Enhancing Cushing's disease diagnosis: exploring the impact of desmopressin on ACTH gradient during BIPSS.

Introduction: The differential diagnosis between Cushing's disease (CD) and ectopic ACTH syndrome (EAS) is complex, and bilateral inferior petrosal sinus sampling (BIPSS) is considered the gold-standard test. However, BIPSS with corticotropin-releasing hormone (CRH) stimulation is rarely available. Objective: This retrospective cohort study aimed to assess the accuracy of the inferior petrosal sinus to peripheral ACTH gradient (IPS:P) before and after desmopressin stimulation for the differential diagnosis of ACTH-dependent Cushing's syndrome (CS), applying different cutoff values. Methods: A total of 50 patients (48 with CD and 2 with EAS) who underwent BIPSS were included in this study. The sensitivity and specificity of IPS:P in BIPSS before and after desmopressin stimulation were evaluated. Various cutoff values for IPS:P were examined to determine their diagnostic accuracy. Results: Using the traditional IPS:P cutoff, the sensitivity was 85.1% before stimulation, 89.6% after stimulation, and a combined sensitivity of 91.7%. Applying cutoff values of IPS:P >1.4 before and >2.8 after stimulation, the sensitivity was 87.2% and 89.6%, respectively, with a combined sensitivity of 91.7%. Receiver operating characteristic (ROC) curve analysis determined optimal cutoff values of 1.2 before stimulation and 1.57 after stimulation, resulting in a sensitivity of 93.6% and 93.8%, respectively, with a combined sensitivity of 97.9%. Specificity remained at 100% throughout all analyses. Among the 43 patients who responded positively to stimulation, 42 (97.7%) did so within the first three minutes, and all 43 (100%) did so within the first five minutes. None of the assessed clinical variables predicted the ACTH response to stimulation in BIPSS with statistical significance. Discussion: ACTH stimulation with desmopressin during BIPSS improves the accuracy of IPS:P, making it a valuable tool for investigating ACTH-dependent Cushing's syndrome. Considering the low risk of complications, we recommend the use of desmopressin stimulation during BIPSS for the differential diagnosis of ACTH-dependent CS.

Clinical outcomes of cystic fibrosis patients with hemoptysis treated with bronchial artery embolization.

OBJECTIVE: Massive hemoptysis is one of the most serious complications in patients with cystic fibrosis (CF). This study aimed to evaluate the hemoptysis-free period following bronchial and non-bronchial artery embolization (BAE/non-BAE) in CF patients and to investigate predictors of recurrent bleeding and mortality by any cause. METHODS: This was a retrospective cohort study of CF patients ≥ 16 years of age undergoing BAE/non-BAE for hemoptysis between 2000 and 2017. RESULTS: We analyzed 39 hemoptysis episodes treated with BAE/non-BAE in 17 CF patients. Hemoptysis recurrence rate was 56.4%. Of the sample as a whole, 3 (17.6%) were hemoptysis-free during the study period, 2 (11.8%) underwent lung transplantation, and 3 (17.6%) died. The median hemoptysis-free period was 17 months. The median hemoptysis-free period was longer in patients with chronic infection with Pseudomonas aeruginosa (31 months; 95% CI: 0.00-68.5) than in those without that type of infection (4 months; 95% CI: 1.8-6.2; p = 0.017). However, this association was considered weak, and its clinical significance was uncertain due to the small number of patients without that infection. CONCLUSIONS: BAE appears to be effective in the treatment of hemoptysis in patients with CF.

Clinical outcomes of cystic fibrosis patients with hemoptysis treated with bronchial artery embolization / Desfechos clínicos de pacientes com fibrose cística e hemoptise tratada por meio de embolização arterial brônquica

ABSTRACT Objective: Massive hemoptysis is one of the most serious complications in patients with cystic fibrosis (CF). This study aimed to evaluate the hemoptysis-free period following bronchial and non-bronchial artery embolization (BAE/non-BAE) in CF patients and to investigate predictors of recurrent bleeding and mortality by any cause. Methods: This was a retrospective cohort study of CF patients ≥ 16 years of age undergoing BAE/non-BAE for hemoptysis between 2000 and 2017. Results: We analyzed 39 hemoptysis episodes treated with BAE/non-BAE in 17 CF patients. Hemoptysis recurrence rate was 56.4%. Of the sample as a whole, 3 (17.6%) were hemoptysis-free during the study period, 2 (11.8%) underwent lung transplantation, and 3 (17.6%) died. The median hemoptysis-free period was 17 months. The median hemoptysis-free period was longer in patients with chronic infection with Pseudomonas aeruginosa (31 months; 95% CI: 0.00-68.5) than in those without that type of infection (4 months; 95% CI: 1.8-6.2; p = 0.017). However, this association was considered weak, and its clinical significance was uncertain due to the small number of patients without that infection. Conclusions: BAE appears to be effective in the treatment of hemoptysis in patients with CF.

RESUMO Objetivo: A hemoptise maciça é uma das complicações mais graves em pacientes com fibrose cística (FC). O objetivo deste estudo foi avaliar o período livre de hemoptise após a embolização arterial brônquica/não brônquica (EAB/não EAB) em pacientes com FC e investigar preditores de sangramento recorrente e mortalidade por qualquer causa. Métodos: Trata-se de um estudo retrospectivo de coorte de pacientes com FC com idade ≥ 16 anos submetidos a EAB/não EAB para o tratamento de hemoptise entre 2000 e 2017. Resultados: Foram analisados 39 episódios de hemoptise tratada por meio de EAB/não EAB em 17 pacientes com FC. A taxa de recidiva da hemoptise foi de 56,4%. Do total de pacientes, 3 (17,6%) permaneceram sem hemoptise durante o estudo, 2 (11,8%) foram submetidos a transplante de pulmão e 3 (17,6%) morreram. A mediana do período sem hemoptise foi de 17 meses. A mediana do período sem hemoptise foi maior em pacientes com infecção crônica por Pseudomonas aeruginosa (31 meses; IC95%: 0,00-68,5) do que naqueles sem esse tipo de infecção (4 meses; IC95%: 1,8-6,2; p = 0,017). No entanto, essa associação foi considerada fraca, e sua importância clínica foi considerada incerta em virtude do pequeno número de pacientes sem essa infecção. Conclusões: A EAB parece ser eficaz no tratamento de hemoptise em pacientes com FC.

Treatment strategies for locally advanced hepatocellular carcinoma.

Liver cancer ranks fifth in incidence and fourth in overall cancer-related mortality, with approximately 854,000 new cases and 810,000 deaths per year worldwide. Hepatocellular carcinoma (HCC) accounts for 90% of these cases, and, over time, both the incidence and mortality of this cancer have been rising in many regions. Several staging systems are used to assess the extent of primary tumor, presence of metastasis, and underlying liver disease, and thereby aid in the definition of treatment strategies and prognosis for these patients. The consequence of this heterogeneity in HCC staging is that no consensual definition of advanced disease exists, and there is still ongoing debate on the optimal treatment for these patients. Patients with advanced tumors can be candidates for multiple therapies, ranging from potentially curative options such as transplantation and resection-to locoregional and systemic treatments; these should be evaluated on an individual basis by a multidisciplinary team. This paper provides an overview of treatment options for advanced stage HCC, based on a review of the latest relevant literature and the personal experience of the authors.

Transarterial Embolization for Hepatocellular Carcinoma: A Comparison between Nonspherical PVA and Microspheres.

Transarterial chemoembolization (TACE) and transarterial embolization (TAE) have improved the survival rates of patients with unresectable hepatocellular carcinoma (HCC); however, the optimal TACE/TAE embolic agent has not yet been identified. The aim of this study was to compare the effect of two different embolic agents such as microspheres (ME) and polyvinyl alcohol (PVA) on survival, tumor response, and complications in patients with HCC submitted to transarterial embolization (TAE). Eighty HCC patients who underwent TAE between June 2008 and December 2012 at a single center were retrospectively studied. A total of 48 and 32 patients were treated with PVA and ME, respectively. There were no significant differences in survival (P = 0.679) or tumoral response (P = 0.369) between groups (PVA or ME). Overall survival rates at 12, 18, 24, 36, and 48 months were 97.9, 88.8, 78.9, 53.4, and 21.4% in the PVA-TAE group and 100, 92.9, 76.6, 58.8, and 58% in the ME-TAE group (P = 0.734). Patients submitted to TAE with ME presented postembolization syndrome more frequently when compared with the PVA group (P = 0.02). According to our cohort, the choice of ME or PVA as embolizing agent had no significant impact on overall survival.

Survival rates according to barcelona clinic liver cancer sub-staging system after transarterial embolization for intermediate hepatocellular carcinoma.

AIM: To investigate the survival rates after transarterial embolization (TAE). METHODS: One hundred third six hepatocellular carcinoma (HCC) patients [90 barcelona clinic liver cancer (BCLC) B] were submitted to TAE between August 2008 and December 2013 in a single center were retrospectively studied. TAE was performed via superselective catheterization followed by embolization with polyvinyl alcohol or microspheres. The date of the first embolization until death or the last follow-up date was used for the assessment of survival. The survival rates were calculated using the Kaplan-Meier method, and the groups were compared using the log-rank test. RESULTS: The overall mean survival was 35.8 mo (95%CI: 25.1-52.0). The survival rates of the BCLC A patients (33.7%) were 98.9%, 79.0% and 58.0% at 12, 24 and 36 mo, respectively, and the mean survival was 38.1 mo (95%CI: 27.5-52.0). The survival rates of the BCLC B patients (66.2%) were 89.0%, 69.0% and 49.5% at 12, 24 and 36 mo, respectively, and the mean survival was 29.0 mo (95%CI: 17.2-34). The survival rates according to the BCLC B sub-staging showed significant differences between the groups, with mean survival rates in the B1, B2, B3 and B4 groups of 33.5 mo (95%CI: 32.8-34.3), 28.6 mo (95%CI: 27.5-29.8), 19.0 mo (95%CI: 17.2-20.9) and 13 mo, respectively (P = 0.013). CONCLUSION: The BCLC sub-staging system could add additional prognosis information for post-embolization survival rates in HCC patients.

Maintenance of hemodialysis arteriovenous fistulas by an interventional strategy: clinical and duplex ultrasonographic surveillance followed by transluminal angioplasty.

OBJECTIVE: A native arteriovenous fistula (NAF) is a widely used access location for hemodialysis (HD). Monitoring of the NAF followed by percutaneous transluminal angioplasty (PTA) as needed may reduce the incidence of NAF failure according to nonrandomized studies. The aim of this randomized study was to determine whether an interventional strategy consisting of clinical and duplex ultrasonographic (DUS) surveillance of NAFs followed by PTA reduces the rate of the need of central venous dialysis catheters (CVCs) and NAF thrombosis in patients undergoing HD. METHODS: A total of 108 patients with 111 functioning NAFs in an HD program were randomized to control and interventional strategy groups. The control group received standard care: clinical and hemodynamic NAF assessment followed by vascular surgeon consultation in cases of dysfunction. In the interventional group, the patients underwent clinical monitoring and systematic DUS surveillance every 3 months. Cases with access dysfunction underwent angiography followed by PTA for stenosis of 50% or greater. Primary outcomes were the need of temporary CVCs and fistula thrombosis. RESULTS: Fifty-eight NAFs were randomized to the control group, and 53 were randomized to the interventional group. Groups had similar baseline characteristics. The interventional strategy showed a significant reduction in the CVC need (25.9% versus 7.5% for control and interventional groups, respectively; P = .021). No significant difference was observed for thrombosis rates (24.1% versus 17.0%; P = .487). The composite end point of NAF thrombosis or CVC need was reduced by the interventional strategy (44.8% versus 20.8%; P = .033). CONCLUSIONS: This randomized study indicates the benefit of a surveillance program for maintenance of NAFs based on clinical and DUS surveillance followed by PTA of major stenosis.

Malformação de veia cava inferior e trombose venosa profunda: fator de risco de trombose venosa em jovens / Inferior vena cava malformation and deep venous thrombosis: a risk factor of venous thrombosis in the young

A ausência da veia cava inferior, alteração no processo de formação embriológica que ocorre entre a sexta e a oitava semanas de gestação, é uma rara anomalia congênita. Porém, recentemente foi confirmada como sendo um fator de risco importante para o desenvolvimento de trombose venosa profunda, especialmente em jovens. Apresentamos um caso de trombose em veias cava inferior, ilíacas, femorais e poplíteas num jovem de 16 anos com agenesia de um segmento de veia cava infra-renal e veia renal esquerda retroaórtica.

Absence of inferior vena cava, caused by aberrant development within the sixth to eighth weeks of gestation, is a rare congenital anomaly. However, it has been recently confirmed as a major risk factor for the development of deep venous thrombosis, especially in young patients. We report a case of inferior vena cava, iliac, femoral and popliteal vein thrombosis in a 16-year-old patient with inferior vena cava agenesis and retroaortic left renal vein.

Abordagem percutânea das obstruçõesmalignas da via biliar através da colocação de endoprótese metálica / Percutaneous biliary metallic stents in the management of malignant biliary obstruction

Objetivos: Demonstrar o uso de endoprótese metálica por via percutânea no manejoda obstrução biliar neoplásica.Metodologia: De janeiro de 2004 a dezembro de 2005, 19 casos de obstrução malignairressecável das vias biliares foram encaminhados ao Serviço de Radiologia Intervencionistado Hospital da PUCRS para tratamento percutâneo, com média de idade de 65anos. A maioria dos pacientes apresentavam colangiocarcinoma, totalizando 63% dospacientes. A colocação de endoprótese (stent) metálica auto-expansível (STM) por viapercutânea foi realizada em 18 casos. Todos os casos foram seguidos mensalmente atravésde níveis de bilirrubina e fosfatase alcalina, bem como com controle ecográfico.Revisão colangiográfica foi indicada em pacientes com icterícia clínica ou laboratorial,sintomas de colangite ou evidência de dilatação das vias biliares. Patência primáriafoi considerada como o período entre a colocação do STM e a data de nova intervenção,percutânea ou cirúrgica. Patência primária assistida foi considerada como o período entrea colocação de STM até a morte ou perda do paciente no estudo sem a necessidade dederivação biliar cirúrgica.Resultados: Não houve complicações maiores relativas ao procedimento.Observou-se perviedade precoce de 100% durante controle colangiográfico em 72horas. Foram obtidos índices de patência primária de 94,4%, e de patência primária assistidade 94,4 %, sendo necessária reintervenção em 02 casos. Um deles foi encaminhado aprocedimento cirúrgico de ressecção tumoral e, em outro caso, foi realizada colangioplastiacom balão para desobstrução da prótese por obstrução após um período de 04meses. Nos demais casos, as endopróteses implantadas mantiveram-se pérvias até o óbitodos pacientes ou até o momento do seguimento.Conclusões: A colocação de STM é um procedimento seguro e efetivo no controle daicterícia obstrutiva nesse grupo de pacientes.

Purpose: To present the technical technique and results of the clinical use applicationof using an expandable metallic stents (EMS) for the treatment of to treat malignantbiliary obstruction.Materials and methods: Between January 2004 and December 2005, 19 cases patientswith unresectable malignant biliary obstruction were percutaneously treated in ourhospital. Sixty tree percent of the patients had colangiocarcinoma. Eigtheen pacientswere treated with EMS. Bilirubin and alkaline phosphatase levels were measured monthlyas well as imaging control with ultrasound. Primary patency rates were consideredbetween the EMS insertion and a percutaneous or surgical reintervention. Assisted primarypatency were considered between the EMS insertion and death or lost to follow-up.Results: There were no major procedure-related complications. Successful deploymentand initial patency of the device were achieved in 18 of 19 patients. Primary patencyrates were and assisted primary patency rates were 94,4%, too. Reintervention wasneccessary in 2 cases. In the others, the stents were effective until death or at the momentthis paper was written of writing.Conclusion: The EMS insertion is a safe and effective procedure.

Distúrbios das glândulas salivares / Diseases of the salivary glands

Os autores propõem uma revisão atual sobre os principais distúrbios das glândulas salivars, envolvendo aspectos relativos à anatomia, etiopatogenia, classificação, diagnóstico e tratamento dessas patologias

Vacina contra hepatite A: uma revisão atual da literatura / Hepatitis A vaccine: a current review of the literature

Os autores apresentam uma revisão da literatura sobre as vacinas da hepatite A atualmente disponíveis, enfocando indicações, esquemas de utilização, efeitos adversos e resultados obtidos em vários estudos. Além disso, fazem breve descrição da fisiopatogenia da doença e suas possíveis complicações. Cabe salientar que esta revisão teve como objetivo estabelecer, através de evidências científicas, as adequadas indicações para a utilização da vacina da hepatite A, bem como sugerir futuras pesquisas e discussões sobre a ampliaçã o de seu uso

Avaliaçäo dos pacientes com hérnia discal foraminal tratados cirurgicamente no Hospital Säo Lucas no período de 1990 a 1995 / Evaluation of patients with foramen disc hernia surgically treated at the Hospital Säo Lucas from 1990 to 1995

Os autores realizaram um estudo retrospectivo do período de março de 1990 a julho de 1995 dos pacientes com hérnia distal foraminal tratados cirurgicamente no Hospital Sao Lucas, da Pontifícia Universidade Católica do RS, em Porto Alegre. Foram avaliados 20 pacientes quanto aos aspectos epidemiológicos, clínicos e radiológicos, bem como a técnica cirúrgica utilizada. Dentre os casos, 65 por cento eram do sexo masculino e 35 por cento do feminino, com média de idade de 39,25 anos. O principal achado clínico foi a lombociatalgia, presente em 100 por cento dos casos. A TC foi o método de imagem mais utilizado para o diagnóstico das hérnias foraminais. Os níveis L4-L5 e L5-S1 estavam acometidos em 95 por cento dos pacientes estudados. A abordagem cirúrgica foi a interlaminar clássica em 95 por cento dos casos.