Comparación entre nefrolitotomía percutánea y ureteroscopia flexible para el tratamiento de litiasis renales de entre 2 y 3 cm / Comparison between percutaneous nephrolithotomy and flexible ureteroscopy for the treatment of 2 and 3cm renal lithiasis

Contexto y objetivos: El tratamiento de primera elección para litiasis > 2 cm es la nefrolitotomía percutánea (NLP), dejando a la ureteroscopia flexible (URS-F) como una segunda opción. En la presente revisión se evaluaron la tasa libre de litiasis y las complicaciones de ambas técnicas en el tratamiento de litiasis de tamaño entre 2 y 3 cm. Material y métodos: Revisión sistemática de estudios que compararon las dos técnicas. Fueron excluidos aquellos estudios que no fueran comparativos, los realizados en población pediátrica o con litiasis menores de 2 cm o mayores de 3 cm. Dos investigadores realizaron independientemente la búsqueda, obteniendo 5 estudios que abarcaban un total de 815 pacientes: 252 pertenecieron al grupo de URS-F y 563 al de NLP. Cuatro fueron retrospectivos y uno fue prospectivo no aleatorizado. Resultados: La tasa libre de litiasis osciló entre el 47,0 y el 95,0% para la URS-F y entre el 87,0 y el 100% para la NLP. La tasa de complicaciones fue del 8,8-29,0% en la URS-F y del 11,9-27,0% en la NLP. La URS-F requirió un número mayor de procedimientos y tuvo un menor descenso de hemoglobina y ascenso de creatinina en comparación con la NLP. Conclusiones: La tasa libre de litiasis fue mayor en la NLP, aunque la URS-F podría alcanzar unos resultados comparables a expensas de realizar varios procedimientos. Ambas técnicas tienen una frecuencia de complicaciones similar, pero con más alteraciones analíticas posquirúrgicas en el grupo de NLP

Context and objectives: The first-line treatment for > 2 cm lithiasis is percutaneous nephrolithotomy (PNL), leaving flexible ureteroscopy (FURS) as a second option. In the present review, the stone-free rate and the complications of both techniques were evaluated in the treatment of 2-3 cm stones. Material and methods: Systematic review of studies that compared both techniques. Studies that were not comparative, as well as those carried out in the paediatric population or with < 2 cm or > 3 cm stones, were excluded. Two researchers independently performed the investigation, obtaining 5 studies that made up a total of 815 patients: 252 belonged to the FURS group and 563 to the PNL group. Four studies were retrospective, and one was non-randomised prospective. Results: Stone-free rate ranged between 47.0% and 95.0% for the FURS and between 87.0% and 100% for the PNL. The complication rate was 8.8-29.0% in the FURS and 11.9-27.0% in the PNL. FURS required a greater number of procedures, and had a lower decrease in haemoglobin and creatinine rise compared to PNL. Conclusions: The stone-free rate was higher for PNL, although the FURS could reach comparable results at the expense of performing several procedures. Both techniques have a similar frequency of complications, but the PNL has more postsurgical analytical alterations

Optimizing post-operative pain management in Latin America / Aprimorar o controle da dor no pós-operatório na América Latina

Abstract Post-operative pain management is a significant problem in clinical practice in Latin America. Insufficient or inappropriate pain management is in large part due to insufficient knowledge, attitudes and education, and poor communications at various levels. In addition, the lack of awareness of the availability and importance of clear policies and guidelines for recording pain intensity, the use of specific analgesics and the proper approach to patient education have led to the consistent under-treatment of pain management in the region. However, these problems are not insurmountable and can be addressed at both the provider and patient level. Robust policies and guidelines can help insure continuity of care and reduce unnecessary variations in practice. The objective of this paper is to call attention to the problems associated with Acute Post-Operative Pain (APOP) and to suggest recommendations for their solutions in Latin America. A group of experts on anesthesiology, surgery and pain developed recommendations that will lead to more efficient and effective pain management. It will be necessary to change the knowledge and behavior of health professionals and patients, and to obtain a commitment of policy makers. Success will depend on a positive attitude and the commitment of each party through the development of policies, programs and the promotion of a more efficient and effective system for the delivery of APOP services as recommended by the authors of this paper. The writing group believes that implementation of these recommendations should significantly enhance efficient and effective post-operative pain management in Latin America.

Resumo O controle da dor no período pós-operatório é um problema significativo na prática clínica na América Latina. O controle insuficiente ou inadequado da dor é devido, em grande parte, à insuficiência de conhecimento, atitudes e formação e à comunicação precária em vários níveis. Além disso, a falta de conscientização da disponibilidade e importância de políticas e diretrizes inequívocas para avaliar a intensidade da dor, o uso de analgésicos específicos e a abordagem adequada para instruir o paciente levaram ao subtratamento consistente da dor na região. Contudo, esses problemas não são insuperáveis e podem ser abordados no âmbito tanto do provedor quanto do paciente. Políticas e diretrizes substanciais podem ajudar a garantir a continuidade dos cuidados e reduzir as variações desnecessárias na prática. O objetivo deste artigo é chamar a atenção para os problemas associados à dor aguda no pós-operatório (DAPO) e sugerir recomendações para solucioná-los na América Latina. Um grupo de especialistas em anestesiologia, cirurgia e dor desenvolveu recomendações que levarão a um controle mais eficiente e eficaz da dor. Será preciso mudar o conhecimento e o comportamento dos profissionais de saúde e pacientes e obter um compromisso por parte de legisladores. O sucesso dependerá de uma atitude positiva e do compromisso de cada parte através do desenvolvimento de políticas e programas e da promoção de um sistema mais eficiente e eficaz para a prestação de serviços para a DAPO, como recomendado pelos autores deste trabalho. O grupo que as redigiu acredita que a aplicação dessas recomendações deve melhorar de modo significativo a eficiência e eficácia do controle da dor no período pós-operatório na América Latina.

[Optimizing post-operative pain management in Latin America]. / Aprimorar o controle da dor no pós­operatório na América Latina.

Post-operative pain management is a significant problem in clinical practice in Latin America. Insufficient or inappropriate pain management is in large part due to insufficient knowledge, attitudes and education, and poor communications at various levels. In addition, the lack of awareness of the availability and importance of clear policies and guidelines for recording pain intensity, the use of specific analgesics and the proper approach to patient education have led to the consistent under-treatment of pain management in the region. However, these problems are not insurmountable and can be addressed at both the provider and patient level. Robust policies and guidelines can help insure continuity of care and reduce unnecessary variations in practice. The objective of this paper is to call attention to the problems associated with Acute Post-Operative Pain (APOP) and to suggest recommendations for their solutions in Latin America. A group of experts on anesthesiology, surgery and pain developed recommendations that will lead to more efficient and effective pain management. It will be necessary to change the knowledge and behavior of health professionals and patients, and to obtain a commitment of policy makers. Success will depend on a positive attitude and the commitment of each party through the development of policies, programs and the promotion of a more efficient and effective system for the delivery of APOP services as recommended by the authors of this paper. The writing group believes that implementation of these recommendations should significantly enhance efficient and effective post-operative pain management in Latin America.

Tratamiento del linfoma cutáneo de células T con ligandos selectivos del receptor retinoide X: alteraciones endocrinológicas y metabólicas / Treatment of cutaneous T-cell lymphoma with retinoid receptor x- selective ligands: endocrine and metabolic disorders

Los ligandos selectivos del receptor retinoide X se utilizan actualmente en el tratamiento de estadios avanzados del linfoma cutáneo de células T resistentes a otros tratamientos sistémicos, siendo el bexaroteno el primer fármaco de este grupo aprobado en Europa. Se han descrito numerosos efectos adversos asociados a su utilización, entre los que destacan las alteraciones endocrino-metabólicas. Presentamos a 2 pacientes con linfoma cutáneo de células T, tratados con bexaroteno, que desarrollaron hipotiroidismo central y dislipemia de forma precoz tras su inicio. Se describen también la respuesta de estas alteraciones al tratamiento y su remisión completa tras suspender el bexaroteno (AU)

The retinoid X receptor-selective ligands has been used for advanced stages of cutaneous T-cell lymphoma refractory to previous systemic therapy, being bexarotene the first drug in this group approved in Europe. Multiple drug-related adverse events has been reported such as endocrine-metabolic disorders. We report 2 patients with cutaneous T-cell lymphoma, treated with bexarotene, that developed central hypothyroidism and dyslipidaemia immediately after the beginning of this treatment. We also showed the successfully treatment response of these alterations and the total clinical remission after discontinuing the drug (AU)

[Treatment of cutaneous T-cell lymphoma with retinoid receptor X-selective ligands: endocrine and metabolic disorders]. / Tratamiento del linfoma cutáneo de células T con ligandos selectivos del receptor retinoide X: alteraciones endocrinológicas y metabólicas.

The retinoid X receptor-selective ligands has been used for advanced stages of cutaneous T-cell lymphoma refractory to previous systemic therapy, being bexarotene the first drug in this group approved in Europe. Multiple drug-related adverse events has been reported such as endocrine-metabolic disorders. We report 2 patients with cutaneous T-cell lymphoma, treated with bexarotene, that developed central hypothyroidism and dislipidaemia inmediately after the begining of this treatment. We also showed the successfully treatment response of these alterations and the total clinical remission after discontinuing the drug.

[99m-Tc sestamibi scintigraphy in primary hyperparathyroidism. Importance of lateral projections using a pin-hole collimator]. / Gammagrafía con sestamibi-Tc99m en el hiperparatiroidismo primario. Importancia de las proyecciones laterales con colimador pin-hole.

UNLABELLED: 99mTc-Sestamibi double-phase scintigraphy has been improved with digital and tomographic procedures as well as additional projections. Since two years ago, we have introduced additional early lateral views of neck to the conventional double-phase scintigraphy. We have tried to give anatomic data about the depth of the adenomas and to evaluate the possibility of obviating the late images of the double-phase study. METHOD: Two observers reviewed 50 studies performed for primary hyperparathyroidism in two different ways. The first one reviewed only conventional double-phase studies and the second one, with the additional report of the lateral views. RESULTS: in 32/50 patients (64 %) the report of the additional lateral views and the conventional early views was enough to diagnose parathyroid adenomas. No additional lesions were observed in the late views. These views did not provide any additional useful data and could have been obviated. Four ectopic adenomas were found, 1 mediastinal and 3 in paraesophagic area; three intrathyroidal focus; all of these atypical lesions were identified by lateral pinhole views. CONCLUSION: The performance of additional lateral projections of the parathyroids supplies additional information to the surgeon on the depth of the lesion in atypical sites and would have made it possible to obviate the late phase in more than half of the patients since this did not supply additional information to that of the early images that had reached a diagnosis.

Gammagrafía con Sestamibi-Tc99m en el HiperparatiroidismoPrimario. Importancia de las Proyecciones Laterales con ColimadorPin-Hole / 9Mtc-sestamibi scintigraphy in primary hyperparathyroidism

La gammagrafía de paratiroides con sestamibi-Tc99m en dos fases se ha ido complementando con técnicas digitales, tomográficas y proyecciones adicionales. Desde hace dos años hemos incorporado la realización selectiva de proyecciones laterales con colimador pin-hole a 90° en las imágenes precoces en un intento sencillo de proporcionar información acerca de la situación en profundidad, por un lado, para complementar el diagnóstico intentando acortar la exploración y, por otro, para facilitar el abordaje quirúrgico al cirujano en las ectopias. Método: Dos observadores revisaron los estudios de 50 hiperparatiroidismos primarios de dos formas distintas: una a partir de las proyecciones anteriores convencionales en dos fases y otra con la información adicional de las proyecciones laterales. Resultados: En 32/50 pacientes (64 por ciento) la información de las proyecciones laterales adicionales fue suficiente para diagnosticar la presencia de adenomas paratiroideos sin que las imágenes tardías aportasen datos de interés pudiéndose obviar la fase tardía. No se observaron lesiones adicionales en las imágenes tardías. Se encontraron 4 adenomas ectópicos (3 paraesofágicos y 1 mediastínico). 3 captaciones nodulares intratiroideas fueron perfectamente localizadas por las proyecciones laterales. Conclusión: La realización de proyecciones laterales adicionales de paratiroides aporta información adicional al cirujano acerca de la profundidad de la lesión en localizaciones atípicas y hubiera permitido obviar la fase tardía en más de la mitad de los pacientes ya que ésta no aportó información adicional a la de las imágenes precoces que habían alcanzado un diagnóstico (AU)

[Spinal extradural lipomatosis. Revision of 108 cases. Case induced by exogenous contribution of ACTH]. / Lipomatosis estradural espinal. Revisión de 108 casos. Caso inducido por aporte exógeno de ACTH.

Authors present a male patient with Spinal Extradural Lipomatosis, previously treated of a cerebral astrocytoma with surgery and radiotherapy, after which he received ACTH for a long period of time. Clinical manifestations were rachialgia, paraparesia with pain and dysestesias in both lower extremities. Diagnosis was carried out by Magnetic Resonance imaging. After a progressive withdrawal of the treatment with ACTH, the patient achieved a complete recovery and neuroimaging studies showed the dissappearance of the compression caused by the lipomatosis. We carry out a revision of the literature showing data we consider of interest derived from the wide series subjected to study.

Lipomatosis extradural espinal. Revisión de 108 casos. Caso inducido por aporte exógeno de ACTH / Spinal extradural lipomatosis. Revision of 108 cases. Case induced by exogenous contribution of ACTH

Presentamos un caso de Lipomatosis extradural espinal en un paciente previamente tratado de un glioma anaplásico cerebral mediante cirugía y radioterapia, que recibió tratamiento con ACTH durante un largo período. Las manifestaciones clínicas fueron de raquialgia, paraparesia con dolor y disestesias en ambas extremidades inferiores. El diagnóstico se realizó mediante Resonancia Magnética. La retirada progresiva del tratamiento con ACTH hasta su supresión logró la recuperación clínica completa del paciente y la desaparición en los estudios de neuroimagen de la compresión provocada por la lipomatosis. Realizamos una revisión de la literatura aportando datos que consideramos de interés y que se derivan de la amplitud de la serie sometida a estudio (AU)

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[Primary adrenal insufficiency and primary antiphospholipid syndrome]. / Insuficiencia suprarrenal primaria y síndrome antifosfolípido primario.

Primary adrenal insufficiency (PAI) is a rare complication of antiphospholipid syndrome (APS). The hypercoagulable state in the APS may lead to adrenal vein thrombosis and subsequently to hemorrhagic necrosis of the adrenal glands. This complication of APS is important to recognize because it may be fatal if untreated. We describe one case of PAI and primary APS, with magnetic resonance studies consistent with hemorrhagic necrosis of the adrenal glands.

Insuficiencia suprarrenal primaria y síndrome antifosfolípido primario / Primary adrenal insufficiency and primary antiphospholipis syndrome

La insuficiencia suprarrenal primaria (ISP) es una complicación excepcional del síndrome antifosfolípido (SAF). El estado de hipercoagulabilidad en el SAF puede causar una trombosis de las venas suprarrenales con posterior necrosis hemorrágica de las glándulas. Es importante reconocer esta complicación del SAF, ya que si no se trata adecuadamente puede ser fatal. Presentamos un paciente con ISP y SAF primario, con hallazgos en la resonancia magnética compatibles con necrosis hemorrágica de las glándulas suprarrenales (AU)

[Thyrotropin-producing hypophyseal adenomas]. / Adenomas hipofisarios productores de tirotropina.

Thyrotropin (TSH)-producing adenoma or TSH-oma is an uncommon entity. Most cases correspond to macroadenomas, and microadenomas are exceptional. The differential diagnosis should include mainly hypophyseal resistance to thyroid hormones, which can be difficult because of normal findings of imaging studies of the pituitary gland in some cases of TSH-oma and also because of the clinical and biochemical heterogeneity of both entities. Hypophyseal surgery is the treatment of choice for TSH-omas, although clinical and biochemical recovery of hyperthyroidism is not achieved in a considerable proportion of cases. When surgery fails or is contraindicated, radiotherapy and somatostatine analogues are therapeutic alternatives. We report here two cases of TSH-producing microadenoma which were confirmed after hypophyseal surgery.

[Ketoconazole in the control of arterial hypertension in Cushing's syndrome]. / Ketoconazol en el control de la hipertensión arterial en el síndrome de Cushing.

OBJECTIVE: To determine the usefulness of ketoconazole for the control of arterial hypertension (AH) in Cushing syndrome (CS) as temporary treatment. PATIENTS AND METHODS: Fifteen cases of CS were collected (eleven cases of Cushing disease, two cases of ectopic secretion of ACTH, one case of adrenal adenoma, and one case of adrenal carcinoma). The clinical characteristics as well as laboratory data of patients with AH and the response to therapy were studied. RESULTS: Six patients (40%) had AH. A significant difference was observed of an older age, a higher frequency of association with diabetes mellitus and a higher 24 hour free urine cortisol (FUC) for patients with AH compared with non hypertensive patients. Ketoconazole was efficient for controlling AH in five cases, and in all of them the return to normal levels of 24 hour FUC was achieved. A failure of AH control under treatment with ketoconazole occurred in the only case of adrenal carcinoma. There was no significant secondary adverse reaction to ketoconazole. CONCLUSIONS: Ketoconazole is an efficient drug for the control of AH in CS and is well tolerated. In our series, the return to normal levels of FUC was associated with control of AH.

[Cushing's syndrome: clinical study of fifteen cases]. / Síndrome de Cushing: estudio clínico de quince casos.

OBJECTIVE: To study the epidemiological and clinical features and diagnostic tests of Cushing's syndrome (CS) of non-iatrogenic etiology, because of there are few similar studies in the last ten years. METHODS: Fifteen cases of CS were diagnosed from 1992 to 1997 at our hospital. We describe the epidemiological, clinical, biochemical, radiologic, therapeutic and evolutive characteristics. RESULTS: Both diabetes mellitus and hypertension were observed in 40% of patients. The frequency of etiologies was: Cushing's disease, 66.6%; ectopic ACTH syndrome, 13.3%; adrenal adenoma, 6.6%; adrenal carcinoma, 6.6%; and undiagnosed, 6.6%. The 24-hour urine free cortisol (UFC) and the overnight 1 mg oral dexamethasone suppression test yielded 93.3 and 100% diagnostic sensitivity for CS, respectively. The overnight 8 mg oral dexamethasone suppression test, the metyrapone test and the 7 mg intravenous dexmethasone test had 75, 50 and 60% diagnostic sensitivity for Cushing's disease, respectively. Ketoconazole treatment had success in to normalize the 24-hour UFC in all patients, except for the case of adrenal carcinoma. CONCLUSIONS: The Cushing's disease was the most common form of CS. The 24-hour UFC and overnight 1 mg oral dexamethasone suppression test were good screening studies. Ketoconazole was successful in normalizing the adrenal cortex function.