Cancer and thrombosis: new insights to an old problem.

Venous thromboembolism (VTE) is a common complication in patients with cancer and portends a poor prognosis. Our understanding of the underlying pathophysiology of VTE in cancer has advanced since Trousseau first described hypercoagulability in patients with malignancy and Virchow described his famous triad of thrombosis formation. Malignancy itself induces a thrombophilic state by increasing the risk of venous stasis, endothelial injury and an imbalance of pro and anti-thrombotic factors leading to a hypercoaguable state. Additional insults to this thrombotic balance are introduced by patient-specific, treatment related and tumor-specific factors. The importance of understanding the factors associated with increased thrombosis in cancer is paramount in order to adequately identify patients who will benefit from thromboprophylaxis.

Los problemas auditivos aumentan el riesgo de deterioro cognitivo en adultos mayores chilenos / Hearing impairments increase the risk of cognitive impairment in older Chilean adults

RESUMEN Introducción: Estudios previos han asociado la pérdida auditiva con un acelerado deterioro cognitivo durante el envejecimiento; no obstante, esta asociación no ha sido estudiada en adultos mayores chilenos. Objetivo: Investigar la asociación entre la discapacidad auditiva y la sospecha de deterioro cognitivo a través del cuestionario Mini Mental State Examination (MMSE, versión abreviada) en esta población. Material y método: Se incluyeron 1.384 adultos mayores de 60 años de la encuesta nacional de salud 2009-2010. Un puntaje <13 puntos en el MMSE se consideró sospecha de deterioro cognitivo. La discapacidad auditiva se determinó a través de un cuestionario de tamizaje autorreportado de tres preguntas. La asociación entre estas dos variables se investigó mediante análisis de regresión logística. Resultados: Se identificó una asociación significativa entre el MMSE alterado y cada una de las discapacidades auditivas estudiadas. A su vez, existió una tendencia a aumentar en 59% la probabilidad de desarrollar deterioro cognitivo en la medida que aumentaron las discapacidades auditivas (OR: 1,59 [95% IC: 1,38 a 1,82], p <0,0001). Conclusión: La disminución de la percepción auditiva es un factor de riesgo para el desarrollo de deterioro cognitivo y posteriormente demencia. La creación de políticas públicas, orientadas al tamizaje temprano en población de riesgo, podría ser una solución efectiva para prevenir las consecuencias asociadas con esta condición.

ABSTRACT Introduction: Hearing loss has been associated with an accelerated cognitive impairment during ageing. However, this association has not been investigated in older Chilean adults. Aim: To investigate the association between hearing impairment and cognitive impairment, using the Mini-Mental State Examination (MMSE, abridged version), in the Chilean population. Material and methods: 1,384 older adults aged ≥60 years, from 2009-2010 Chilean national health survey, were included. <13 points in the MMSE were considered suspicion of cognitive impairment. Hearing impairment was determined through a questionnaire including 3 domains. The association between cognitive and hearing loss was investigated using logistic regression. Results: An association between MMSE and each hearing disabilities studied was identified. As hearing impairments increased, the odd for cognitive impairment incremented by 59% (OR: 1.59 [95% IC: 1.38 a 1.82], p <0.0001). Conclusion: Hearing loss is a risk factor to develop cognitive impairment, which could translate into a high risk of dementia. Public politics implementation, focused in an early screening, could be an effective approach to prevent the complications associated with this hearing loss in older adults.

The role of the extracellular matrix in primary myelofibrosis.

Primary myelofibrosis (PMF) is a myeloproliferative neoplasm that arises from clonal proliferation of hematopoietic stem cells and leads to progressive bone marrow (BM) fibrosis. While cellular mutations involved in the development of PMF have been heavily investigated, noteworthy is the important role the extracellular matrix (ECM) plays in the progression of BM fibrosis. This review surveys ECM proteins contributors of PMF, and highlights how better understanding of the control of the ECM within the BM niche may lead to combined therapeutic options in PMF.

Prevalencia de factores de riesgo cardiovascular en trabajadores de la Universidad Austral de Chile / Prevalence of cardiovascular risk factors in workers from Universidad Austral de Chile

Background: Cardiovascular diseases (CVDs) are the first cause of death worldwide. Latin American countries including Chile has experience an increment in the prevalence of risk factors for CVDs. Aim: To estimate the prevalence of cardiovascular risk factors in workers from Universidad Austral de Chile and to evaluate its relation with age and sex. Subjects and methods: This was a cross-sectional study conducted in 2012 in 258 participants (55% males). Lifestyle and socio-economic questionnaire were applied and anthropometric (body mass index and waist circumference) and metabolic markers (glucose, lipid profile, and blood pressure) were measured in all participants. Results: Overall, 31.8% were obese, 38.9% had central obesity, 31.6% had high total cholesterol, 45.2% had lower HDL cholesterol, 34.4% had higher triglycerides, 7.4% had diabetes, 29.6% had hypertension, 35.6% had metabolic syndrome and 23.6% were physically inactive. Conclusions: The study population shows a high prevalence of cardiovascular risk factors. These cardiovascular risk factors increase with age, however this increase did not differ by sex.

Antecedentes: Las enfermedades cardiovasculares (ECV) constituyen la principal causa de muerte a nivel mundial. En Chile, al igual que en otros países latinoamericanos, se han observado incrementos en las prevalencias de los principales factores de riesgo para estas enfermedades en la población general. Objetivo: Determinar la prevalencia de factores de riesgo cardiovascular (FRCV) en funcionarios de la Universidad Austral de Chile y evaluar su relación con la edad y sexo. Sujetos y métodos: Estudio de corte transversal realizado el año 2012. Se aplicó un cuestionario de estilos de vida y caracterización socio-económica. Se determinaron las características antropométricas (índice de masa corporal y circunferencia de cintura) y metabólicas (glicemia, perfil lipídico y presión arterial). Resultados: Se evaluaron 258 participantes (55,4% hombres). Se observó 31,8% de obesidad, 38,9% obesidad abdominal, 31,6% colesterol total elevado, 45,2% colesterol HDL disminuido, 34,4% triglicéridos elevados, 7,4% diabetes, 29,6% hipertensión, 35,6% síndrome metabólico, 23,6% actividad física insuficiente. Conclusiones: La población estudiada presenta alta prevalencia de los principales FRCV, los que aumentan con la edad, siendo esta asociación similar para ambos sexos.

[Effects of an intervention to reduce cardiovascular risk factors in university students]. / Efecto de una intervención centrada en la reducción de factores de riesgo cardiovascular en estudiantes universitarios.

BACKGROUND: Interventions aiming to reduce obesity and sedentary behaviors in young adults could be a feasible and effective approach to prevent cardiovascular diseases. AIM: To evaluate the effect of a lifestyle-based intervention on reducing cardiovascular risk factors in university students. MATERIAL AND METHODS: Sixty university students aged 21 ± 1 years (n = 44 females) took part on a 17 weeks lifestyle intervention consisting in education about healthy lifestyles and physical training, during a curricular course about health promotion and healthy lifestyles. At baseline and at the end of the intervention participants completed a lifestyles questionnaire and provided fasting blood samples to quantify glucose and lipids profile. RESULTS: After the intervention significant reductions in the prevalence of hyperglycemia (-10.0%), high blood pressure (-16.7%) and physical inactivity (-26.7%) were observed. Moreover, a significant reduction in body weight, waist circumference, blood pressure, total cholesterol, triglycerides and an increase in HDL cholesterol were observed after intervention. CONCLUSIONS: The implementation of an intervention to promote healthy lifestyles is an effective way of reducing cardiovascular risk factors in university students.

Efecto de una intervención centrada en la reducción de factores de riesgo cardiovascular en estudiantes universitarios / Effects of an intervention to reduce cardiovascular risk factors in university students

Background: Interventions aiming to reduce obesity and sedentary behaviors in young adults could be a feasible and effective approach to prevent cardiovascular diseases. Aim: To evaluate the effect of a lifestyle-based intervention on reducing cardiovascular risk factors in university students. Material and Methods: Sixty university students aged 21 ± 1 years (n = 44 females) took part on a 17 weeks lifestyle intervention consisting in education about healthy lifestyles and physical training, during a curricular course about health promotion and healthy lifestyles. At baseline and at the end of the intervention participants completed a lifestyles questionnaire and provided fasting blood samples to quantify glucose and lipids profile. Results: After the intervention significant reductions in the prevalence of hyperglycemia (-10.0%), high blood pressure (-16.7%) and physical inactivity (-26.7%) were observed. Moreover, a significant reduction in body weight, waist circumference, blood pressure, total cholesterol, triglycerides and an increase in HDL cholesterol were observed after intervention. Conclusions: The implementation of an intervention to promote healthy lifestyles is an effective way of reducing cardiovascular risk factors in university students.

[Cardiovascular risk factors among university students]. / Factores de riesgo cardiovascular en estudiantes de la Universidad Austral de Chile.

BACKGROUND: Cardiovascular diseases are related to particular lifestyle patterns and the presence of cardiovascular risk factors (CVRF). AIM: To evaluate the presence of CVRF in students from Universidad Austral de Chile (UACh). MATERIAL AND METHODS: CVRF were evaluated in 385 university students aged 17 to 26years (63% women). Personal background, lifestyle, anthropometry, blood pressure, serum lipids and blood glucose were evaluated. RESULTS: Eighty eight percent of evaluated students had sedentary habits, 19% had high LDL cholesterol levels, 40% had high blood pressure, 28% smoked, 29% were overweight or obese and 20% had some stress level. CONCLUSIONS: There is a high frequency of non-healthy lifestyles and cardiovascular risk factors in this sample of university students.

Factores de riesgo cardiovascular en estudiantes de la Universidad Austral de Chile / Cardiovascular risk factors among university students

Background: Cardiovascular diseases are related to particular lifestyle patterns and the presence of cardiovascular risk factors (CVRF). Aim: To evaluate the presence of CVRF in students from Universidad Austral de Chile (UACh). Material and Methods: CVRF were evaluated in 385 university students aged 17 to 26years (63% women). Personal background, lifestyle, anthropometry, blood pressure, serum lipids and blood glucose were evaluated. Results: Eighty eight percent of evaluated students had sedentary habits, 19% had high LDL cholesterol levels, 40% had high blood pressure, 28% smoked, 29% were overweight or obese and 20% had some stress level. Conclusions: There is a high frequency of non-healthy lifestyles and cardiovascular risk factors in this sample of university students.

Third kidney transplantation: a permanent medical-surgical challenge.

The aim of this study was to analyze the 30 third transplantations performed at our center since 1976. They were all from cadaveric donors. Recipient mean age was 40 years (range, 21-57 years). Twenty-one patients (70%) had hepatitis C virus infection and 16 (53%) were hypersensitized (panel-reactive antibodies [PRA] >50%), with a mean time on dialysis since second graft loss of 65 months (range, 1-250 months). The imaging tests showed iliac calcifications in 14 patients (47%). The graft was preferably placed in the iliac fossa (27/30). Twenty-five patients (83%) had prior graft nephrectomy and transplantectomy was performed at the same surgery in 2 cases. Immunosuppressive protocol was quadruple therapy in 23 patients (77%). At a mean follow-up of 43 months, 24 grafts were functioning. Mean serum creatinine was 1.5 mg/dL and Modification of Diet in Renal Disease (MDRD) clearance was 64.5 mL/min. Six grafts were lost: 3 due to acute rejection, 2 due to chronic allograft nephropathy, and 1 due to venous thrombosis. Four patients died: 2 due to infectious complications, 1 due to hepatic encephalopathy, and 1 to an accident with a functioning graft. The acute rejection rate was 30% and 4 patients had an acute humoral rejection episode. The main surgical complication was lymphocele in 7 cases (23%). Estimated survival at 5 years was 76% for grafts and 86% for patients. Graft survival worsened among patients with PRA > 80% and among those who had lost the previous grafts in the first month posttransplantation (P < .05). In conclusion, the outcomes of the third kidney transplantations encourage us to continue with this procedure. However, worse graft survival should be expected among hyperimmunized patients and among those who had lost previous grafts early in their course.

Kidneys from elderly deceased donors discarded for transplantation.

Although deceased donors older than 60 years of age (D > 60) are increasing in number, little information exists on the rate of discarded kidneys from these aged individuals. This study sought to analyze causes of discard of kidneys from D > 60. Since 1997, we have transplanted kidneys from D > 60 into elderly recipients after assessing their functional and anatomical viability. Among 3444 renal offers for transplantation between 1997 and 2005, 1967 (57%) came from D > 60. Of these, 1145 offers were discarded, because the kidney donor was not adequate (n = 470) or because there was no elderly recipient on our waiting list (n = 675). We also examined 1745 kidneys, 822 (47%) of which came from D > 60. The percentage of discarded kidneys due to macroscopic or microscopic alterations was 46% in the D > 60 group compared with 14.7% in the donor group younger than 60 years of age (D < 60; P < .01). We transplanted 443 kidneys from D > 60 (85 dual, 273 single) to 358 recipients of matching age and 900 kidneys from D < 60. Three-year death-censored actuarial graft survival rate was 83% for D > 60 compared with 89% for D < 60 transplant (P = not significant). In conclusion, kidneys from D > 60 were discarded for transplantation mainly because there was no elderly recipient on the waiting list and due to macroscopic or microscopic alterations. Given the increasing offer of kidneys from D > 60 and the good results of transplantation with these aged kidneys in elderly recipients, the indications for kidney transplantation should be expanded to include more of the elderly population on dialysis to the waiting list.

Outcome of renal transplantation in adult patients with augmented bladders.

OBJECTIVE: We studied the long-term renal graft functions, survivals, and complications among patients with augmented bladders. PATIENTS AND METHODS: Between 1976 and 2008, we performed 6/2600 renal transplantations in patients with augmented bladders. The mean patient age was 52 years. The cause of end-stage renal disease was chronic interstitial kidney disease in all patients, being secondary to lower urinary tract dysfunction. The etiology of bladder dysfunction was tuberculosis in 4 cases, bladder exstrophy in 1, and myelomeningocele in 1. Enterocystoplasty had been performed at a mean of 19 years prior to transplantation. The ureter was implanted into the native ureter in 5 cases and the bowel segment in 1 case. RESULTS: With a mean follow-up of 56 months (range, 20-100 months), the overall graft survival was 50%. Three grafts were lost due to venous thrombosis (n = 1), and chronic allograft nephropathy (n = 2) at 37 and 100 months posttransplantation. No patient died during follow-up. Mean serum creatinine was 1.44 mg/dL with Modification of Diet in Renal Disease (MDRD) clearance of 76 mL/min/1.73 m(2). One fistula that caused obstructive uropathy and 2 cases of migration of a double J catheter were among the surgical complications. These patients showed a mean of 7 episodes of uncomplicated urinary infections. Only 1 patient was rehospitalized due to a complicated urinary tract infection. CONCLUSIONS: Patients with enterocystoplasty and renal transplantation show a greater risk of urinary tract infections, albeit mostly uncomplicated. Despite this, the long-term results are acceptable.

Urological complications after simultaneous pancreas-kidney transplantation.

OBJECTIVE: We evaluated the incidence of urological complications after simultaneous renal and pancreatic transplantation. PATIENTS AND METHODS: We retrospectively reviewed urological complications following 107 simultaneous kidney-pancreas transplantations performed at our institution between March 1995 and June 2008. The 46 women and 61 men were of mean age 37.8 years (range, 25-66). The mean duration of diabetes mellitus was 23.0 years (range, 9-48) and the mean duration of dialysis was 19.9 months (range, 0-70). The exocrine pancreatic secretions were drained to bladder in 58 cases, or enterically in 49 patients. The mean length of follow-up was 51.7 months. RESULTS: The most frequent urological complication was urinary tract infection, reported in 63.8% of patients: 42 bladder-drained and 25 enteric-drained (P = .011). Hematuria occurred in 13 patients (12.5%): 12 bladder-drained and 1 enteric-drained (P = .002). Five bladder-drained patients developed bladder calculi. Among 58 bladder-drained patients, reflux pancreatitis occurred in 28 patients and urine leaks related to the pancreatic graft occurred in 7 patients. Conversion of exocrine secretions from bladder to enteric diversion was required in 6 patients. One- and 3-year patient survival rates were 92.7% and 89.1%, respectively. Moreover, 1 and 3-year kidney graft survival rates were 90.6% and 84.4%, and pancreas graft survival rates were 78.1 and 70.3%, respectively. CONCLUSION: Simultaneous kidney-pancreas transplantation with bladder drainage is associated with a high frequency of urological complications. Appropriate treatment can resolve most complications. In our opinion, both enteric and bladder drainage seemed to be safe and effective alternatives to manage pancreatic exocrine secretions.

European consensus on diagnosis and treatment of germ cell cancer: a report of the European Germ Cell Cancer Consensus Group (EGCCCG).

Germ cell tumour is the most frequent malignant tumour type in young men with a 100% rise in the incidence every 20 years. Despite this, the high sensitivity of germ cell tumours to platinum-based chemotherapy, together with radiation and surgical measures, leads to the high cure rate of > or = 99% in early stages and 90%, 75-80% and 50% in advanced disease with 'good', 'intermediate' and 'poor' prognostic criteria (IGCCCG classification), respectively. The high cure rate in patients with limited metastatic disease allows the reduction of overall treatment load, and therefore less acute and long-term toxicity, e.g. organ sparing surgery for specific cases, reduced dose and treatment volume of irradiation or substitution of node dissection by surveillance or adjuvant chemotherapy according to the presence or absence of vascular invasion. Thus, different treatment options according to prognostic factors including histology, stage and patient factors and possibilities of the treating centre as well may be used to define the treatment strategy which is definitively chosen for an individual patient. However, this strategy of reduction of treatment load as well as the treatment itself require very high expertise of the treating physician with careful management and follow-up and thorough cooperation by the patient as well to maintain the high rate for cure. Treatment decisions must be based on the available evidence which has been the basis for this consensus guideline delivering a clear proposal for diagnostic and treatment measures in each stage of gonadal and extragonadal germ cell tumour and individual clinical situations. Since this guideline is based on the highest evidence level available today, a deviation from these proposals should be a rare and justified exception.

Helical computed tomography angiography is the most efficient test to assess vascular calcifications in the iliac arterial sector in renal transplant candidates.

UNLABELLED: The increased scope of renal transplant indications has lead to a larger number of recipients with vascular problems due to arterial calcifications in the iliac region. Compared to magnetic resonance and conventional arteriography, helical computed tomography angiography (HCTA) accurately depicts arterial diseases, including the location and extent of arterial calcification. The objective of this study was to assess the value of HCTA with maximum-intensity-projection (MIP) reconstruction to evaluate iliac arterial calcifications and stenosis among candidates for renal transplantation. MATERIAL AND METHODS: From December 1997 to March 2002, 114 HCTA scans with MIP reconstruction were performed in candidates for renal transplantation. Included patients fulfilled some of the following conditions: (a) older than 55 years, (b) diabetic, (c) second transplants, and (d) obvious vascular calcifications on plain abdominal x-ray. RESULTS: Among the 114 patients, 33 (29%) were excluded for transplantation due to universal calcification of the iliac arterial sector, and 81 (71%) were included on the waiting list due to the presence of calcium-free areas for the vascular anastomosis. Transplantation, which was attempted in 28 of the 81 patients, was successful in 25 using the area programmed after HCTA analysis. The transplants failed in three cases because no calcium-free area could be found upon surgical examination. CONCLUSION: HCTA with MIP reconstruction makes it possible to draw an exact map of the arterial calcifications of the iliac arterial sector, allowing better recipient selection and accurate planning for the vascular anastomosis and placement of the renal graft.

EAU guidelines on testicular cancer.

OBJECTIVES: To establish guidelines for the diagnosis, staging, treatment and follow-up of germ cell testicular cancer. METHODS: A search of published work was conducted using Medline. Highly evidence-based articles were selected and their findings analysed by the members of the Oncological Urology Working Group of the EAU. Testis cancer is rare and affects young men in their 3rd and 4th decades of life. The majority of these tumours are derived from germ cells (seminomatous and non-seminoma germ cell testicular cancer), and more than 50% of patients are diagnosed with stage I disease. Epidemiological, pathological and clinical risk factors are well established. The tumour, node, metastasis (TNM) staging system is endorsed, and for metastatic disease a recently devised prognostic-factor-based staging system has proven to be useful. Staging assessment includes pre- and post-orchiectomy marker levels, pathology of the testis, and nodal and visceral status. Following orchiectomy, treatment depends on the tumour type, pathological risk factors for stage I disease and clinical prognostic factors for advanced disease. The cure rate is excellent for disease stages I and II, irrespective of the treatment adopted. However, the pattern of relapse (rate, timing and site) is highly influenced by therapeutic policy. For metastatic disease, survival depends on clinical prognostic factors and treatment. Follow-up schedules are tailored according to stage, tumour type and post-orchiectomy treatment schedules. CONCLUSIONS: Excellent cure rates are achieved for early-stage germ cell testis tumours following accurate staging at diagnosis. Satisfactory survival rate can be achieved in advanced metastatic disease using a multidisciplinary therapeutic approach. Follow-up schedules vary, depending on the pathology and stage of the primary tumour and on the treatment policy adopted following orchiectomy.

Double versus single renal allografts from aged donors.

BACKGROUND: The age limit of the cadaver kidney donors is increasing in response to the growing demand for renal transplantation. Simultaneous double kidney transplantation (SDKT) with kidneys obtained from elderly adults has been proposed to increase the transplantation number and improve its results. However, if SDKT is performed when there are no clear indications, a negative effect could be produced on the total number of transplanted patients as both kidneys would be used for only one recipient. MATERIAL AND METHODS: In December 1996 we designed a transplantation protocol to be able to extend the selection of cadaver kidney donors with normal serum creatinine levels without establishing any age limit. A pregraft renal biopsy was always performed to analyze the glomerulosclerosis (GE) percentage whenever the donors were 60 years of age or older. A SDKT was performed in a single recipient when the donor age was 75 years or older or when the donors between 60 and 74 years old had a GE rate of more than 15%. On the contrary, a single kidney transplantation was performed in two different recipients for kidneys from donors between 60 and 74 years of age with a GE rate of less than 15%. Kidneys having GE rates of more than 50% were discarded for transplantation. Donor kidneys from subjects younger than 60 years of age were always used for a single kidney transplantation. RESULTS: Based on the above mentioned protocol, from December 1996 to May 1998, 181 patients received a kidney transplantation in our hospital. These patients were divided into three groups: group I which included the SDKT recipients (n=21), group II or single kidney recipients from 60- to 74-year-old donors (n=40), and group III or recipients from <60-year-old donors (n=120). The mean follow-up time was 15+/-5 months (range 6-24). Mean donor age was 75+/-7 years in group I, this was significantly higher than in group II (67+/-4, P<0.001) and group III (37+/-15, P<0.001). The primary nonfunction rate was low in the three groups, there being no statistically significant differences (5, 5, and 4%, respectively). A significantly greater percentage of patients from group I (76%) presented immediate renal graft function as compared with group II (43%, P<0.01) and III (50%, P<0.05). The acute rejections rate was very low in all three groups (9.5, 7.5, and 22%, respectively) with significant differences between groups II and III (P<0.05). No significant differences between the different groups were observed for one year actuarial patient survival (100, 95, and 98%, respectively) or graft survival rates (95, 90, and 93%, respectively). The 6-month serum creatinine levels were excellent in the three groups, although there were significant differences between groups I and II (1.6+/-0.3 vs. 1.9+/-0.6 mg/dl, P<0.05), II and III (1.9+/-0.6 vs. 1.4+/-0.4 mg/dl, P<0.001), and I and III (P<0.05). CONCLUSIONS: Simultaneous double kidney transplantations make it possible to use kidneys from extremely elderly donors (>75 years) or those whose GE>15%. In addition, kidneys from donor 60-74 years old in which the GE<15% can be used for single kidney transplantations in two different recipients with excellent results.