[30 year-old patient with multiple pelvic lesions and fecal incontinence]. / Multiple Raumforderungen bei einem 30-Jährigen mit Stuhlinkontinenz.

In a 30 year-old patient with subacute loss of bowel control and perianal anesthesia radiologic examination showed multiple bone lesions. The results of a bone marrow aspiration showed acute myeloid leukemia M2 with translocation t(8,21) associated with granulocytic sarcoma. The patient was treated with high dose chemotherapy and had a complete remission after autologous stem cell transplantation.

[Stress urinary incontinence surgical correction with third generation sub-mid-urethra sling: TVT-secur]. / Corrección quirúrgica de la incontinencia de orina de esfuerzo, con cinta sintética sub-medio-uretral de tercera generación: TVT-Secur.

OBJECTIVE: To review our initial experience with the new system TVT-Secur for the stress urinary incontinence. To evaluate the feasibility, efficacy and main advantages of the surgical correction with the new device. METHOD: Between January and May of 2007, 16 TVT-Secur (Women's Health & Urology, Ethicon, Johnson & Johnson) were made in patients of the Urogynecology Unit, of Clinica Las Condes. Six TVT-Secur were applied in "V" and 10 in "U". The median age was 52 years old, BMI 29, parity of 3. All patients were studied with urodynamic before surgery. All must have the urinary incontinence by more of one year and no must have previous surgical correction. RESULTS: The media surgical time was 10 minutes (8-15 minutes). Complications were not registered during intraoperative and immediate, early or delayed postoperative time. The visual analogue scale of pain was 1 to 2 at 12 hours. All patients were cured. The follow-up was between 1 and 4 months, 2 month media. All patients expressed satisfaction with the surgical results and they would recommend it to other patients in the same conditions. CONCLUSION: According to our initial experience, the new system TVT-Secur is feasible, safe and effective in the surgical correction of the SUI. However, only the long follow-up and the incorporation of new patients to the study, will allow to determine the permanence of these good results in the time.

[Occult stress incontinence identified by preoperative urodynamic study in women with severe pelvic organ prolapse]. / Incontinencia urinaria oculta evidenciada por estudio urodinámico preoperatorio en pacientes con prolapso genital severo.

OBJECTIVE: To review the effectiveness of preoperative urodynamic study made with correction of the severe genital prolapse by Bresky valve in the diagnosis of urinary occult incontinence, in order to plan a correction with a prophylactic sub-mid urethral mesh in the prolapse surgery. PATIENTS AND METHOD: Patients of the Urogynecology and Vaginal Surgery Unit of Las Condes Clinic, between January 2006 and December 2007, with grade III or IV cystocele. A condition was patients without previous prolapse and/or incontinence surgeries. A non multichannel urodynamics test was made with prolapse correction by a Bresky valve. The urethra retro resistance measurement and cystometry was made. In the women in whom the occult urinary incontinence was discards the prolapse surgery was made with Prolift mesh. In the women with occult incontinence a prophylactic sub-mid urethral tape was applied in the prolapse surgery, to avoid the appearance of incontinence after surgery. RESULTS: Thirty eight women fulfilled the criterion to enter in this study, 14 (36.8%) of them did not register occult urinary incontinence in the urodynamic test. In the 24 (63.2%) with occult incontinence: Type I in 1: type II in 2: type III in 1 and type II+III in 10. During the cystometry 3 of them registered an asymptomatic hyperactive detrusor. In 1 (4.2%) of the 24 patients with prophylactic incontinence surgery, in the immediate postoperative time a failure was observed. The rest 23 women did not present incontinence during the observation period between 4 to 24 months. In the 14 women only with prolapse surgery incontinence was not registered. CONCLUSIONS: The preoperative urodynamic test with correction of severe genital prolapse by Bresky valve is an efficient method to detect the occult urinary incontinence. This allows planning a prophylactic incontinence surgery. According to our experience this method is safe and effective to avoid that the occult incontinence appears after a severe cystocele surgery repair and allows to given an integral solution to the pelvic floor problems that frequently sees associate, because they risk factors are the same to these conditions and both cause a high degree of deterioration of quality of life.

[Prolift system in the correction of female genital prolapse]. / Sistema Prolift en la corrección del prolapso genital femenino.

OBJECTIVE: To review the security and effectiveness of female genital prolapse using the new Prolift system. PATIENT AND METHOD: Prospective study of 41 patients that have been submitted to correction of cystocele and/or rectocele or vaginal cuff, between July of 2006 and May of 2007 in the Urogynecology and Vaginal Surgery Unit of Clínica Las Condes. The period of observation was completed at July of 2007. RESULT: Anterior Prolift mesh was used in 29 cystocele: 13 degree II, 14 degree III and 3 degree IV. Thirty rectocele: 12 degree II, 16 degree III and 3 degree IV. Five cases of vaginal cuff prolapse (total mesh): 1 degree II and 4 degree IV. The media time of surgery was 40 minutes for anterior Prolift (30 to 50 minutes); 30 minutes (20 to 40 minutes) for posterior Prolift and 60 minutes for Total Prolift. They did not present intraoperative complications. During the immediate postoperative time a case of peri-rectal hematoma was observed in a patient with posterior mesh for the rectocele correction. It was treated with oral anti-inflammatory. During the delayed postoperative time a case of vaginal erosion and mesh exposition (0.5 centimeters) was observed in a case of vaginal cuff prolapse treated with a Total Prolift. Two asymptomatic recidivate vaginal cuff prolapse were registered; degree IV to III and a case degree IV that was recidivate to cystocele degree II. The visual analogue scale of pain in Anterior Prolift was 3-4 at 12 hours, 2 at 24 hours and 1 at 48 hours. In Posterior Prolift was 4-6 at 12 hours, 3-4 at 24 hours and 1-2 at 48 hours. In cases with Anterior and Posterior Prolift and in Total Prolift the results were the same of Posterior Prolift. All patients indicated satisfaction in the follow-up at 30 days. The media follow up in the 41 patients was 7 months (range of 2 to 12 months). CONCLUSION: According to our experience the correction of the female genital prolapse with Prolift system is safe and effective; nevertheless a long follow-up is required to observe the good results in the time.

[Trans obturator tape (TOT) for female stress incontinence. Experience with three years follow-up in 200 patients]. / Cinta trans-obturadora (TOT) en la corrección de la incontinencia de orina de esfuerzo. Experiencia de tres años con 200 pacientes.

OBJECTIVE: To evaluate the security and effectiveness of the TOT in the female incontinence surgical treatment according to our experience. PATIENT AND METHOD: Prospective study of 200 patients underwent TOT at Gynecology Unit of the Obstetrics and Gynecology Department in Barros Luco-Trudeau Hospital between January 2003 and October 2006. Polypropilene, macropore, mofilament mesh (Prolene) was used. The mean age was 52 years old, parity 3. RESULTS: The mean surgical time of TOT was 15 minutes. In 184 (92%) patients obtained cure, 6 (3%) improvement and 10 (5%) fails. Three cases of bladder injury occurred (one perforation with the scissor and two with TOT needle during the learning phase). During the immediately postoperative time: one case of partial urethral obstruction, two cases of urinary infection and three with pain of the legs. During the delayed postoperative time a case of fail was observed after trauma. CONCLUSION: According to our experience with 200 cases, the TOT appears as a safe and effective technique in the surgical treatment of the stress urinary incontinence.

[Minimal invasive surgery in female urinary incontinence: TVT-O]. / Cirugía mínimamente invasiva en la incontinencia urinaria femenina: TVT-O.

OBJECTIVE: We presented our experience in the application of Tvt-O, a surgical a new technic for SUI. METHOD: Between April and December 2004, 96 patients underwent Tvt-O surgery, in Uroginecology and Vaginal Surgery Unit of the Gynecology and Obstetrics Department, Las Condes Clinic. Median age was 54 years old, weight 65 kgs. Urodinamia test: SUI II 80 cases, SUI III 4, SUI 0 in 3, and mixed urinary incontinence 9. Gynecare TVT Obturator System technique was used, Ethicon Johnson & Johnson. It has three specific instruments: helical passers, plastic tubes fixed to mesh of prolene, and a guide for the introduction of the needle. RESULTS: Media time was 7 minutes (4 to 15). Other gynecological surgery was associated in 77 (80%). Complications did not appear during the surgical act. No injury to bladder and urethra was observed. We observed in immediate postoperative period only one complication (1.04%). It was urinary retention. One complication appeared (1.04%) in remote postoperative period, corresponding polypropylene tape exposition in the anterior vaginal wall. SUI solution was obtained in 100% of patients. The medium time of observation is 6 months, 51 cases have more than 6 months of observation. DISCUSSION: Tvt-O is a surgical SUI correction technique with promissory results. Like the other types of TOT, their effectiveness will have in the long term to be evaluated.

[Tension free monofilament polypropylene mesh in cystocele and rectocele concomitant repair]. / Malla de polipropileno monofilamento libre de tensión en la reparación concomitante de cistocele y rectocele.

OBJECTIVE: We presented our experience in the concomitant correction of cystocele and rectocele with polypropylene monofilament mesh (Gynemesh PS), with transvaginal free tension technique. METHOD: During 2004 correction was made in 7 patients, Urogynecologic and Vaginal Surgery Unit of Gynecology and Obstetrics Department, Las Condes Clinic. Medium age 54 years old, weight 64 kgs. In four patients we used a third mesh for correction of urinary incontinence by TVT-O. RESULTS: They don't present intraoperative complications, neither in immediate or delayed postoperative time. We not observed hematoma, infection, erosion or exposition mesh. Cure of cystocele and rectocele was in the 100% of patients. Complications have not appeared, 4 cases completed three months of observation, 2 cases two months and 1 case one month. DISCUSSION: The use of protesic polypropylene multifilament macropore mesh in the concomitant correction of cistocele and rectocele, by transvaginal route with tension free technique seems to be a safe and effective surgery procedure.

Group Singing as a Therapy during Diabetes Training--A Randomized Controlled Pilot Study.

Comprehensive diabetes treatment has been shown to reduce quality of life in diabetic patients. However, there is evidence to suggest that group singing can have positive effects on quality of life in various clinical settings. In this randomized controlled pilot study, the effect of singing as a therapy to reduce stress and improve quality of life was investigated in insulin-dependent diabetic patients, undergoing a lifestyle intervention program. Patients from the singing group felt less discontented following treatment. This effect, however, was lost after 3 months. No effect on serum cortisol and plasma adrenocorticotropic hormone (ACTH) levels could be seen when comparing the singing group with the control group, although reduced levels of ACTH and cortisol 3 days after treatment could be found and were still present after 3 months within the group of patients who undertook singing as a therapy. Singing led to an increase in bodyweight, which interestingly had no effect on glucose control or methylglyoxal levels. Therefore, singing during a lifestyle intervention program for insulin-dependent diabetic patients had a short lasting and weak effect on patients' mood without affecting glucose control, but no significant effect on stress related hormones.

Validation of WHO classification-based Prognostic Scoring System (WPSS) for myelodysplastic syndromes and comparison with the revised International Prognostic Scoring System (IPSS-R). A study of the International Working Group for Prognosis in Myelodysplasia (IWG-PM).

A risk-adapted treatment strategy is mandatory for myelodysplastic syndromes (MDS). We refined the World Health Organization (WHO)-classification-based Prognostic Scoring System (WPSS) by determining the impact of the newer clinical and cytogenetic features, and we compared its prognostic power to that of the revised International Prognostic Scoring System (IPSS-R). A population of 5326 untreated MDS was considered. We analyzed single WPSS parameters and confirmed that the WHO classification and severe anemia provide important prognostic information in MDS. A strong correlation was found between the WPSS including the new cytogenetic risk stratification and WPSS adopting original criteria. We then compared WPSS with the IPSS-R prognostic system. A highly significant correlation was found between the WPSS and IPSS-R risk classifications. Discrepancies did occur among lower-risk patients in whom the number of dysplastic hematopoietic lineages as assessed by morphology did not reflect the severity of peripheral blood cytopenias and/or increased marrow blast count. Moreover, severe anemia has higher prognostic weight in the WPSS versus IPSS-R model. Overall, both systems well represent the prognostic risk of MDS patients defined by WHO morphologic criteria. This study provides relevant in formation for the implementation of risk-adapted strategies in MDS.

Monosomal karyotype in MDS: explaining the poor prognosis?

Monosomal karyotype (MK) is associated with an adverse prognosis in patients in acute myeloid leukemia (AML). This study analyzes the prognostic impact of MK in a cohort of primary, untreated patients with myelodysplastic syndromes (MDS). A total of 431 patients were extracted from an international database. To analyze whether MK is an independent prognostic marker in MDS, cytogenetic and clinical data were explored in uni- and multivariate models regarding overall survival (OS) as well as AML-free survival. In all, 204/431 (47.3%) patients with MK were identified. Regarding OS, MK was prognostically significant in patients with ≤ 4 abnormalities only. In highly complex karyotypes (≥ 5 abnormalities), MK did not separate prognostic subgroups (median OS 4.9 months in MK+ vs 5.6 months in patients without MK, P=0.832). Based on the number of abnormalities, MK-positive karyotypes (MK+) split into different prognostic subgroups (MK+ and 2 abnormalities: OS 13.4 months, MK+ and 3 abnormalities: 8.0 months, MK+ and 4 abnormalities: 7.9 months and MK+ and ≥ 5 abnormalities: 4.9 months; P<0.01). In multivariate analyses, MK was not an independent prognostic factor. Our data support the hypothesis that a high number of complex abnormalities, associated with an instable clone, define the subgroup with the worst prognosis in MDS, independent of MK.

Survival, prognostic factors and rates of leukemic transformation in 381 untreated patients with MDS and del(5q): a multicenter study.

Myelodysplastic syndromes (MDS) with del(5q) are considered to have a benign course of the disease. In order to address the issue of the propensity of those patients to progress to acute myeloid leukemia (AML), data on 381 untreated patients with MDS and del(5q) characterized by low or intermediate I International Prognostic Scoring System (IPSS) risk score were collected from nine centers and registries. Median survival of the entire group was 74 months. Transfusion-dependent patients had a median survival of 44 months vs 97 months for transfusion-independent patients (P<0.0001). Transfusion need at diagnosis was the most important patient characteristic for survival. Of the 381 patients, 48 (12.6%) progressed to AML. The cumulative progression rate calculated using the Kaplan-Meier method was 4.9% at 2 years and 17.6% at 5 years. Factors associated with the risk of AML transformation were high-risk World Health Organization adapted Prognostic Scoring System (WPSS) score, marrow blast count >5% and red-cell transfusion dependency at diagnosis. In conclusion, patients with MDS and del(5q) are facing a considerable risk of AML transformation. More detailed cytogenetic and molecular studies may help to identify the patients at risk of progression.

Impact of adjunct cytogenetic abnormalities for prognostic stratification in patients with myelodysplastic syndrome and deletion 5q.

This cooperative study assessed prognostic factors for overall survival (OS) and risk of transformation to acute myeloid leukemia (AML) in 541 patients with de novo myelodysplastic syndrome (MDS) and deletion 5q. Additional chromosomal abnormalities were strongly related to different patients' characteristics. In multivariate analysis, the most important predictors of both OS and AML transformation risk were number of chromosomal abnormalities (P<0.001 for both outcomes), platelet count (P<0.001 and P=0.001, respectively) and proportion of bone marrow blasts (P<0.001 and P=0.016, respectively). The number of chromosomal abnormalities defined three risk categories for AML transformation (del(5q), del(5q)+1 and del(5q)+ ≥ 2 abnormalities) and two for OS (one group: del(5q) and del(5q)+1; and del(5q)+ ≥ 2 abnormalities, as the other one); with a median survival time of 58.0 and 6.8 months, respectively. Platelet count (P=0.001) and age (P=0.034) predicted OS in patients with '5q-syndrome'. This study demonstrates the importance of additional chromosomal abnormalities in MDS patients with deletion 5q, challenges the current '5q-syndrome' definition and constitutes a useful reference series to properly analyze the results of clinical trials in these patients.

Tolerability of the cytoprotective agent amifostine in elderly patients receiving chemotherapy: a comparative study.

In order to determine if age and comorbidity influence the tolerability of the cytoprotective agent amifostine, we compared side effects related to amifostine in patients > or = 70 years (group I) with patients < 70 years (group II). We evaluated 268 consecutive administrations of amifostine (119 in group I and 149 in group II, respectively), given i.v. at a dose of 740 mg/m(2) just before platinum-, taxol- or cyclophosphamide-based chemotherapy. Transient hypotension was the most common side effect occurring in association with amifostine. Decreases in systolic blood pressure > 20 mmHg were of similar frequency in both groups (27.1 versus 28.8% of amifostine infusions in group I and II, respectively). Hypotension did not result in medical sequelae in any of the patients. The amifostine infusion was interrupted 16 times in group I and 8 times in group II, respectively, mainly due to hypotension, but could be restarted after a few minutes in all patients except for three cases in group I. Patients in group II more often suffered from nausea/vomiting than in group II (20.8 versus 10.0% in group I). Other subjective symptoms (e.g. warmed, flushed sensation, sneezing, metallic taste, mouth dryness, dizziness and sleepiness) and hypocalcemia occurred with a similar frequency in both groups. Adverse effects associated with amifostine were not observed more frequently in elderly patients than in younger ones, although more elderly patients had a comorbidity than the younger ones.