Malignant Peritoneal Mesothelioma as a Rare Cause of Dyspeptic Complaints and Ascites: A Diagnostic Challenge.

INTRODUCTION: Malignant peritoneal mesothelioma (MPM) is a rare malignancy of the mesothelial cells in the peritoneum. The best-defined risk factor is asbestos exposure, but germline mutations in BAP1 also increase susceptibility to this tumor. The diagnosis of MPM is challenging since clinical manifestations are often nonspecific. CASE PRESENTATION: We describe a case of MPM in a 53-year-old former construction worker with prior asbestos exposure. The clinical presentation was a 3-month history of dyspeptic complaints. As initial workup, abdominal ultrasound and upper gastrointestinal endoscopy were performed. Chronic gastritis due to Helicobacter pylori was detected, which was promptly treated but without symptom relief. Abdominal ultrasound showed small volume ascites with hyperechogenic foci, which was later confirmed on computed tomography scan showing the presence of peritoneal nodules in the greater omentum and mesentery. A thorough investigation was conducted based on the suspicion of peritoneal carcinomatosis. A non-peritoneal primary tumor was not found. Ascitic cytology and immunocytochemical studies were suggestive of mesothelioma. He underwent exploratory laparotomy and inoperable peritoneal disease was observed. Peritoneal biopsy confirmed epithelioid-type MPM. Systemic therapy was initiated with platinum plus pemetrexed with good response. The last follow-up was 38 months after the diagnosis. DISCUSSION/CONCLUSION: The diagnosis of MPM is challenging since it requires a high degree of suspicion. MPM has a poor prognosis. The standard of treatment recommended is cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. For those who are inoperable, systemic therapy with pemetrexed-cisplatin combination is the alternative. Given the infrequency of disease, it is imperative to ensure patient participation in clinical trials with the purpose of treatment standardization.

INTRODUÇÃO: O mesotelioma peritoneal maligno (MPM) é uma neoplasia rara das células mesoteliais no peritoneu. O fator de risco mais estabelecido é a exposição aos asbestos, mas as mutações germinativas BAP1 também aumentam a suscetibilidade a esse tumor. O diagnóstico é desafiador, uma vez que as manifestaçõs clínicas são frequentemente inespecíficas. CASO CLÍNICO: Reporta-se o caso de um homem de 53 anos, ex-trabalhador da construção civil, com história de exposição a asbestos. O doente apresentava um quadro de queixas dispépticas com 3 meses de evolução. Para estudo inicial, foram realizadas ecografia abdominal e endoscopia digestiva alta. Na endoscopia foi documentada gastrite crónica por Helicobacter pylori tendo feito tratamento de erradicação, mas sem melhoria sintomática. A ecografia abdominal revelou ascite de pequeno volume com focos hiperecogénicos em suspensão, o que foi posteriormente confirmado em tomografia computorizada, demonstrando a presença de nódulos peritoneais no grande epíplon e mesentério. Uma investigação exaustiva foi conduzida na suspeita de carcinomatose peritoneal, mas não foi encontrado nenhum tumor primário noutra localização. A citologia do líquido ascítico e os estudos imunocitoquímicos foram sugestivos de mesotelioma. O doente foi submetido a uma laparotomia exploradora na qual se documentou doença peritoneal inoperável. A biópsia peritoneal confirmou MPM do tipo epitelióide. Foi iniciado tratamento de quimioterapia com platino em associação com pemetrexed, com boa resposta. Seguimento atual de 38 meses pós-diagnóstico. DISCUSSÃO/CONCLUSÃO: O diagnóstico de MPM é desafiante uma vez que requer um alto grau de suspeição. MPM tem um prognóstico reservado. O tratamento standard recomendado é a cirurgia citorredutora com a quimioterapia intraperitoneal hipertérmica. No entanto, nos doentes inoperáveis, a alternativa é a quimioterapia sistémica com pemetrexed-cisplatina. Dada a raridade da doença, é imperativo integrar estes doentes em ensaios clínicos com o objetivo de padronização do tratamento.

Disseminated Bacillus Calmette-Guérin (BCG) infection with pulmonary and renal involvement: A rare complication of BCG immunotherapy. A case report and narrative review.

Intravesical Bacillus Calmette-Guérin (BCG) instillation is a mainstay of adjunctive therapy for superficial bladder cancer that increases length of disease progression-free survival. Although usually well tolerated, moderate to severe local and systemic infectious complications can occur with this immunotherapy. Diagnosis is difficult and often based on high clinical suspicion since in many cases Mycobacterium bovis is not isolated. Treatment is not fully standardized but the combination of anti-tuberculosis drugs and corticosteroids is advocated in severe cases. The authors present an unusual case of a severe infectious complication following intravesical BCG instillation with pulmonary and kidney involvement. Prompt anti-tuberculosis treatment associated to corticosteroid resulted in a marked clinical and radiological improvement, supporting the diagnosis of disseminated BCG infection. Based on this, the authors aimed to review the literature on this exceptional complication of this immunotherapy.

[The Short Nicotine Dependence Syndrome Scale (NDSS-S) in Spanish smokers]. / La escala breve de evaluación del Síndrome de Dependencia de la Nicotina (NDSS-S) en fumadores españoles.

We present a brief scale derived from the Nicotine Dependence Syndrome Scale (NDSS). We used a sample of 1.061 daily smokers, which was obtained from five Primary Care Health Centers, a Unit of Alcoholism, and a Smoking Cessation Unit. All smokers were evaluated with the NDSS and the SCID to assess nicotine dependence according to DSM-IV criteria. The results indicate the existence of a general factor of nicotine dependence according to the NDSS. We selected the items with a higher factor loading (>.50), obtaining a short scale of 6 items. With this brief scale, we obtained results similar to those of the total scale in the diverse variables (sociodemographic and smoking) of the study. Scale reliability is satisfactory (a= .79), the correlation between the short and the total scale is very high (r=.95, p<.001) and the short scale discriminates the smokers in terms of cigarette consumption and nicotine dependence, as assessed with the SCID. The operation under the ROC curve is excellent (area under the curve .84). The data indicate the usefulness of this brief scale (NDSS-S) to assess nicotine dependence in smokers.

[Psychometric properties of the Nicotine Dependence Syndrome Scale (NDSS) in a sample of smokers treated for their alcohol dependence]. / Propiedades psicométricas de la Escala del Síndrome de Dependencia de la Nicotina (NDSS) en una muestra de fumadores que solicitan tratamiento por su dependencia del alcohol.

The assessment of nicotine dependence with brief instruments is of great relevance for the better detection of this disorder. Here we present the results with the Nicotine Dependence Syndrome Scale (NDSS) by Shiffman, Waters and Hickcox (2004) in a sample of 183 patients treated at an Alcohol Dependence Unit who were also cigarette smokers. The results indicate that the general factor which evaluates nicotine dependence (NDSS-T) has good reliability (Cronbach's alpha = 0.80). Factor analysis identifies four of the five factors proposed in the original version, those of drive, priority, continuity and stereotypy. Reliability of the scales derived ranges from very good (0.80) to moderate (0.63). The NDSS-T correlates significantly with the Fagerström Tolerance Questionnaire (FTQ), with the DSM-IV criteria for nicotine dependence assessed through the SCID, and with the number of cigarettes smoked per day. The ROC curves indicate an NDSS-T score of 0.80 under the curve (0.70 for the FTND), showing that it adequately predicts nicotine dependence. This study confirms the utility of this new instrument for assessing nicotine dependence in smokers who also abuse or depend upon alcohol.

Prostatic stromal cells derived from benign prostatic hyperplasia specimens possess stem cell like property.

INTRODUCTION: The hyper-proliferative activity of stromal smooth muscle (SM) cells is believed to be responsible for the pathogenesis of benign prostatic hyperplasia (BPH). We have observed that those stromal cells can differentiate into unrelated specialized cells. We thus hypothesize that stromal cells derived from adults prostate specimens may contain adult stem cells. To test this hypothesis, human prostate stromal primary cultures were established and used for characterization of their stem cell properties. METHODS: Immunoblotting, immunohistochemistry, RT-PCR, and tissue culture techniques were used to characterize the primary cultured human prostate-derived stromal cells for their stem cell and differentiation properties. The plasticity of these stromal cells was analyzed using cell culture and histology techniques. RESULTS: Primary cultured prostate stromal cells from BPH patient possess polygonal and elongated fibroblast/myofibroblast cellular morphology. They are positive in CD30, CD34, CD44, NSE, CD133, Flt-1, stem cell factor (SCF), and neuron-specific enolase (NSE), but negative in C-Kit, stem cell antigen (SCA), SH2, CD11b. Expression of SM myogenic markers in these cells may be induced by sodium butyrate (NaBu) treatment. Induction to osteogenic and adipogenic differentiation in these cells is also evident. CONCLUSIONS: Our study on primary stromal cells from BPH patients have yielded many interesting findings that these prostate stroma cells possess: (1) mesenchymal stem cell (MSC) markers; (2) strong proliferative potential; and (3) ability to differentiate or transdifferentiate to myogenic, adipogenic, and osteogenic lineages. These cell preparations may serve as a potential tool for studies in prostate adult stem cell research and the regulation of benign prostatic hyperplasia.

Elastin expression and elastic fibre width in the anterior vaginal wall of postmenopausal women with and without prolapse.

OBJECTIVES: To compare elastin expression and elastic fibre width in the anterior vaginal wall of postmenopausal women with and with no bladder prolapse. PATIENTS AND METHODS: Full-thickness specimens were obtained from the upper lateral anterior vaginal wall of women having a large cystocele repaired (stage III or IV; prolapse group, 33) and the same location in patients with no prolapse having radical cystectomy (control group, 10). The percentage of elastin-positive tissue and elastic fibre width were measured by immunohistochemistry on 6 microm thick tissue sections from 10 random field readings per sample using image analysis software. The examiner was unaware of sample identity and the patients' clinical history. RESULTS: The age was comparable between the control and prolapse groups (median 70.5 years), and the parity, vaginal deliveries, hormone replacement use, cigarette smokers and body mass index were no different between the groups. Immunohistochemical staining and morphometric analysis indicated that elastin expression in the prolapse group was 10.6%, vs 14.4% in the control group (P = 0.049). The median width of elastic fibres was 0.9 microm in the prolapse and 1.8 microm in the control groups (P < 0.001). Elastin expression and elastic fibre width appeared to be stable with increasing age in the prolapse group. CONCLUSIONS: In this case-control study investigating elastin changes in postmenopausal women with prolapse, the elastin expression and fibre width were significantly lower in the vaginal wall of patients with a large cystocele than in controls of a similar age.

Alpha(2) macroglobulin, a PSA binding protein, is expressed in human prostate stroma.

BACKGROUND: Benign prostatic hyperplasia (BPH) is characterized as a stromal process. The stroma smooth muscle (SM) may alter its phenotype during the progression of BPH. We have identified gene transcripts that may be differentially expressed in BPH using a differential display method. Among the fragments isolated, alpha(2) macroglobulin (alpha(2)-M) is one of the most interesting. alpha(2)-M is a binding protein of a variety of proteinases, including prostatic specific antigen (PSA). It also plays roles in molecular trapping and targeting. In this study, we characterized alpha(2)-M expression in the human prostate. METHODS: Differential display was used to identify and isolate the differentially expressed transcripts between normal prostate and BPH tissues. RT-PCR, Western blot, in situ hybridization, and immunohistochemistry were utilized to confirm and characterize alpha(2)-M expression in the prostate. RESULTS: Real-time RT-PCR results revealed that a 3.2-fold increase in alpha(2)-M mRNA expression is observed in BPH compared with normal prostate tissue. A 1.9-fold increase at protein level was also observed. In situ hybridization and immunohistochemistry showed that alpha(2)-M expression is primarily localized to the stromal compartment. Cultured primary stroma cells maintained alpha(2)-M expression, while prostate epithelial cells had a significantly lower level of alpha(2)-M expression. Furthermore, stromal cells in culture produce and secrete alpha(2)-M in the medium. CONCLUSIONS: We identified alpha(2)-M expression in the human prostate. An increased alpha(2)-M expression appears to be associated with BPH. Considering the unique features of its protein binding and targeting properties, alpha(2)-M expressed in the prostate may play an important role in regulating benign and malignant prostatic growth.

Heterogeneity of 5 alpha-reductase gene expression in benign prostatic hyperplasia.

PURPOSE: The search for molecular markers of benign prostatic hyperplasia in general is based on an analysis of a limited number of biopsy samples. Little is known about the homogeneity of the expression of key genes in different zones of the prostate. We studied the intraprostatic (that is within the same gland) and inter-prostatic (that is between glands) variability of 5 alpha-reductase 2 (5aR2) gene expression. MATERIALS AND METHODS: Ten tissue samples removed by open prostatectomy were the source of tissue specimens. Two frozen sections were generated from each of several random biopsies taken from each adenoma immediately after enucleation, 1 of which was used for 5aR2 gene expression analysis and 1 for morphometric analysis. Results among biopsies were compared using the 5 alpha-reductase index (ratio of 5 alpha-reductase expression to an internal standard measured as electrophoretic band intensity). Morphometric composition was determined for smooth muscle, collagen, epithelium and glandular lumens. Statistical comparisons were performed with ANOVA by pairwise multiple comparison (Dunn) and Spearman's rank correlation procedure. RESULTS: For the 71 biopsies analyzed mean 5 alpha-reductase index was 0.23 +/- 0.16 and overall tissue distribution was smooth muscle 34%, collagen 35%, epithelium 14% and glandular lumens 17%. Inter-prostate and intraprostate variability in 5 alpha-reductase index was statistically significant (p = 0.004) as was the variability in stromal-to-epithelial ratio (p = 0.012). The 5 alpha-reductase index showed strong correlation with stroma (%) and negative correlation with epithelium (%). CONCLUSIONS: Benign prostatic hyperplasia is heterogeneous in terms of tissue morphometry and expression of single important genes. This finding limits the use of single biopsy based markers to predict biological behavior, and has significant impact on the ability of distinguishing longitudinal changes in tissue composition from sampling artifacts.

Perfil socioeconómico del paciente con intento de suicidio / Socioeconomic characteristics of patients with suicide attempt

Antecedentes. El intento de suicidio es una de las 10 principales causas de ingreso a una sala de urgencias. En nuestro hospital hemos encontrado que constituye una de las causas primordiales de morbilidad en pacientes jóvenes, que afectan sobre todo a mujeres entre los 15 y los 24 años. Objetivo. Determinar las características socioeconómicas del paciente adulto con intento de suicidio, que ingresa a la sala de urgencias de acuerdo con edad y sexo. Material y métodos. Se incluyeron en el estudio 101 pacientes que intentaron suicidarse; dicho grupo de estudio se conformó de hombres y mujeres mayores de 15 años que ingresaron entre el primero de marzo de 1996 al 15 de septiembre de 1997. En forma individual se les aplicó la cédula de Mad Master para estudio socieconómico de pacientes con intento suicida, una vez recabados los datos se procedió a analizarlos. Resultados. Se estudiaron 101 pacientes, 71 mujeres y 30 hombres, cuya edad promedio fue de 39.5 años. En 76 casos constituyó el primer episodio, en 22 de ellos , se detectó como segundo o tercer reintento y tres consumaron el acto. El método más utilizado en hombre y en mujeres fue la ingestión de medicamentos. En este grupo predominaron los solteros y casados en comparación con los viudos, divorciados y en los que vivían unión libre. La mayoría de los sujetos eran estudiantes con un grado máximo de estudios de bachillerato. En cuanto a las características de la familia, la mayoría provenía de una familia nuclear, pero con un patron de autoridad rígido y con comunicación oscura y enmascarada. El déficit económico que se encontró se estimó entre 20 y 30 por ciento, y la mayor parte de las familias percibía entre tres y cuatro salarios mínimos. El factor emocional fue el que originó el intento suicida. Conclusiones. El número de casos por intento de suicidio se ha incrementado con los últimos cinco años. Nuestra población de estudio en su mayoría conrrespondió a mujeres de la tercera década de la vida, estudiante de bachillerato, soltera, provenientes de familia nuclear, cuya autoridad intrafamiliar era rígida y con comunicación oscura y enmascarada, lo que originó el conflicto y la desintegración de ésta. Todos los pacientes utilizaron como método para el intento ingestión de medicamentos

Identificación de la ideación suicida en una población abierta / Identification of suicidal ideation in an open population

Tomando como muestra la población que asiste por cualquier motivo al Hospital Regional 1o. de Octubre, se aplicó un cuestionario en forma individual con el fin de investigar el grado de ideación suicida (SIS-Q), el cual explora los siguientes parámetros: 1) Trastornos del sueño, 2) trastornos del ánimo, 3) sentimientos de culpa y 4) minusvalía. La población se dividió en ocho grupos: I, sujetos con trastornos del sueño; II, con trastornos del ánimo; II, con sentimiento de culpabilidad; IV, con minusvalía; V, con trastornos del sueño y de la conducta; VI, con depresión; VII, con franca ideación suicida, y VIII, personas sin ninguna alteración. Se estudió una población total de 1,000 pacientes, de los cuales 675 (67.5 por ciento) correspondieron al sexo masculino y 325 (32.5 por ciento) al sexo femenino, cuya edad osciló entre 15 y 81 años, con una media de 48. Setenta y nueve de los sujetos encuestados (12.2 por ciento) presentaron franca ideación suicida, siendo 27 (4.1 por ciento) hombres y 52 (8.0 por ciento) mujeres, con predominio en el grupo de mujeres de 35.44 años, con 14 casos (17.7 por ciento), y la mayor frecuencia se presentó en hombre de 45-54 años con seis casos (7.5 por ciento). El 9.1 por ciento (59) de los encuestados tuvieron depresión, 21 (3.2 por ciento) hombres y 38 (5.9 por ciento) mujeres. Se encontró una mayor frecuencia en el grupo de mujeres de 35-44 añois, con 11 casos, y en varones de 45-54 años con seis casos (1.6 por ciento). Del grupo estudiado, 152 personas (23.6 por ciento) manifestaron trastornos del sueño, 51 (7.8 por ciento) hombres y 93 (15.6 por ciento) mujeres, en donde la edad que predominó en uno y otro sexo fue de 35-44 años; en el resto de la población, 60 (9.3 por ciento) casos cursaron con trastornos del ánimo, el 2.9 por ciento (19) presentó sentimiento de culpa y 11 (1.7 por ciento) minusvalía. Llamó la atención que de una población aparentemente sana se encuentra que 12.2 por ciento presenten franca ideación suicida y 9.16 por ciento cursen con criterios mayores para depresión, que es el factor más importante asociado al suicidio