Return-to-Competition Progression After Exertional Heat Stroke in an Adolescent Runner: A Case Report.

A 14-year-old runner indigenous to the tropics collapsed during his first 10-km race in a hot and humid climate. Dizziness, stumbling, and loss of consciousness were symptoms of exertional heat stroke. Two days postcollapse, blood tests revealed elevated hepatic transaminases consistent with hepatic injury. We discuss the return-to-competition progression, which included a gradual increase in exercise duration, initially in a cool and then in a tropical climate, and 2 field-based (wet-bulb globe temperature > 29.0°C) running evaluations that simulated the environmental conditions and training intensity the athlete would encounter in his sport. The thermoregulatory results guided the training progression, his tolerance to running in the heat improved, blood values normalized, and he was cleared to compete in a tropical climate. This exploration case report presents a novel field-based protocol that replicates the physiological demands of training in the tropics to evaluate thermoregulatory responses during exercise-heat stress in young runners after exertional heat stroke to facilitate a safe return to competition.

Prospective clinical trial of the feasibility and safety of modified retroperitoneal lymph node dissection at time of nephroureterectomy for upper tract urothelial carcinoma.

UNLABELLED: What's known on the subject? and What does the study add? Very little is known about the safety and potential oncological benefit of performing a retroperitoneal lymph node dissection at time of nephroureterectomy for upper tract tumours. This study is the first clinical trial to prospectively validate the safety and feasibility of a retroperitoneal lymph node dissection at time of nephroureterectomy for upper tract tumours. The onus is now on the scientific community at large to conduct adequately powered multicentre clinical trials to evaluate the potential oncological benefit it may impart to patients with upper tract tumours. OBJECTIVE: • To determine the safety and feasibility of modified retroperitoneal lymph node dissection (RPLND) at the time of radical nephroureterectomy (RNU). PATIENTS AND METHODS: • Between 2009 and 2011, 20 patients with suspected upper urinary tract urothelial carcinoma (UUT-UC) underwent open (n= 10), laparoscopic (n= 4), or robot-assisted (n= 6) RNU with modified RPLND. • Demographic, clinical and pathological data, histological nodal status, peri-operative complications and recurrence data were collected. RESULTS: • On histopathological review, one patient had a benign angioma and was excluded from the final data analysis. Of the remaining 19 patients, 10 had pTa, five had pT1, one had pT2, and three pT3 disease. • The mean (range) lymph node count was 7 (2-17), with one patient having pathologically proven lymph node metastasis. The mean (range) operating time was 279 (146-500) min. The mean EBL was 396 (100-1100) mL, with the mean (range) hospital stay 7.1 (4-18) days. The mean (range) duration of follow-up after surgery was 12 (2-24) months. • Overall, nine patients developed postoperative complications, which included eight minor (Clavien Grade I-II) and one major complication (Clavien grade IIIb). The major complication was a postoperative chylous lymphatic leak requiring surgical exploration. CONCLUSION: • The present results indicate that modified RPLND during RNU for UUT-UC is a feasible procedure with acceptable morbidity. A larger prospective clinical trial is needed to adequately assess its potential therapeutic benefit.

Optimizing cancer control and functional outcomes following robotic prostatectomy.

BACKGROUND: Since robotic-assisted laparoscopic radical prostatectomy was introduced, different modifications in the technique have been described to improve cancer control and minimize the possibility of erectile dysfunction and incontinence. METHODS: We reviewed the recent English literature on specific topics including when to preserve the neurovascular bundle (NVB), and we describe techniques to diminish the rate of positive margins and to preserve continence and potency. RESULTS: Identifying predictor factors of local advanced disease helps in deciding when to preserve the NVB without compromising cancer control. Techniques to decrease the positive margins based on experience and modifications of the apical dissection are reviewed. Minimal disruption or reconstruction of the anatomic structures of the periprostatic tissues helps to maintain continence. Different degrees of NVB preservation can be performed based on the characteristics of the cancer. Cautery-free techniques and other modifications in the dissection to minimize the NVB injury are also discussed. CONCLUSIONS: The understanding of the predictor factors of local advanced disease, together with modifications in the technique, helps to not only achieve cancer control but also improve quality of life after robotic-assisted laparoscopic radical prostatectomy.

Bladder cancer: a review of non-muscle invasive disease.

BACKGROUND: Bladder cancer is one of the most common cancers affecting men and women and thus has a profound impact on health care. The majority of patients (75%) with newly diagnosed urothelial tumors have non-muscle invasive disease confined to the bladder mucosa or the lamina propria. METHODS: The authors review the literature as well as recently published clinical guidelines regarding the bladder cancer risk and causative factors, diagnostic and pathologic evaluation, prognostic variables, and management strategies for patients with non-muscle invasive bladder cancer. RESULTS: Recurrence and progression remain problematic for many patients and are dependent on multiple clinical and pathological features, the most important of which are tumor stage, grade, multifocality, size, recurrence patterns, and the association with carcinoma in situ. Accurate assessment of clinical stage and tumor grade is critical in determining management and surveillance strategies. Intravesical therapies positively influence tumor recurrence rates. Disease progression rates may be impacted in high-risk patients who receive both induction bacille Calmette-Guérin (BCG) and a maintenance BCG regimen. Cystectomy still plays a pivotal role in patients with high-risk tumors and in patients who fail more conservative attempts to eradicate non-muscle invasive disease. CONCLUSIONS: Non-muscle invasive bladder cancers represent a broad group of tumors with varying biologic potential. Successful treatment depends on the careful integration of diagnostic and surveillance tests, macroablation through transurethral resection, accurate assessment of clinical stage, and the timely and appropriate delivery of intravesical chemotherapeutic and immunomodulatory agents.

Robotic-assisted partial cystectomy with en bloc excision of the urachus and the umbilicus for urachal adenocarcinoma.

We report two cases of urachal adenocarcinoma managed with robotic-assisted partial cystectomy. A detailed description of the robotic technique including methods used to resect the tumor, urachus, and umbilicus en bloc is described. A review of the management of urachal adenocarcinoma is presented. The robotic approach is technically feasible and safe, and is an attractive alternative to traditional open or laparoscopic-assisted partial cystectomy for this uncommon genitourinary malignancy.

Robotic assisted laparoscopic partial cystectomy and urachal resection for urachal adenocarcinoma.

INTRODUCTION AND OBJECTIVE: Standard treatment for urachal adenocarcinomas is open partial cystectomy and urachal resection; however, minimally invasive surgical approaches including laparoscopic and recently described robotic assisted laparoscopic partial cystectomy and urachal resection is feasible with potential less morbidity. A case of robotic assisted partial cystectomy and urachal resection for urachal adenocarcinoma is presented. Few articles in the literature have being published describing this technique and to the best of our knowledge, this is the largest and potentially most complex case approached in such a manner. METHODS: A 55 years old African American male presented with hematuria and mucosuria, cystoscopy demonstrated a tumor involving the dome of the bladder. Transurethral biopsy confirmed a urachal adenocarcinoma. Further studies revealed a negative metastatic evaluation. Preoperative abdominal/pelvic CT imaging revealed an enhancing mass extending from the inferior level of the umbilicus to the dome of the bladder. A total of 6 laparoscopic ports were used. The robotic assisted laparoscopic dissection was started at the level of the umbilicus, dissecting lateral to the right and left medial umbilical ligaments up until the dome of the bladder. A simultaneous cystoscopy with transillumination to define the bladder boundaries of this mass, with robotic assisted laparoscopic opening of the bladder, with the entire mass (including bladder component) excised and sent for frozen pathology for margin evaluation. After specimen extraction, the bladder was closed in two layers. Total surgery time was 300 minutes and intra-operative blood loss was 150cc. RESULTS: Final pathology reported a pT2N0Mx adenocarcinoma with negative margins and negative pelvic lymph nodes. Patient was started on clear liquids on postoperative day 2 and on regular diet on postoperative day 3. He was discharged on postoperative day 4. A cystogram perfomed on postoperative day 7 revealed a good bladder capacity (350 cc) and no leakage was identified. CONCLUSIONS: Robotic assisted partial cystectomy and urachal resection for urachal adenocarcinoma of the bladder is feasible even in challenging cases. This surgical approach is less morbid in terms of postoperative pain and cosmesis when compared to the open standard approach. The postoperative recovery is faster; however, application of oncological principles and comfort with laparoscopic and robotic surgery is needed prior to attempting such challenging cases. [Video - Available at: www.brazjurol.com.br/videos/september_october_2009/Spiess_609].

Surgery plus targeted therapy for renal cell carcinoma with isolated spermatic cord metastasis.

We present a case of renal cell carcinoma with metastasis to the ipsilateral spermatic cord. We report the clinical presentation and management of this case and review the scientific literature of this unusual case presentation.

[Analgesic effect of intra-artcular fentanyl in knee arthroscopy to treat patellofemoral lateral hyperpressure syndrome]. / Efecto analgésico del fentanyl intraarticular en artroscopía de rodilla para el síndrome de hiperpresión lateral patelofemoral.

INTRODUCTION: During arthroscopy for the treatment of patellofemoral lateral hyper-pressure syndrome (LHS), intra-articular morphine or its derivatives (fentanyl) may reduce postoperative pain when combined with anesthetics. We therefore decided to determine whether adding fentanyl to epinephrine and bupivacaine produced an increased analgesia. MATERIAL AND METHODS: We randomly distributed 40 patients into two groups. The experimental group (n=20) was given 0.5% bupivacaine (2 mg/kg), epinephrine (100 microg) and fentanyl (2.5 microg/kg). The control group (n=20) received 0.5% bupivacaine (2 mg/kg) and epinephrine (100 microg). Patients underwent chondroplasty and retinacular release, and we assessed pain, time of analgesia and postoperative range of motion at postoperative hours 6 and 24. RESULTS: The age and the grade of patellofemoral chondromalacia (PFC) were similar in both groups (p > 0.05). No differences were found in pain and ranges of motion intraoperatively and at postoperative hours 6 and 24 (p > 0.05) between both groups. The postoperative analgesia time was similar (p > 0.05). CONCLUSIONS: Adding intra-articular fentanyl to the combination of epinephrine plus bupivacaine did not decrease pain, and did not increase neither the analgesia time nor the range of motion in patients with LHS undergoing knee arthroscopy.

Laparoscopic retroperitoneal lymph node dissection in the management of testis cancer.

BACKGROUND: The surgical approach to management of testis cancer has been traditionally through an open incision, but in the last decade, several centers have reported their experience with laparoscopic retroperitoneal lymph node dissection (LRPLND). METHODS: We reviewed the English literature, summarized the outcomes, and included our initial experience with the LRPLND procedure. RESULTS: Improvements in operative time, complications, and morbidity have occurred as surgical experience has increased. The procedure is more challenging in postchemotherapy patients. Outcomes at our institute are comparable to reported series from other institutions, and LRPLND is our current procedure of choice for RPLND. CONCLUSIONS: LRPLND has been shown to be a safe, effective, minimally invasive procedure in the management of testicular cancer patients who require surgery to address the retroperitoneal lymph nodes.

Perfil de utilización de los servicios de salud durante los XVII Juegos Deportivos Centroamericanos y del Caribe: Delegación de Puerto Rico, Ponce 1993 / Profile of health services utilization during the XVII Central and Caribbean Sport Games: Delegation of Puerto Rico, Ponce 1993

During the XVII Central American and Caribbean Sports Games held in Ponce in 1993 the health services offered to the Puerto Rico Delegation included medical, dental and psychological assistance, physical therapy and services on the playing field. Information about the use of these services was obtained from the encounter sheets. The Puerto Rican delegation of 750 members had 1,800 encounters with the health team; 612 (34.0 per cent ) individual consults; 896 (54.8 per cent ) physical therapy sessions; 166 (9.2 per cent ) encounters in the sports venues; and 36 (20 per cent ) group therapies. The most common diagnoses were athletic injuries (304; 58.2 per cent ) and diseases of the respiratory system (76; 14.5 per cent ). The most frequent athletic injuries were first degree strains (75; 24.7 per cent ) and tendinitis (73, 24.0 per cent ). This pattern is similar to that observed in other sports games and delegations with mild conditions prevailing. An interdisciplinary work and biopsychosocial approach will be important for the better health and performance of our athletes

Patterns of injuries in athletes evaluated in an interdisciplinary clinic

The pattern of sports injuries appears to be population-specific. The purpose of the present study is to describe 1750 injuries evaluated between April 1988 and April 1994 in our Olympic Training Center Interdisciplinary Sports Injury Clinic. Our patient population included elite and recreational athletes of both sexes between the ages of 7 and 71 years. Males comprised 73 per cent of the patient population and approximately 80 per cent of the injuries corresponded to the 10 to 29 age range. The most frequent sports in males were baseball (21.9 per cent ) and basketball (15.9 per cent ) and in females were track and field (17.1 per cent ) and gymnastics (15.1 per cent ). Most injuries (52 per cent ) were traumatic in nature, chronic (71.6 per cent ), and occurred during training sessions (57.4 per cent ). The most commonly affected anatomical areas were the knee (31.2 per cent ) and shoulder (15.5 per cent ). The most common diagnoses were tendinitis (25.4 per cent ), and first degree strains (11.8 per cent ) and sprains (9.3 per cent ). Finally, treatment strategies included medications (61.0 per cent ), physical therapy (48.9 per cent ), relative rest (35.7 per cent ), and home exercise programs (35.2 per cent ). The variety of musculoskeletal disorders seen in combination with the frequent use of conservative treatment confirms the importance of an interdisciplinary approach to sports injuries

Morbilidad durante los XVI Juegos Deportivos Centroamericanos y del Caribe: Delegación de Puerto Rico, México 1990 / Morbidity during the XVI Central American and Caribbean Games: Puerto Rico delegation, Mexico 1990

The health services offered to the Puerto Rican Delegation during the XVI Central American and Caribbean Sports Games in México in 1990 included: medical, dental and psychological assistance, physical therapy and services on the playing field. From the consultation sheets completed during the Games we obtained information about the use of these services. The 336 members of the Puerto Rico Delegation in the village at México City had 1,838 encounters with the health team. Of these, 991 were medical consults, 55 group therapies, 466 physical therapy sessions and 326 encounters in the sports venues. Among the encounters for medical evaluation the most frequent problems were athletic injuries (318; 32.1 percent), respiratory problems (240; 24.2 percent), gastrointestinal conditions (126; 12.7 percent) and dental services (119; 12.0 percent). The most frequent athletic injuries were first degree strains (83; 26.1 percent), tendinitis (56; 17.6 percent), contusions (42; 13.2 percent), myositis (40; 12.6 percent) and first degree sprains (28; 8.8 percent). The health problems found were diversed and in the majority of cases mild in character, which can be attend by adequately trained on sports health primary health professionals