[Massive vesicoinguinal hernia and acute renal failure. An infrequent association]. / Hernia vesicoinguinal masiva y fracaso renal agudo. Una asociación poco frecuente.

OBJECTIVE: To report a rare complication of acute renal failure secondary to massive vesicoinguinal hernia. To our knowledge, only 4 cases have been previously reported in the literature. METHODS: Herein we describe a case of massive vesicoinguinal hernia in a patient that had presented at the emergency services with symptoms of acute renal failure. The diagnostic and therapeutic aspects of this rare complication are discussed. RESULTS: Patient evaluation showed a left inguinal hernia and benign hyperplasia of the prostate. Blood analytical findings were compatible with acute renal failure. A left massive vesicoinguinal hernia was detected on ultrasound evaluation and confirmed by retrograde cystography. Treatment was by surgical repair of the inguinal hernia, bladder repositioning and cervicoprostatotomy plus TUR of the excrescent bladder lesions to resolve the obstruction. CONCLUSIONS: Massive vesicoinguinal hernia may go undetected if the symptoms are unremarkable and may mimick those of acute renal failure.

[Spontaneous renal hemorrhage. Report of 8 cases]. / Hemorragia renal espontánea. A propósito de ocho casos.

Spontaneous renal haemorrhage or Wünderlich syndrome is a rare condition; it is however of great significance given the emergency, sometimes vital, situation that it creates. The etiology of the condition is varied, the most frequent being tumoral. The clinical manifestations and the use of imaging techniques are of great interest to establish the diagnosis. The choice treatment is controversial. This paper presents eight cases of Wünderlich syndromes seen in our urology service. The background, etiology, clinical manifestations, diagnostic methods and treatment used in each case are analyzed.

[Leiomyosarcoma and rhabdomyosarcoma: rare tumors of the kidney]. / Leiomiosarcoma y rabdomiosarcoma: tumores raros del riñón.

Renal sarcoma represents 2.8% of all renal malignant tumours. The most common kind is leiomyosarcoma while rhabdomyosarcoma is the most unusual. Clinical presentation and diagnosis of both types of tumours are unspecific. Treatment is controversial and the overall prognosis poor. The present paper presents two cases, one leiomyosarcoma and one rhabdomyosarcoma which were treated surgically and were followed by chemo- and radiotherapy. A revision of the criteria for grading these as primary tumours of the kidney is also included.

[Relationship between female stress urinary incontinence intensity and the data of urethral pressure profile]. / Relación entre la intensidad de la incontinencia urinaria de esfuerzo femenina y los datos del perfil de presión uretral.

OBJECTIVE: To determine the utility of the urethral pressure profile in the diagnosis of stress urinary incontinence and its possible correlation with the degree of severity of incontinence. METHODS: 175 female patients with a clinical history of urinary incontinence were evaluated; of these, 50 cases with bladder instability demonstrated by the urodynamic studies were excluded. Patient evaluation included clinical history, physical examination, analytical studies, radiological evaluation and complete urodynamic assessment, including uroflowmetry, filling and voiding cystometry, and static and dynamic urethral pressure profiles. A 10 Fr microtransducer catheter was utilized for the urethral pressure profile studies. ICS recommendations were observed. Patients were classified into three groups according to the severity of urinary incontinence based on the clinical data, physical examination and urodynamic findings. The Wilcoxson test and 2 x 2 contingency table were employed for the statistical analysis. RESULTS: Of the parameters analyzed for the static urethral pressure profile, statistically significant differences were found only for the maximum urethral pressure and maximum closing urethral pressure in the different groups of patients. No differences in total length or functional urethral length were observed. Comparison of the dynamic urethral pressure profiles of the different groups showed a statistically significantly higher proportion of patients with a negative dynamic urethral closing pressure in the group of patients with urodynamically and clinically demonstrated urinary incontinence than in those with no urodynamically or clinically demonstrable incontinence. CONCLUSIONS: The urethral pressure profile is sufficiently reliable to confirm the diagnosis of urinary incontinence and its degree of severity. As a diagnostic test in urinary stress incontinence, it has a sensitivity of 89% and a specificity of 95%.

[Experience with the of treatment renal cell carcinoma with thrombus in inferior vena cava and right atrium]. / Experiencia en el tratamiento del carcinoma de células renales con trombo en vena cava inferior y aurícula derecha.

Retrospective analysis of definite staging and surgery results in 17 patients with renal cell tumour disseminated to lower cava vein who underwent radical nephrectomy and tumoral thrombectomy. Magnetic resonance predicted presence and level of tumoral thrombus in 100% and 88% cases, respectively. Neither venacavography or doppler echography provided additional information. Dissemination was infrahepatic in 9 (53%) cases, suprahepatic in 4 (24%) and to the right atrium in 4 (23%). Cardiopulmonary by-pass and hypothermic cardioplegia was used in 9 (53%) cases. Operative mortality and morbidity rates were 11% and 65%, respectively. The level of the thrombus did not significantly affect the prognosis which was highly affected however by regional node invasion. In all, CT and MRI can determine the extension and level of the cava vein thrombus in most cases. In our experience, disease-free survival is determined by the pathological stage and not by the extent of the cava thrombus. Radical nephrectomy and tumoral thrombectomy can provide long survival to patients with locoregional disease.

[Myasthenia gravis as paraneoplastic syndrome in small cell tumor of the bladder]. / Miastenia gravis como síndrome paraneoplásico en tumor vesical de células pequeñas.

Only 0.48% of vesical tumours are of the small cells epithelial type with positive neuroendocrine immunohistochemical markers, although the description of new cases is becoming increasingly common. These tumours may be associated to paraneoplastic syndromes of the endocrine and neurological types. This paper contributes one case report of a female patient diagnosed with a small cells epithelial vesical tumour associated to myasthenia gravis. The histological and histochemical features as well as the differential diagnosis with other tumours of vesical location are explained. Clinically, these entities evolve with acute haematuria and have a highly aggressive evolution. Quite frequently the tumour is associated to neuromuscular syndromes such as Lamber-Eaton's, myasthenia-like syndromes, and in rare occasions to myasthenia gravis. Different studies have reported anti-acetylcholine receptors in cells of this tumoral class that may stimulate the formation of antibodies against the neuromotor plaque. Diagnosis of this neurological syndrome and other similar ones may be attributed to early treatment and better prognosis of this tumoral entity.

Effectiveness of cloxacillin with and without gentamicin in short-term therapy for right-sided Staphylococcus aureus endocarditis. A randomized, controlled trial.

BACKGROUND: It is often difficult to administer extended antibiotic therapy in the hospital for right-sided Staphylococcus aureus endocarditis. Although the effectiveness of single-drug therapy given for 4 to 6 weeks and that of two-drug therapy given for 2 weeks have been shown, no data are available on the effectiveness of short-course single-drug therapy. OBJECTIVE: To compare the efficacy of cloxacillin alone with that of cloxacillin plus gentamicin for the 2-week treatment of right-sided S. aureus endocarditis in intravenous drug users. DESIGN: Open, randomized study. SETTING: An academic tertiary care hospital in Barcelona, Spain. PATIENTS: 90 consecutive intravenous drug users who had isolated tricuspid valve endocarditis caused by methicillin-susceptible S. aureus, had no allergy to study medications, and had no systemic infectious complications that required prolonged therapy. An efficacy subset consisted of 74 of these patients who did not meet an exclusion criterion. INTERVENTION: Cloxacillin (2 g intravenously every 4 hours for 14 days) alone or combined with gentamicin (1 mg/kg of body weight intravenously every 8 hours for 7 days). MEASUREMENTS: Clinical or microbiological evidence of active infection after 2 weeks of therapy, relapse of staphylococcal infection, or death. RESULTS: In an analysis of the efficacy subset, treatment was successful in 34 of the 38 patients who received cloxacillin alone (89% [95% CI, 75% to 97%]) and 31 of the 36 patients who received cloxacillin plus gentamicin (86% [CI, 71% to 95%]). Three patients died: one in the cloxacillin group and two in the combination therapy group. Of the 37 patients who completed 2-week treatment with cloxacillin, 34 (92%) were cured, and 3 (8%) needed prolonged treatment to cure the infection. Of the 34 patients who completed 2-week treatment with cloxacillin plus gentamicin, 32 (94%) were cured and 2 (6%) required treatment for 4 weeks. One patient in the combination group had relapse. CONCLUSIONS: A penicillinase-resistant penicillin used as single-agent therapy for 2 weeks was effective for most patients with isolated tricuspid endocarditis caused by methicillin-susceptible S. aureus. Adding gentamicin did not appear to provide any therapeutic advantages. Additional studies to confirm the therapeutic equivalence of short-course therapy with penicillinase-resistant penicillin alone and therapy with combined regimens are warranted.

[Cytokines and nitric oxide in streptococcal toxic shock syndrome]. / Citocinas y óxido nítrico en el síndrome de shock tóxico estreptocócico.

The plasma levels of endotoxin, tumor necrosis factor- alpha (TNF-alpha), interleukin -1 beta (IL-beta), IL-6, IL-8 and the nitrites and nitrates (NO2-/NO3-) as stable metabolites of nitric oxide (NO) were studied in the plasma of 2 patients with the streptococci toxic shock syndrome (STSS) associated to necrotizing fasciitis. A plasma profile of inflammatory mediators with high cytokine concentrations and NO2-/NO3- were observed with circulating endotoxin not being detected in plasma. The first patient died of fulminant refractory shock while the second survived following subacute evolution. The mediators profile, which was much higher in the first case, coincided with clinical severity. These data suggest that the cytokines and NO may have a role in the physiopathology of STSS and the severity of it is related to the levels of these mediators in the acute phase.

Interleukin-10 and the monocyte/macrophage-induced inflammatory response in septic shock.

Interleukin (IL)-10 is a potent immunosuppressant of monocyte/macrophage function and may help control the inflammatory response induced by bacterial infection. To analyze whether IL-10 is detectable in plasma of patients with septic shock and to evaluate its relationship with endotoxin (lipopolysaccharide [LPS])-induced and monocyte/macrophage-induced inflammatory response, plasma IL-10, tumor necrosis factor (TNF)-alpha, IL-1 beta, IL-6, IL-8, LPS, and neopterin were studied in 24 patients with septic shock and in 12 critically ill patients. Eighty-three percent of patients with septic shock and 25% of critically ill patients had detectable levels of IL-10 (P < .001). There was a significant correlation between plasma IL-10, neopterin (r = .72), TNF-alpha (r = .76), IL-6 (r = .68), and IL-8 (r = .61) levels in patients with septic shock. Monocyte/macrophage activation leads to massive secretion of IL-10, which, however, seems to be unable to control the increased production of proinflammatory mediators during septic shock.

L-arginine: nitric oxide pathway in endotoxemia and human septic shock.

OBJECTIVE: To investigate the relationship between nitric oxide production, endotoxemia, and hemodynamic alterations in human septic shock. DESIGN: Prospective study. SETTING: A 32-bed intensive care unit in a university referral hospital. PATIENTS: Two groups of septic patients with shock (n = 13) or without shock (n = 16) and an additional group of nonseptic patients as control group (n = 25). MEASUREMENTS: Plasma nitrite and nitrate concentrations were measured as an index of nitric oxide generation. Nitrite and nitrate concentrations were correlated with plasma endotoxin and hemodynamic variables. MAIN RESULTS: Increased plasma nitrite and nitrate concentrations were found in patients with septic shock (p < .01). Nitrite and nitrate correlated directly with endotoxin concentration (r2 = .21, p < .05) and cardiac output (r2 = .49, p < .05), and inversely with systolic blood pressure (r2 = .24, p < .01). CONCLUSIONS: This study demonstrated the activation of the L-arginine:nitric oxide pathway in human endotoxemic septic shock, suggesting that nitric oxide may be an important mediator of the hemodynamic disturbances in this pathophysiologic situation.

Inflammatory mediators and their influence on haemostasis.

Sepsis is the most important cause of mortality in the Intensive Care Units. At present, sepsis is understood to be the inflammatory response of the host to infection, rather than a direct effect of microbial aggression. From the clinical standpoint, this inflammatory response is known as systemic inflammatory response syndrome (SIRS). Pathophysiologically, SIRS is characterized by the activation of several groups of cell (monocytes/macrophages, PMNs, and endothelial cells) and by the release of inflammatory mediators (cytokines and others). Tumor necrosis factor (TNF) is the first cytokine released by endotoxin action over monocyte/macrophage. TNF secretion, modulated by interferon gamma (IFN gamma) and interleukin 10 (IL-10), is followed by release of other cytokines such as interleukins (IL) (IL-1, IL-6 and IL-8). These mediators are able to act over hemostasis activating the extrinsic pathway through tissue factor expression. The action of the mediators over endothelial cells induces an increase in plasminogen activator inhibitor type 1 (PAI-1) levels with inhibition of fibrinolysis. Both coagulation activation and fibrinolysis blockade result in fibrin deposit in the microvascular system. The complexity of the mechanisms implicated in systemic inflammatory response make a general rule so difficult to establish, because patient response is highly individualized and it is not possible to know which moment of this dynamic process is being analyzed.

Randomized trial comparing ceftriaxone with cefonicid for treatment of spontaneous bacterial peritonitis in cirrhotic patients.

We compared cefonicid (2 g every 12 h) and ceftriaxone (2 g every 24 h) for their efficacy and safety in treating spontaneous bacterial peritonitis in cirrhotic patients in an open randomized clinical trial (30 patients in each group). Clinical, laboratory, and bacteriologic characteristics were similar in both groups. Ceftriaxone-susceptible strains were isolated on 44 occasions (94%), and cefonicid-susceptible strains were isolated on 43 occasions (91.5%). The antibiotic concentration in ascitic fluid/MIC ratio for ceftriaxone was > 100 throughout the dose interval (24 h), while it was lower for cefonicid (between 1 and 18). A total of 100% of patients treated with ceftriaxone, and 94% of those treated with cefonicid were cured of their infections (P was not significant). Hospitalization mortality was 37% in the cefonicid group and 30% in the ceftriaxone group (P was not significant). The time that elapsed between the initiation of treatment and the patient's death was shorter in the cefonicid group patients (5.3 +/- 3.90 days) than in the ceftriaxone group patients (11.8 +/- 9.15 days) (P < 0.05). None of the patients presented with superinfections, and only two patients treated with cefonicid and three patients treated with ceftriaxone developed colonizations with Enterococcus faecalis or Candida albicans. Ceftriaxone and cefonicid are safe and useful agents for treating cirrhotic spontaneous bacterial peritonitis, although the pharmacokinetic characteristics of ceftriaxone seem to be more advantageous than those of cefonicid.

[Bacterial peritonitis in cirrhosis. Prospective study of 80 episodes]. / Peritonitis bacteriana del cirrótico. Estudio prospectivo de 80 episodios.

BACKGROUND: The high incidence, recognition of the different variants and the important changes introduced in the methods of diagnosis of bacterial peritonitis of cirrhotic patients led the authors to study this entity according to the most up to date and standardized criteria. METHODS: The clinical-epidemiological, biological and bacteriological characteristics of 80 episodes of ascitic fluid infection (AFI) were studied. Diagnostic paracentesis was performed in all the patients and were evaluated according to a prospective study protocol. RESULTS: The patients with AFI were classified into three groups: 1) spontaneous bacterial peritonitis (SBP) (761 episodes); 2) secondary bacterial peritonitis (BP) (5 cases); and 3) bacteriascitis (BA) (4 episodes). The clinical manifestations were not specific, with absence of abdominal pain and fever in 9% of the cases. There were no clinical differences between the variants of AFI. The ascitic fluid culture was positive in 80% of the cases of SBP while it was only so in 9% of the Gram stain. Most of the cases of peritonitis were caused by Gram negative bacilli (77%), predominantly E. coli (64%). The culture was positive in 100% of the cases of BP, generally being polymicrobian, and Gram stain was positive in 67% of the cases. The inflammatory response of the ascitic fluid in the different variants of AFI was gradual, being lower in BP and nul in BA. In 52 episodes of SBP (73.8%) the infection was cured. In the group of SBP all the patients died without having resolved the peritonitis (p < 0.001). Forty-four patients (62%) with BP were discharged from hospital. A multivariate logistic regression analysis demonstrated that from a total of 32 variables analyzed, only the absence of fever (p < 0.0001), the presence of advanced hepatic encephalopathy (p < 0.0001), the presence of leukocytosis, serum bilirubin higher than 137 mumol/l, urine sodium levels lower than 10 mmol/l, the level of LDH in ascitic fluid higher than 2 microKat/l and ascitic fluid culture positivity had independent prognostic value. CONCLUSIONS: Infection of ascitic is a frequent entity. Although its variants are clinically indifferentiable, there are clear biochemical, bacteriological and evolutive differences. The mortality of ascitic fluid infection remains high. Its prognosis fundamentally depends of the degree of evolution of the hepatopathy and the severity of the peritoneal infection.