografia/métodos , Vagina/patologia , Adulto , Meios de Contraste , Enema , Feminino , Humanos , Estudos Prospectivos , Sensibilidade e Especificidade , ÁguaRESUMO
OBJECTIVES: To compare the performance of computed tomographic colonography (CTC) and rectal water-contrast transvaginal sonography (RWC-TVS) in the diagnosis of rectosigmoid endometriosis, and compare precision in estimating the length of the rectosigmoid nodules and the distance between the nodules and the anal verge. METHODS: This prospective study included 70 patients of reproductive age with clinical suspicion of rectosigmoid endometriosis. Patients underwent RWC-TVS and CTC before laparoscopic excision of endometriotic nodules. The findings of RWC-TVS and CTC were compared with surgical and histological results. RESULTS: Of the 70 patients included in the study, 40 (57.1%) had rectosigmoid endometriosis. CTC and RWC-TVS had similar accuracy in the diagnosis of rectosigmoid endometriosis (P = 0.508) and similar precision in estimating the length of the endometriotic nodules (P = 0.077). CTC was more precise than RWC-TVS in estimating the distance between the rectosigmoid nodule and the anal verge (P < 0.001). The intensity of pain experienced during CTC was higher than that perceived during RWC-TVS (P < 0.001); however, intestinal distension for CTC was well-tolerated in all patients without significant adverse effects. CONCLUSIONS: RWC-TVS and CTC have similar accuracy in the diagnosis of rectosigmoid endometriosis and similar precision in estimating the size of the nodules; however, CTC is more precise than RWC-TVS in estimating the distance between the nodules and the anal verge, yet patients tolerate RWC-TVS better than CTC. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Assuntos
Colonografia Tomográfica Computadorizada/métodos , Endometriose/diagnóstico por imagem , Ultrassonografia/métodos , Vagina/diagnóstico por imagem , Meios de Contraste , Endometriose/patologia , Feminino , Humanos , Projetos Piloto , Estudos Prospectivos , Sensibilidade e Especificidade , Vagina/patologia , ÁguaRESUMO
OBJECTIVES: To establish the diagnostic accuracy of obstetric ultrasound at a tertiary fetal medicine center in the prenatal detection of unilateral and bilateral multicystic dysplastic kidney (MCDK) in fetuses in which this condition was suspected, and to undertake a systematic review of the relevant literature. METHODS: This was a retrospective observational study of all cases referred to a regional tertiary fetal medicine unit due to suspicion of either unilateral or bilateral MCDK between 1997 and 2015. Diagnosis was confirmed by postnatal ultrasound reports or postmortem examination. The accuracy of prenatal ultrasound in the diagnosis of MCDK was calculated. Using a systematic search strategy we also performed a review of the literature regarding the prenatal diagnosis and diagnostic accuracy of MCDK. RESULTS: We included 144 women in our analysis; 37 (25.7%) opted for pregnancy termination (TOP) (due to unilateral MCDK with additional abnormalities, suspected bilateral MCDK or severe obstructive uropathy). Complete pre- and postnatal data were available in 126 pregnancies, including 104 livebirths, 19 TOPs with postmortem findings available and three intrauterine fetal deaths. Two infants died shortly after birth (due to known bilateral MCDK or known cranial vault defect). The overall number of cases of MCDK confirmed postnatally was 100; of these, 98 were diagnosed prenatally (true positive), while two were thought to be hydronephrosis prenatally (false negative) and the diagnosis of MCDK was made after birth. In nine cases, the initial antenatal diagnosis of suspected MCDK was revised, either later in pregnancy (n = 2) or postnatally (n = 7) (false positive). Overall, the diagnostic accuracy in our population for the use of antenatal ultrasound to detect MCDK was 91.3%, while that reported in the existing literature was found to range from 53.3% to 100%. MCDK was isolated in the majority (71%) of cases, while in 29% of cases it was found to be associated with other renal and extrarenal fetal abnormalities. CONCLUSIONS: Antenatal ultrasound had a diagnostic accuracy of about 91% in the prediction of postnatal MCDK and can therefore be used to guide antenatal counseling. However, prenatal or postnatal revision of the diagnosis occurred in about 7% of cases and parents should be counseled appropriately. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Assuntos
Aborto Induzido/estatística & dados numéricos , Rim Displásico Multicístico/diagnóstico por imagem , Natimorto/epidemiologia , Ultrassonografia Pré-Natal , Áustria , Feminino , Idade Gestacional , Humanos , Rim Displásico Multicístico/embriologia , Rim Displásico Multicístico/mortalidade , Gravidez , Resultado da Gravidez , Segundo Trimestre da Gravidez , Reprodutibilidade dos Testes , Estudos Retrospectivos , Literatura de Revisão como Assunto , Sensibilidade e EspecificidadeRESUMO
STUDY QUESTION: Do endometriotic ovarian cysts influence the rate of spontaneous ovulation? SUMMARY ANSWER: Endometriotic cysts, no matter what their volume, do not influence the rate of spontaneous ovulation in the affected ovary. WHAT IS KNOWN ALREADY: Endometriotic ovarian cysts may negatively affect spontaneous ovulation in the affected ovary. STUDY DESIGN, SIZE, DURATION: This was a prospective observational study performed between September 2009 and June 2013. PARTICIPANTS/MATERIALS, SETTING, METHODS: This study included women of reproductive age with regular menstrual cycles and unilateral ovarian endometriomas (diameter ≥20 mm) desiring to conceive. Exclusion criteria were: hormonal therapies in the 3 months prior to study entry and previous adnexal surgery. Patients underwent serial transvaginal ultrasound to assess the side of ovulation (for up to six cycles). MAIN RESULTS AND THE ROLE OF CHANCE: Ovulation was monitored in 1199 cycles in 244 women (age, mean ± SD, 34.3 ± 4.9 years). 55.3% of the patients had left endometriomas and 44.7% had right endometriomas (P = 0.024). The mean (±SD) diameter of the endometriomas was 5.3 cm (±1.7 cm). Ultrasonographically documented ovulation occurred in 596 cycles in the healthy ovary (49.7%; 95% CI, 46.8-52.6%) and in 603 cycles in the affected ovary (50.3%; 95% CI, 47.1-53.2%; P = 0.919). This observation was confirmed in patients with diameter of the cyst ≥4 cm (n = 166) and in those with diameter of the cyst ≥6 cm (n = 45). One hundred and five patients spontaneously conceived (43.0%; 95% CI, 36.7-49.5%). LIMITATIONS, REASON FOR CAUTION: The high pregnancy rate reported in this study was observed in a selected population of women with endometriomas and cannot be extrapolated to all patients with endometriosis. WIDER IMPLICATIONS OF THE FINDINGS: Since ovarian endometriomas do not impair spontaneous ovulation, the impact on fertility of surgical excision of ovarian endometriomas should be further investigated.
Assuntos
Endometriose/fisiopatologia , Cistos Ovarianos/fisiopatologia , Ovário/fisiopatologia , Ovulação , Adulto , Endometriose/diagnóstico por imagem , Endometriose/patologia , Endométrio/diagnóstico por imagem , Endométrio/patologia , Feminino , Seguimentos , Humanos , Infertilidade Feminina/epidemiologia , Infertilidade Feminina/etiologia , Itália/epidemiologia , Perda de Seguimento , Tamanho do Órgão , Cistos Ovarianos/diagnóstico por imagem , Cistos Ovarianos/patologia , Ovário/diagnóstico por imagem , Gravidez , Taxa de Gravidez , Fatores de Risco , Índice de Gravidade de Doença , UltrassonografiaRESUMO
In recent years, black fungi have been increasingly reported as causing opportunistic infections after solid organ transplantation. Here, we report a case of insidious, relentless, and multifocal Exophiala xenobiotica infection in a kidney transplant recipient that eventually required multiple surgical excisions along with oral and intravenous antifungal combination therapy using liposomal amphotericin B and posaconazole. We compare the present case with all previously reported cases of Exophiala infection after kidney transplantation.
Assuntos
Exophiala , Rejeição de Enxerto/prevenção & controle , Hospedeiro Imunocomprometido , Imunossupressores/efeitos adversos , Transplante de Rim , Infecções Oportunistas/etiologia , Feoifomicose/etiologia , Idoso , Feminino , Humanos , Infecções Oportunistas/imunologia , Infecções Oportunistas/patologia , Feoifomicose/imunologia , Feoifomicose/patologia , TransplantadosRESUMO
OBJECTIVES: The primary objective was to estimate the prevalence of aberrant right subclavian artery (ARSA) in fetuses with Down syndrome. Secondary objectives were to assess the prevalence of ARSA in euploid fetuses, the feasibility of ultrasound evaluation of the right subclavian artery (RSA) in the first and second trimesters of pregnancy, the performance of ARSA in screening for trisomy 21 and its association with other abnormalities. METHODS: Web-based databases (PubMed, EMBASE and MEDLINE) were searched up to July 2014. The STROBE, PRISMA and QUIPS instruments were used to assess all included studies and for reporting of methodology, results and conclusions. Original studies that reported prenatal ultrasound evaluation of ARSA, assessment of its prevalence in Down-syndrome and euploid fetuses, feasibility of ultrasound evaluation of the RSA in the first and second trimesters of pregnancy and correlation of ARSA with other abnormalities were included, excluding duplications and case reports. Collected data were summarized to estimate prevalence and feasibility. A meta-analysis was performed pooling the study-specific positive and negative likelihood ratios (LR+ and LR-), detection rates and false-positive rates for trisomy 21. RESULTS: Prevalence of ARSA in Down-syndrome fetuses was 23.6% (95% CI, 19.4-27.9%), whereas in euploid fetuses it was 1.02% (95% CI, 0.86-1.10%). Ultrasound evaluation of the RSA course and origin in the first and second trimesters of pregnancy was feasible in 85% and 98% of cases (first and second trimester, respectively) and it was directly related to sonographic experience and fetal crown-rump length and inversely related to maternal body mass index. In more than 20% of fetuses with ARSA there was an association with other abnormalities but ARSA seemed to be an independent marker of trisomy 21. The meta-analysis showed that ARSA is a significant risk factor for Down syndrome (pooled LR+ = 26.93, 95% CI, 19.36-37.47, P for effect < 0.001, P for Q = 0.3, I(2) = 17.3%), whereas normal RSA is a significant protective marker (pooled LR- = 0.71, 95% CI, 0.51-0.99, P for effect = 0.043, P for Q = 0.9, I(2) = 0%). CONCLUSIONS: ARSA appears to be a clinically useful prenatal ultrasound marker of Down syndrome. Additional testing when ARSA is diagnosed should involve evaluation of all risk factors by applying a mathematical model. There is insufficient evidence to recommend fetal karyotyping in cases with isolated ARSA. If the background risk is higher or additional markers are present, full fetal karyotyping is advisable, including analysis for 22q11 microdeletion.
Assuntos
Aneurisma/epidemiologia , Anormalidades Cardiovasculares/epidemiologia , Transtornos de Deglutição/epidemiologia , Síndrome de Down/diagnóstico por imagem , Artéria Subclávia/anormalidades , Ultrassonografia Pré-Natal , Aneurisma/diagnóstico por imagem , Anormalidades Cardiovasculares/diagnóstico por imagem , Transtornos de Deglutição/diagnóstico por imagem , Feminino , Humanos , Modelos Estatísticos , Gravidez , Primeiro Trimestre da Gravidez , Segundo Trimestre da Gravidez , Prevalência , Artéria Subclávia/diagnóstico por imagemRESUMO
OBJECTIVE: To investigate the effects of fractional microablative CO2 laser on sexual function and overall satisfaction with sexual life in postmenopausal women with vulvovaginal atrophy (VVA). METHOD: This prospective study included 77 postmenopausal women (mean age 60.6 ± 6.2 years) treated for VVA symptoms with the fractional microablative CO2 laser system (SmartXide(2) V(2)LR, Monalisa Touch, DEKA, Florence, Italy). Sexual function and quality of life were evaluated with the Female Sexual Function Index (FSFI) and the Short Form 12 (SF-12), respectively, both at baseline and at 12-week follow-up. A 10-mm visual analog scale was used to measure the overall satisfaction with sexual life and the intensity of VVA symptoms (vaginal burning, vaginal itching, vaginal dryness, dyspareunia and dysuria) before and after the study period. RESULTS: We observed a significant improvement in the total score and the scores in each specific domain of the FSFI at 12-week follow-up compared to baseline (p < 0.001). After concluding the laser treatment, the overall satisfaction with sexual life significantly improved (p < 0.001). Seventeen (85%) out of 20 (26%) women, not sexually active because of VVA severity at baseline, regained a normal sexual life at the 12-week follow-up. Finally, we also found a significant improvement in each VVA symptom (p < 0.001) and in quality-of-life evaluation, both for the scores in the physical (p = 0.013) and mental (p = 0.002) domains. CONCLUSIONS: Fractional microablative CO2 laser treatment is associated with a significant improvement of sexual function and satisfaction with sexual life in postmenopausal women with VVA symptoms.
Assuntos
Lasers de Gás/uso terapêutico , Comportamento Sexual/fisiologia , Vagina/patologia , Vagina/cirurgia , Vulva/patologia , Vulva/cirurgia , Idoso , Atrofia , Feminino , Humanos , Pessoa de Meia-Idade , Satisfação do Paciente , Pós-Menopausa/fisiologia , Estudos Prospectivos , Qualidade de Vida , Disfunções Sexuais Fisiológicas/etiologia , Disfunções Sexuais Fisiológicas/cirurgiaRESUMO
Adenine phosphoribosyltransferase (APRT) deficiency is a rare autosomal recessive enzyme defect of purine metabolism that usually manifests as 2,8-dihydroxyadenine (2,8-DHA) nephrolithiasis and more rarely chronic kidney disease. The disease is most often misdiagnosed and can recur in the renal allograft. We analyzed nine patients with recurrent 2,8-DHA crystalline nephropathy, in all of whom the diagnosis had been missed prior to renal transplantation. The diagnosis was established at a median of 5 (range 1.5-312) weeks following the transplant procedure. Patients had delayed graft function (n=2), acute-on-chronic (n=5) or acute (n=1) allograft dysfunction, whereas one patient had normal graft function at the time of diagnosis. Analysis of allograft biopsies showed birefringent 2,8-DHA crystals in renal tubular lumens, within tubular epithelial cells and interstitium. Fourier transformed infrared microscopy confirmed the diagnosis in all cases, which was further supported by 2,8-DHA crystalluria, undetectable erythrocyte APRT enzyme activity, and genetic testing. With allopurinol therapy, the allograft function improved (n=7), remained stable (n=1) or worsened (n=1). At last follow-up, two patients had experienced allograft loss and five had persistent chronic allograft dysfunction. 2,8-DHA nephropathy is a rare but underdiagnosed and preventable disorder that can recur in the renal allograft and may lead to allograft loss.
Assuntos
Adenina Fosforribosiltransferase/deficiência , Rejeição de Enxerto , Transplante de Rim , Erros Inatos do Metabolismo/etiologia , Urolitíase/etiologia , Adulto , Idoso , Feminino , Humanos , Masculino , Erros Inatos do Metabolismo/fisiopatologia , Pessoa de Meia-Idade , Recidiva , Urolitíase/fisiopatologiaRESUMO
Pretransplant donor biopsy (PTDB)-based marginal donor allocation systems to single or dual renal transplantation could increase the use of organs with Kidney Donor Profile Index (KDPI) in the highest range (e.g. >80 or >90), whose discard rate approximates 50% in the United States. To test this hypothesis, we retrospectively calculated the KDPI and analyzed the outcomes of 442 marginal kidney transplants (340 single transplants: 278 with a PTDB Remuzzi score<4 [median KDPI: 87; interquartile range (IQR): 78-94] and 62 with a score=4 [median KDPI: 87; IQR: 76-93]; 102 dual transplants [median KDPI: 93; IQR: 86-96]) and 248 single standard transplant controls (median KDPI: 36; IQR: 18-51). PTDB-based allocation of marginal grafts led to a limited discard rate of 15% for kidneys with KDPI of 80-90 and of 37% for kidneys with a KDPI of 91-100. Although 1-year estimated GFRs were significantly lower in recipients of marginal kidneys (-9.3, -17.9 and -18.8 mL/min, for dual transplants, single kidneys with PTDB score<4 and =4, respectively; p<0.001), graft survival (median follow-up 3.3 years) was similar between marginal and standard kidney transplants (hazard ratio: 1.20 [95% confidence interval: 0.80-1.79; p=0.38]). In conclusion, PTDB-based allocation allows the safe transplantation of kidneys with KDPI in the highest range that may otherwise be discarded.
Assuntos
Sobrevivência de Enxerto , Rim , Doadores de Tecidos , Adulto , Idoso , Biópsia , Feminino , Humanos , Rim/patologia , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVE: This pilot study aimed to assess the efficacy and feasibility of fractional CO2 laser in the treatment of vulvovaginal atrophy (VVA) in postmenopausal women. METHODS: VVA symptoms were assessed before and after three applications of laser over 12 weeks in 50 women (age 59.6 ± 5.8 years) dissatisfied with previous local estrogen therapies. Subjective (visual analog scale) and objective (Vaginal Health Index Score, VHIS) measures were used during the study period to assess VVA. Quality of life was measured by using the SF-12. A subjective scale to evaluate the degree of pain related to the laser application and the degree of difficulty to perform the laser procedure was used. RESULTS: Fractional CO2 laser treatment was effective to improve VVA symptoms (vaginal dryness, vaginal burning, vaginal itching, dyspareunia, dysuria; p < 0.001) at 12-week follow-up, as well as the VHIS (13.1 ± 2.5 at baseline vs. 23.1 ± 1.9; p < 0.001). Both physical and mental scores of quality of life were significantly improved in comparison with baseline (p < 0.001). Satisfaction with the laser procedure was reported by 42 women (84%) and a minimal discomfort was experienced at the first laser application, mainly because of the insertion and the movements of the probe. Finally, the technique was very easy to perform in all women starting from the second application at week 4 and no adverse events were recorded during the study period. CONCLUSIONS: A 12-week treatment with the fractional CO2 laser was feasible and induced a significant improvement of VVA symptoms by ameliorating vaginal health in postmenopausal women. Further controlled studies should be performed to confirm the present data and to assess the long-term effects of the laser procedure on vaginal tissues.
Assuntos
Terapia com Luz de Baixa Intensidade , Pós-Menopausa , Vagina , Doenças Vaginais/radioterapia , Vulva , Doenças da Vulva/radioterapia , Atrofia/complicações , Atrofia/etiologia , Atrofia/fisiopatologia , Atrofia/radioterapia , Dispareunia/etiologia , Dispareunia/patologia , Dispareunia/prevenção & controle , Dispareunia/psicologia , Estudos de Viabilidade , Feminino , Humanos , Lasers de Gás/uso terapêutico , Terapia com Luz de Baixa Intensidade/instrumentação , Terapia com Luz de Baixa Intensidade/métodos , Pessoa de Meia-Idade , Projetos Piloto , Pós-Menopausa/fisiologia , Pós-Menopausa/psicologia , Qualidade de Vida , Resultado do Tratamento , Vagina/patologia , Vagina/efeitos da radiação , Doenças Vaginais/complicações , Doenças Vaginais/diagnóstico , Doenças Vaginais/fisiopatologia , Vulva/patologia , Vulva/efeitos da radiação , Doenças da Vulva/complicações , Doenças da Vulva/diagnóstico , Doenças da Vulva/fisiopatologiaRESUMO
The immune cell function assay (ICFA) and de novo anti-donor-specific HLA antibodies (DSA) have been proposed as assays for immune monitoring in renal transplantation, but longitudinal studies examining the modification of both parameters over time and their relation with clinical events are lacking. We prospectively measured longitudinal changes in ICFA and DSA levels in 55 kidney transplant recipients over 3-year follow-up (534 visits) and analyzed their relation with the risk of developing acute rejections or infections. Seven patients (12.7%) developed biopsy-proven acute rejection, and 20 (36.4%) developed viral infections. At 3 years posttransplant, 28% of the patients had developed de novo DSA. ICFA levels peaked at 1-2 months posttransplant (p = 0.005) and leveled off thereafter. They were not associated with the risk of acute rejections, viral infections or development of de novo DSA. Instead, the incidence of de novo DSA was higher in patients who previously had viral infections (adjusted-odds ratio of de novo DSA associated with prior infections: 6.03 [95% CI, 1.64-22.06; p = 0.007]). Our prospective, longitudinal study does not support using ICFA to quantify the immune risk in kidney transplantation. Further studies are needed to confirm the relationship between viral infections and the subsequent development of de novo DSA.
Assuntos
Anticorpos/química , Antígenos HLA/química , Transplante de Rim , Adulto , Linfócitos T CD4-Positivos/imunologia , Feminino , Rejeição de Enxerto , Sobrevivência de Enxerto/imunologia , Teste de Histocompatibilidade , Humanos , Imunossupressores/uso terapêutico , Doadores Vivos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Monitorização Imunológica , Transplante de Pâncreas , Estudos Prospectivos , RiscoRESUMO
Antibody mediated rejection (AMR) is associated with a variety of graft-reactive antibodies following kidney transplant. To characterize these antibodies, we immortalized 107 B cell clones from a patient with AMR. In a previous study, we showed that six clones were reacting to multiple self-antigens as well as to HLA and MICA for two of them, thus displaying a pattern of polyreactivity. We show here that all six polyreactive clones also reacted to apoptotic but not viable cells. More generally we observed a nearly perfect overlap between polyreactivity and reactivity to apoptotic cells. Functionally, polyreactive antibodies can activate complement, resulting in the deposition of C3d and C4d at the surface of target cells. Testing the serum of 88 kidney transplant recipients revealed a significantly higher IgG reactivity to apoptotic cells in AMR patients than in patients with stable graft function. Moreover, total IgG purified from AMR patients had increased complement activating properties compared to IgG from non-AMR patients. Overall, our studies show the development of polyreactive antibodies cross-reactive to apoptotic cells during AMR. Further studies are now warranted to determine their contribution to the detection of C4d in graft biopsies as well as their role in the pathophysiology of AMR.
Assuntos
Apoptose/fisiologia , Autoanticorpos/sangue , Ativação do Complemento/imunologia , Complemento C4b/imunologia , Rejeição de Enxerto/imunologia , Transplante de Rim , Fragmentos de Peptídeos/imunologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Western Blotting , Estudos de Casos e Controles , Ensaio de Imunoadsorção Enzimática , Feminino , Imunofluorescência , Humanos , Imunidade Humoral , Imunoglobulina G/sangue , Imunoglobulina G/imunologia , Pessoa de Meia-Idade , Transplante Homólogo , Adulto JovemRESUMO
OBJECTIVES: This study was designed to investigate the response to chemotherapy of supradiaphragmatic disease diagnosed by preoperative imaging. As secondary objectives, oncologic outcomes of patients affected by supradiaphragmatic disease and their pattern of recurrence were also evaluated. METHODS: Data of consecutive patients with newly diagnosed FIGO stage IV (for supradiaphragmatic disease) epithelial ovarian cancer undergoing either primary debulking surgery or neoadjuvant chemotherapy plus interval debulking surgery between 2004 and 2021, were retrospectively collected. All patients were preoperatively evaluated by chest/abdominal CT scan or 18F-FDG PET/CT preoperatively and at follow-up to evaluate response to chemotherapy. At follow-up visits, site of recurrence diagnosed by imaging techniques was systematically recorded as it occurred. Progression-free and overall survival were measured by using Kaplan-Meier and Cox models. RESULTS: A total of 130 patients was included in this study with a median (range) follow-up of 32.9 (12.8-176.7) months. Complete or partial response was achieved in most of the patients after 3 cycles (77.7%) and 6 cycles (85.4%) of chemotherapy. At follow-up, recurrence occurred in 96 (73.8%) patients and the main site of recurrence was abdomen only in 64 (66.7%) patients. At multivariate analysis, residual disease after surgery was the only variable influencing survival outcomes. CONCLUSIONS: Supradiaphragmatic disease respond to chemotherapy in most patients affected by advanced EOC and recurrence mainly occurs in the abdomen. Results from this study confirms that abdominal optimal cytoreduction is the main surgical goal in the treatment of women affected by FIGO stage IV EOC.
Assuntos
Neoplasias Ovarianas , Humanos , Feminino , Prognóstico , Neoplasias Ovarianas/cirurgia , Neoplasias Ovarianas/tratamento farmacológico , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Estudos Retrospectivos , Estadiamento de Neoplasias , Procedimentos Cirúrgicos de Citorredução/métodos , Terapia Neoadjuvante , Quimioterapia AdjuvanteRESUMO
Central nervous system (CNS) lymphoma is a rare posttransplant lymphoproliferative disorder (PTLD), which usually has a poor outcome. To date, no specific conditions predisposing to this complication have been identified. We here describe the case of a renal transplant patient who was initially diagnosed as having Epstein-Barr virus (EBV)-associated leukoencephalopathy and ultimately developed EBV-positive CNS lymphoma. The patient was a young lady who, 2 years after transplantation, presented with focal neurological and electroencephalographic abnormalities and diffuse white matter lesions on brain magnetic resonance imaging. EBV-DNA was detected in the cerebrospinal fluid (CSF) by polymerase chain reaction. After acyclovir therapy and immunosuppressive drug tapering, the symptoms and electroencephalographic abnormalities subsided, and EBV-DNA disappeared from the CSF. Ten years later, a bulky cerebral mass was found. After excision, a diagnosis of EBV-positive, Hodgkin-like monomorphic B-cell PTLD was made. This case illustrates the potential pathophysiological relationships between EBV infection, leukoencephalopathy and CNS lymphoma; although a long time elapsed from the initial neurological illness to CNS lymphoma, a link between these two conditions cannot be excluded. Therefore, a careful long-term follow-up of EBV-related encephalopathy is advisable.