Paratiroidectomía en pacientes renales crónicos en Argentina: estudios prequirúrgicos, tipos de cirugía, recurrencia y persistencia / Parathyroidectomy in chronic kidney disease patients in Argentina: pre surgical studies, types of surgery, recurrence and persistence

La paratiroidectomía (PTx) es el tratamiento de elección en pacientes con HPT 2º severo, refractario al tratamiento médico. Se cuenta con muy poca información en Argentina de este procedimiento, por lo cual se realizó este estudio. Material y Métodos: Se incluyeron 255 pacientes con PTx entre el año 2003 al 2007 de un registro voluntario. Se evaluaron los estudios de localización prequirúrgicos, de laboratorio de metabolismo fosfocálcico previo y posterior a la cirugía y el tipo de técnica quirúrgica utilizada. Se analizó la persistencia y recidiva del HPT postcirugía. Resultados: La tasa de PTx fue de 2,7/1000 pacientes año. 83% de los pacientes tuvieron ecografía de cuello y 59% Sesta Mibi con Tc 99. Hubo una correlación positiva (p<0.001) entre el número de glándulas detectadas por ecografía y Sesta Mibi. La paratiroidectomía realizada fue: subtotal en 77%, total con autoimplante en 14% y total sin autoimplante en 9%. Hubo descensos significativos de Ca y P, fosfatasa alcalina y PTH (1744 ± 788 pg/ml a 247 ±450 pg/ml; p<0.0001) postcirugía. A los 2,4 ±2,5 meses de la PTx, el 72% de los pacientes tenía PTH <250 pg/ml, 19,8% tenía persistencia y 8,3% había recidivado. De acuerdo al tipo de cirugía la persistencia y recidiva fueron para PTx subtotal 22% y 8,3%, PTx total con implante 11% y 11% y PTx total sin autoimplante 13% y 4% respectivamente. La realización de Sesta Mibi no influyó en los resultados de la PTx. No se observaron diferencias entre los centros en relación con persistencia y recidiva. Conclusiones: La tasa de PTx fue muy baja, la ecografía fue el método de localización prequirúrgico preferido y la PTX subtotal la técnica quirúrgica más utilizada. La PTx fue exitosa en la mayoría de los pacientes y la persistencia y recidiva no estuvieron relacionadas con la técnica.

Parathyroidectomy (PTx) is the selecte treatment for patients with severe secondary hyperparathyroidism, refractory to medical treatment. There is not enough information about this procedure in Argentina, that is the reason why we performed this study. Material and Methods: 255 patients with PTx were included from the year 2003 to 2007 on a voluntary register. Studies of pre-surgical localization, phosphocalcic metabolism laboratories before and after surgery were evaluated, and the type of surgical technique used. The persistence and recurrence of post-surgical hyperparathyroidism was analyzed. Results: The PTx rate was 2,7/1000 patients year. 83% of the patients had neck echography and 59% Sestamibi scans with Tc 99. There was a positive correlation (p<0,001) between the number of detected glands by echography and Sestamibi. The parathyroidectomy performed was: subtotal in 77%, total with self-implant in 14% and total without self-implant in 9%. There were significant falls of Ca and P, Alkaline Phosphatase and PTH (1744±788 pg/ml to 247±450 pg/ml; p<0.0001) post-surgical. 2.4 ±2,5 months after the PTx, 72% of patients had PTH <250 pg/ml, 19,8% had persistence and 8,3% had recurrence. According to the type of surgery, the persistence and recurrence were for subtotal PTx 22% and 8,3%, total PTx with implant 11% and 11%, and total PTx without selfimplant 13% and 4% respectively. The performance of the Sestamibi scan did not affect the PTx results. No noticeable differences were observed among the centers for persistence and recurrence. Conclusions: The PTx rate was very low, echography was the preferred method of pre-surgical localization, and subtotal PTx was the most used surgical technique. PTx was successful in most of the patients, and persistence and recurrence were not related to the technique.

Preoperative chemoradiation with or without induction oxaliplatin plus 5-fluorouracil in locally advanced rectal cancer. Long-term outcome analysis.

BACKGROUND AND PURPOSE: It has been previously reported that a short FOLFOX-4 induction significantly improves pathologic complete response in locally advanced rectal cancer (LARC) patients treated with preoperative chemoradiation (CRT). In a larger and updated patient series, we analyzed FOLFOX-4 efficacy in terms of sphincter preservation and long-term outcomes. PATIENTS AND METHODS: From January 1995 to December 2010, 335 LARC patients were treated with preoperative chemoradiation (4500-5040 cGy). Starting in May 2001, 207 consecutive patients additionally received induction FOLFOX-4. Surgery was performed 6 weeks (range 3-12 weeks) after chemoradiation. RESULTS: Incidence of total tumor (63 vs. 54 %, p = 0.02) and nodal downstaging (60 vs. 43 %, p = 0.002) was significantly increased by induction FOLFOX-4. In an analysis of tumors located below 5 cm from the anal verge (n = 114, 34 %), sphincter preservation was feasible in 30 % in the FOLFOX-4 versus 13 % in the upfront CRT group (p = 0.04). Median follow-up time for the entire cohort of patients was 72.6 months (range 4-205 months). FOLFOX-4 was not associated with superior locoregional control (HR 0.88, p = 0.78), disease-free survival (HR 0.83, p = 0.55), distant metastases-free survival (HR 0.94, p = 0.81), or cancer-specific survival (HR 0.70, p = 0.15). CONCLUSION: Short-intense induction FOLFOX-4 significantly improves downstaging and sphincter preservation in low rectal tumors. Long-term outcomes were not improved in the FOLFOX-4 group of patients.

Post-chemoradiation anastomotic recurrence in locally advanced rectal cancer: no increased risk associated with distal margin.

BACKGROUND AND PURPOSE: Anastomotic recurrence after radical sphincter-preserving surgery preceded by neoadjuvant therapy in locally advanced rectal cancer is an uncommon event that merits further assessment. The aim of this study is to analyze the effect of preoperative chemoradiation on the risk of anastomotic recurrence. Based on the initial extension of the tumor, we analyzed whether the distal surgical section was calculated through the virtual initial extension of the rectal tumor. PATIENTS AND METHODS: Eligible patients with locally advanced rectal cancer were offered preoperative chemoradiation, sphincter sparing surgery and intraoperative radiation therapy boost. RESULTS: 180 patients were treated with anterior resection (40 %), low anterior resection (45.6 %) and ultra-low anterior resection (14.4 %). With a median follow-up of 41.1 months (0.36-143 months), anastomotic recurrence was diagnosed in 9 patients (5 %). There was no statistical correlation with downstaging (T or N), downsizing effects, or with distance from the lower limit of the residual lesion to the distal margin. Virtual intratumoral surgical section was speculated in 44 patients (3 developed anastomotic recurrence; 6.8 vs 4.8 %, p = 0.482). CONCLUSION: Anastomotic recurrence in patients with rectal cancer treated with neoadjuvant chemoradiation is an infrequent event. Virtual intratumoral surgical sections followed by anastomosis do not contribute to an excessive risk of recurrence. Our findings encourage the development of policies for preservation of the ano-rectal complex in rectal cancer patients.

Hipovitaminosis D en pacientes hemodiálizados (HD): factores relacionados e influencia sobre la fuerza muscular / Hypovitaminosis D in patients on hemodialysis (HD): related factors and influence on muscle strength

Introducción: La deficiencia de 25 (OH) vitamina D es una alteración prevalente en los pacientes con enfermedad renal crónica (ERC) , sin embargo en nuestro medio no es medida de manera rutinaria y por ende no suele hacerse reposición vitamínica. Nuestro objetivo fue determinar la prevalencia y los factores relacionados a deficiencia de 25 (OH) D en pacientes con ERC en hemodiálisis (HD), particularmente la relación con la función y masa muscular. Métodos: Efectuamos un estudio prospectivo, multicéntrico, en pacientes adultos en HD crónica que no estuvieran recibiendo ningún derivado de la vitamina D. Se midieron en sangre los niveles de 25(OH) D, Hemoglobina, PCR, Albúmina, Ca, P, FAL, PTHi. Se realizó la medición de la fuerza del puño con dinamómetro, y la prueba de sentado-parado. Se aplicó el índice de Karnofsky para clasificar el estado funcional., Se realizó una bioimpedanciometría (BCM; Frese nius Medical Care) en aquellos pacientes sin, contraindicación. Resultados: Se incluyeron 138 pacientes. La 25(OH) vitamina fue de 20.43 ± 10.5 ng/ml, la prevalencia de insuficiencia /defi ciencia 87% (37% con menos de 15 ng/ml). Las concentraciones de vitamina D/deficiencia mostraron correlación/relación significativa con la edad, la presencia de diabetes, los niveles de hemoglobina y albúmina, la fuerza y la masa muscular y la clase funcional (p<0.05) . Conclusión: Alta prevalencia de hipovitaminosis D en pacientes hemodializados particularmente gerontes y diabéticos. Esto estaría relacionado con la desnutrición, anemia, clase funcional y la fuerza/masa muscular de los pacientes, estos últimos dos factores no reportados hasta ahora. Todos estos factores deben ser considerados al momento de la sustitución vitamínica y en la evaluación de la efectividad de la misma.

Background: 25 (OH) vitamin D deficiency is a prevailing alteration in patients with chronic kidney disease (CKD); however, in our environment, it is not routinely measured and, therefore, vitamin replacement is unusual. Our purpose was assessing the prevalence of and the factors related to 25 (OH) vitamin D deficiency in patientswith CKD in hemodialysis (HD), especially the relation to function and muscle mass. Methods: We conducted a prospective, multicenter study in adult patients on chronic HD who were not receiving any vitamin D derivative. Blood levels of 25 (OH) D, Hemoglobin, CRP, Albumin, Ca,P, ALP and PTHi were measured. The handgrip strength was measured with a dynamometer and the sitting-rising test was carried out. A bioimpedance analysis (BCM; Fresenius Medical Care) was conducted in the patients who had no contraindications. Results: 138 patients were included. The levels of 25 (OH) vitamin D were 20.43±10.5 ng/ml; the insufficiency/deficiency had 87% prevalence (and 37% prevalence with less than 15 ng/ml). Vitamin D concentrations/ deficiency showed a significant correlation with/ relation to age, diabetes, hemoglobin and albumin levels, muscle strength and mass, and functional class (p<0.05). Conclusion: High prevalence of hypovitaminosis D in patients on hemodialysis, particularly in the elderly and in patients with diabetes. This should be related to undernutrition, anemia, the functional class and the muscle strength/mass of patients, the latter two being unreported factors until now. All these factors should be considered when vitamin replacement is conducted and when its effectiveness is assessed.

Results of European pooled analysis of IORT-containing multimodality treatment for locally advanced rectal cancer: adjuvant chemotherapy prevents local recurrence rather than distant metastases.

BACKGROUND: The purpose of this study is to analyze the pooled results of multimodality treatment of locally advanced rectal cancer (LARC) in four major treatment centers with particular expertise in intraoperative radiotherapy (IORT). PATIENTS AND METHODS: A total of 605 patients with LARC who underwent multimodality treatment up to 2005 were studied. The basic treatment principle was preoperative (chemo)radiotherapy, intended radical surgery, IORT and elective adjuvant chemotherapy (aCT). In uni- and multivariate analyses, risk factors for local recurrence (LR), distant metastases (DM) and overall survival (OS) were studied. RESULTS: Chemoradiotherapy lead to more downstaging and complete remissions than radiotherapy alone (P < 0.001). In all, 42% of the patients received aCT, independent of tumor-node-metastasis stage or radicality of the resection. LR rate, DM rate and OS were 12.0%, 29.2% and 67.1%, respectively. Risk factors associated with LR were no downstaging, lymph node (LN) positivity, margin involvement and no postoperative chemotherapy. Male gender, preoperatively staged T4 disease, no downstaging, LN positivity and margin involvement were associated with a higher risk for DM. A risk model was created to determine a prognostic index for individual patients with LARC. CONCLUSIONS: Overall oncological results after multimodality treatment of LARC are promising. Adding aCT to the treatment can possibly improve LR rates.

Metastatic crohn's disease--penile and scrotal involvement.

Crohn's disease is a chronic granulomatous disorder, which may involve any segment of the gastrointestinal tract from the mouth to the anus. Although extraintestinal manifestations are frequent, involvement of skin distant to the gastrointestinal tract is uncommon. We report a case of Crohn's disease affecting penile and scrotal skin.

The impact of influenza viruses on hospitalizations in infants younger than two years old during epidemics of respiratory syncytial virus infection.

In order to evaluate the association of influenza viruses with hospitalizations for acute respiratory infection in infants younger than two years old during epidemics of respiratory syncytial virus infection, we studied 512 nasal washes from this population. The samples were obtained from 1997 to 2000. A total of 337 viruses were isolated: 264 respiratory syncytial viruses, 62 influenza viruses, eight parainfluenza viruses, two adenovirus and one rhinovirus. Hospitalizations for acute respiratory infection were owing to influenza and respiratory syncytial viruses in 18.3% vs. 78.3% of all cases, and 32.5% vs. 65.8%, respectively, in the group of infants between 6 months and 2 years old.

Human rhabdomyosarcoma cells for rapid detection of enteroviruses by shell-vial assay.

The ability of the RD (rhabdomyosarcoma) and MRC-5 cell-lines to detect enteroviruses in 33 clinical samples (cerebrospinal fluid, stools and throat swabs) was evaluated. The samples had previously tested enterovirus-positive by traditional tube-culture and had been frozen after their initial processing. By traditional tube-culture, 100 and 85 % of samples were positive for enterovirus in RD and MRC-5 cells, respectively. By rapid shell-vial assay, 94 and 45.5 % were positive after 48 h incubation in RD and MRC-5 cells, respectively. RD cells supported growth of all enterovirus serotypes, whereas MRC-5 cells were not able to detect any of the three coxsackieviruses that were found (one coxsackievirus A9 and two coxsackievirus B5). The shell-vial assay with RD cell-lines may be a useful tool for rapid diagnosis of enteroviral infection.

[Low gastrointestinal bleeding due to ectopic varices as a result of adhesions]. / Hemorragia digestiva baja por varices ectópicas sobre bridas.

Portal hypertension frequently causes the appearance of porto-systemic shunts, such as esophageal varices and also, but with much less frequency, other atypical shunts known as ectopic varices. Despite their infrequency/rarity, ectopic varices can cause serious gastrointestinal bleeding. Intraabdominal adhesions, especially post-operative ones, promote their appearance. The therapeutic management of ectopic varices is initially the same as that for esophageal varices but surgical treatment is usually necessary as a diagnostic and therapeutic procedure.

[Bronchiectasia in HIV-positive patients]. / Bronquiectasias en pacientes HIV positivos.

Between July 1995 and July 1997 we diagnosed bronchiectasis confirmed by CT scan chest in 25 (18 men and 7 women) out of 295 hospitalised patients with HIV infection who suffered from lower respiratory infection. Median age at time of diagnosis of bronchiectasis was 32 years old. The patients were mostly intravenous drug addicts. In all cases a previous pulmonary infection was revealed (Pneumocystis carinii pneumonia, tuberculosis, recurrent pneumonia) with impairment of immune status (CD4 media = 64.8 mm3). Presence of persistent or intermittent cough with purulent sputum, repeated low respiratory infection and abnormal chest radiograph were correlated to bronchiectasis by chest CT scan. We conclude, that there is a significant occurrence of bronchiectasis in patients with HIV infections and pulmonary disease, thus increasing morbidity and mortality in these patients and being the cause of repeated hospitalisations due to bacterial respiratory infections.

Prevalencia de litiasis renal en la población general de la Ciudad de Buenos Aires - 1998 / Prevalence of urolithiasis in the general population of the City of Buenos Aires - 1998

El propósito de este estudio fue evaluar la prevalencia de litiasis renal en la población de la Ciudad de Buenos Aires. Se obtuvo una muestra probabilística de viviendas, y en cada vivienda se encuestó a todos los habitantes de ambos sexos y todas las edades, por medio de un Formulario Epidemiológico estructurado anónimo autoadministrado, averiguando sexo, edad, y si tenían o habían tenido antes una evidencia de padecer litiasis renal; para afirmar la existencia de litiasis se incluyeron otros datos confirmatorios. De 1086 encuestados 43 contestaron tener o haber tenido cálculos, todos ellos por haber recibido diagnóstico médico y además algunos por ver el cálculo al ser eliminado. Hubo diferencia en la tasa de prevalencia según sexo, con valores mayores en los varones, pero la diferencia no fue estadísticamente significativa. No se encontraron personas con litiasis en edades inferiores a los 20 años.

[Metabolic changes in 2612 patients with nephrolithiasis]. / Alteraciones metabólicas en 2612 pacientes con litiasis renal.

Nephrolithiasis is one of the most frequent pathologies of the urinary tract. Its prevalence in the city of Buenos Aires is 4%. Different biochemical and physiological disturbances may create an environment conductive to renal stone formation. We present the results of an ambulatory evaluation in 2612 patients for the purpose of updating the classification of nephrolithiasis. An abnormal urinary biochemistry was observed in 2423 patients (92.8%) that could be classified in 15 categories. A single diagnosis was documented in 61.5% of the patients, and the remaining 31.2% had more than one diagnosis (concurrent abnormalities). No abnormality was found in 189 stone formers (7.2%). Idiopathic hypercalciuria was the most frequent abnormality, it was encountered in 31.2%; hyperuricosuria and gouty diathesis (presence of urine pH < 5.5, with normal or high uricemia) accounted for 9.4% and 5.4% of patients, respectively. On the other hand, hypomagnesuria affected 6.7% of the stone formers and hypocitraturia was observed in 4.5%. Primary hyperparathiriodism, hyperoxaluria and cystinuria were seen less frequently in 2.6%, 1.3 and 0.45% of patients. Low urine volume was found in 12% of the patients. Among those patients with more than one abnormality, we found that hypercalciuria together with hyperuricosuria and hypocitraturia (12%) was the prevalent association followed by hypercalciuria with hyperuricosuria (9.1%). Our results show the importance of studying nephrolithiasis patients from a biochemical point of view, since this is the only way to achieve a diagnosis of the metabolic abnormality and introduce a specific therapy to prevent recurrence.

Squamous cell carcinoma complicating perianal hidradenitis suppurativa.

Hidradenitis suppurativa or Verneuil's disease is usually a chronic, recurrent, suppurative and cicatricial disorder. It most often affects the skin of the axillae, groins and perineum, and less commonly the buttocks and upper thighs. A squamous cell carcinoma located in the hidradenitis-affected area is a rare complication. We present a review of the twenty-six published cases adding one of our own.