Clinical and histological predictive factors of reclassification of prostate cancer patients on active surveillance.

INTRODUCTION AND OBJECTIVE: Active surveillance (AS) has been established as a therapeutic strategy in patients with low-risk prostate cancer. Demographic and anatomopathological factors that increase the probability of reclassifying patients have been identified. MATERIALS AND METHODS: Laboratory and histopathological data were collected from 116 patients included on AS since 2014. Univariate analysis was performed with Chi-square, t-student and Kendall's Tau, multivariate analysis according to logistic regression and Kaplan-Meier curves were calculated. RESULTS: Of the 116 patients in AS, the median age at diagnosis was 66 years and the median follow-up was 13 months (2-72). Of these, 61 (52.6%) are still on surveillance, while 55 (47.4%) have left the program, mostly due to histological progression (52 patients (45.2%)); radical prostatectomy was performed in 27 (49.1%). Prostate volume (PV)≤60cc and the number of positive cylinders >1 in diagnostic biopsy (P=.05) were associated with higher reclassification rate in univariate analysis (P<.05). Multivariate analysis showed that these two variables significantly correlated with higher reclassification rate (PV 60 cc: OR 4.39, P=.04; >1 positive cylinder at diagnostic biopsy: OR 2.48, P=.03). CONCLUSIONS: It has been shown that initial ultrasound volume and the number of positive cylinders in the diagnostic biopsy are independent risk factors for reclassification. Initial PSA, laterality of the affected cylinders and PSA density were not predictive factors of progression in our series.

Factores clínicos e histológicos predictores de reclasificación en pacientes incluidos en programa de vigilancia activa de cáncer de próstata / Clinical and histological predictive factors of reclassification of prostate cancer patients on active surveillance

Introducción y objetivo La vigilancia activa (VA) se ha establecido como estrategia terapéutica en pacientes con cáncer de próstata de bajo riesgo. Se han identificado factores demográficos y anatomopatológicos que aumentan la probabilidad de reclasificar a los enfermos. Materiales y métodos Se han recogido datos analíticos e histopatológicos de 116 pacientes incluidos en VA desde 2014. Se ha realizado un análisis univariante con X2, t de Student y Tau de Kendall, un análisis multivariante según regresión logística y se han calculado las curvas de Kaplan-Meier. Resultados De los 116 pacientes en VA, la mediana de edad al diagnóstico fue 66 años y la mediana de seguimiento fueron 13 meses (2-72). De todos ellos, 61 (52,6%) siguen en vigilancia mientras que 55 (47,4%) han salido del programa, la mayoría por progresión histológica (52 pacientes [45,2%]), realizándose prostatectomía radical en 27 (49,1%). El volumen prostático (Vp) ≤ 60cc y el número de cilindros positivos >1 en la biopsia diagnóstica (p = 0,05) se asociaron con mayor tasa de reclasificación en el análisis univariante (p < 0,05). En el análisis multivariante, estas dos variables se correlacionaron significativamente con una mayor tasa de reclasificación (Vp ≤ 60 cc: OR 4,39, p = 0,04; >1 cilindro positivo en la biopsia diagnóstica: OR 2,48, p = 0,03). Conclusiones Se ha objetivado que el volumen ecográfico inicial y el número de cilindros positivos en la biopsia diagnóstica son factores de riesgo independientes para la reclasificación. El antígeno prostático específico (PSA) inicial, la lateralidad de los cilindros afectos y la densidad de PSA no fueron elementos predictores de progresión en nuestra serie (AU)

Introduction and Objective Active surveillance (AS) has been established as a therapeutic strategy in patients with low-risk prostate cancer. Demographic and anatomopathological factors that increase the probability of reclassifying patients have been identified. Materials and Methods Laboratory and histopathological data were collected from 116 patients included on AS since 2014. Univariate analysis was performed with Chi-square, t-student and Kendall's Tau, multivariate analysis according to logistic regression and Kaplan-Meier curves were calculated. Results Of the 116 patients in AS, the median age at diagnosis was 66 years and the median follow-up was 13 months (2-72). Of these, 61 (52.6%) are still on surveillance, while 55 (47.4%) have left the program, mostly due to histological progression (52 patients (45.2%)); radical prostatectomy was performed in 27 (49.1%). Prostate volume (PV) ≤ 60cc and the number of positive cylinders > 1 in diagnostic biopsy (p = 0.05) were associated with higher reclassification rate in univariate analysis (p < 0.05). Multivariate analysis showed that these two variables significantly correlated with higher reclassification rate (PV 60 cc: OR 4.39, p = 0.04; > 1 positive cylinder at diagnostic biopsy: OR 2.48, p = 0.03). Conclusions It has been shown that initial ultrasound volume and the number of positive cylinders in the diagnostic biopsy are independent risk factors for reclassification. Initial PSA, laterality of the affected cylinders and PSA density were not predictive factors of progression in our series (AU)

Desarrollo e implementación de una unidad de inmunoterapia en un servicio de urología / Development and implementation of an immunotherapy unit in a urology department

Introducción La inmunoterapia está revolucionando el tratamiento del cáncer, siendo los anticuerpos monoclonales dirigidos contra moléculas reguladoras del punto de control la terapia más ampliamente utilizada en la actualidad. Un total de seis fármacos inhibidores del punto de control inmunitario (CPI) han sido aprobados por la U.S. Food and Drug Administration (FDA) y por la European Medicines Agency (EMA) para su uso en diversos tumores sólidos del aparato genitourinario. Material y métodos Se revisó la literatura y se analizó la metodología y experiencia propia adquirida para instaurar el tratamiento con CPI en un servicio de Urología. Resultados Se describen los requisitos recomendables desde el punto de vista formativo, logístico y procedimental para implementar una unidad de inmunoterapia en un servicio de Urología que permita ofrecer con seguridad el tratamiento experto con CPI a los pacientes con tumores genitourinarios. Conclusiones El cumplimiento del programa propuesto garantiza la administración segura de CPI en un entorno hospitalario (AU)

Introduction Immunotherapy is revolutionizing cancer treatment, with monoclonal antibodies directed against checkpoint regulatory molecules currently being the most widely used therapy. A total of six immune checkpoint inhibitor (CPI) drugs have been approved by the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for use in various solid tumors of the genitourinary tract. Material and methods the literature is reviewed and the methodology, as well as our own experience, are analyzed to establish treatment with CPI in a urology department. Results The requirements recommended in terms of training, logistics and procedure are described in order to safely offer expert treatment with CPI to patients with genitourinary tumors. Conclusions Compliance with the proposed program ensures safe administration of immune checkpoint inhibitors in a hospital setting (AU)

Development and implementation of an immunotherapy unit in a urology department.

INTRODUCTION: Immunotherapy is revolutionizing cancer treatment, with monoclonal antibodies directed against checkpoint regulatory molecules currently being the most widely used therapy. A total of six immune checkpoint inhibitor (CPI) drugs have been approved by the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA) for use in various solid tumors of the genitourinary tract. MATERIAL AND METHODS: The literature is reviewed and the methodology, as well as our own experience, are analyzed to establish treatment with CPIs in a urology department. RESULTS: The requirements recommended in terms of training, logistics and procedure are described in order to safely offer expert treatment with CPIs to patients with genitourinary tumors. CONCLUSIONS: Compliance with the proposed program ensures safe administration of immune checkpoint inhibitors in a hospital setting.

Prevención y diagnóstico precoz de osteoporosis infantil: ¿estamos haciendo lo correcto? / Prevention and early diagnosis of childhood osteoporosis: are we doing the right thing?

Objetivos: Evaluar la prevención, el diagnóstico precoz y la formación recibida de la osteoporosis en la Pediatría de nuestro medio. Material y métodos: Encuesta dirigida a facultativos de Pediatría de Atención Primaria (AP) y Atención Especializada (AE) que valora su actividad en prevención, detección y formación recibida en osteoporosis, y que fue difundida a través de las sociedades científicas pertinentes. Resultados: Participaron 420 pediatras (324 de AP y 96 de AE). El 93,5% de los pediatras de AP y el 89,6% de los de AE valoraban la actividad física de los pacientes; el 85,19% y 35,4% de ellos, respectivamente, la ingesta de lácteos. El 45,68% de AP y el 70,2% de AE suplementaban con calcio y vitamina D ante aporte nutricional bajo, realizándoles seguimiento el 39,2% de AP y el 47,2% de AE. El 39,6% de pediatras de AE solicitaba densitometría ósea ante enfermedad o tratamiento de riesgo, y el 47,9% medía los niveles de 25-OH-vitamina D. El 25,93% de AP y el 45,3% de AE preguntaban por la existencia de fracturas, el 90,4% y 96,8% valoraban el mecanismo etiopatogénico. El 40% de AP y el 86,2% de AE solicitaban una densitometría ósea o derivaban al especialista ante fracturas por traumatismos de baja energía, con criterios específicos en el 13,7% y 5,86%, respectivamente. El 92% de AP y el 82,3% de AE no habían recibido formación reciente en osteoporosis infantil. Conclusión: La detección, los circuitos de derivación y la formación de los pediatras respecto a la salud ósea en nuestro país es mejorable. Optimizar estos aspectos es fundamental para favorecer el pico de masa ósea en nuestra población

Objectives: To assess prevention, early diagnosis and training received regarding osteoporosis among the pediatrics professionals in our area. Material and methods: Survey directed to physicians of pediatricians of Primary Care (PC) and Specialized Care (SC) in order to evaluate their activity in prevention, detection and training received in osteoporosis. The survey was disseminated through the relevant scientific societies. Results: 420 pediatricians participated (324 from PC and 96 from SC). 93.5% of PC pediatricians and 89.6% of SC pediatricians valued the physical activity of the patients; 85.19% and 35.4% of them, respectively, the intake of dairy products. 45.68% of PC and 70.2% of SC recommended calcium and vitamin D supplements in the case of low nutritional intake, whereas 39.2% of PC and 47.2% of SC favored follow-up. 39.6% of SC pediatricians requested bone densitometry for this disease or risk treatment, and 47.9% measured the levels of 25-OH-vitamin D. 25.93% of PC and 45.3% of SC asked about the existence of fractures, 90.4% and 96.8% requested etiopathogenic mechanism. 40% of PC and 86.2% of SC requested a bone densitometry or referred to the specialist for fractures due to low trauma energy, with specific criteria in 13.7% and 5.86%, respectively. 92% of PC and 82.3% of SC had not received recent training in childhood osteoporosis. Conclusion: Detection, derivation circuits and the training of pediatricians regarding bone health in our country can be improved. Optimizing these aspects is essential to favor the peak of bone mass in our population

Relación entre la percepción del consumo oral de líquidos y el volumen urinario en población sana / Oral fluid intake perception and urine volume in a healthy population

Introducción: el volumen urinario bajo (< 1 ml/kg/h) es el factor etiológico más frecuente en la litiasis renal. Frecuentemente, se asume que los niños que refieren beber mucho tienen una diuresis protectora. En este estudio analizamos el hábito de consumo de líquidos en niños sanos y su relación con el volumen urinario. Metodología: se estudiaron 84 niños, de 5 a 17 años. Se registró la percepción de consumo habitual de líquidos como: "poco", "normal" o "mucho" y los tipos de bebida habitual. Se cuantificó el volumen en orina de 24 h y se relacionó con la percepción de la ingesta de líquidos. Resultados: la ingesta habitual de líquidos fue calificada como "poca" en el 23% de los casos, "normal" en un 56% y "mucha" en un 21%. El 39% de los niños (33/84) presentó una diuresis > 1 ml/kg/h que, por grupos, supone el 38,9% de los que refirieron una ingesta escasa, el 63% de los de consumo "normal" y el 73,7% de los que refirieron ingesta elevada. El 56% de los niños de los grupos de ingesta "normal" y "elevada" mostraron una diuresis < 1 ml/kg/h. Conclusiones: la mayoría de niños mostraron una diuresis por debajo del límite recomendado, incluso entre los que refieren una ingesta "normal" o "elevada" de líquidos. Estos hallazgos hacen visible la necesidad de promover estrategias encaminadas a aumentar el consumo de agua en la población (AU)

Introduction: a low urine volume is a main etiological factor for renal lithiasis (< 1 ml/kg/h). It is commonly assumed that children who report a high fluid intake have a protective urine volume. The purpose of the present study is to assess the habit of fluid intake in healthy schoolchildren and to evaluate its relation with the urinary volume. Methods: eighty-four healthy schoolchildren (5-17 years) were asked to categorize their usual fluid intake amount by choosing one of the three options: "low", "normal" or "high" fluid intake. The usual consumed types of beverage were also recorded. Twenty-four-hour urine volume was measured in each child. The results of the questionnaire were compared to that from the urine samples. Results: a "low" fluid intake was referred by 23% of children, a "normal" fluid intake by 57% and a "high" fluid intake by 21%. Diuresis values > 1 ml/kg/h were observed in 39% of children (that is: 38.9% of the "low intake" group, 63% of the "normal intake" group and 73.7% of the "high intake" group). Among "normal" and "high" intake groups, a urinary output < 1 ml/kg/h was found in 56% of children. Conclusions: a majority of the studied children did not reach the minimum recommended diuresis to prevent urinary lithiasis, even among children who report a high intake of fluids. Strategies aimed at increasing water intake by children population should be highly encouraged (AU)

Nuevos enfoques en el tratamiento del dolor agudo Postoperatorio / New approaches in the treatment of acute postoperative pain

El control eficaz del dolor postoperatorio se ha convertido en una parte esencial de los cuidados perioperatorios y su adecuado tratamiento, junto a otros factores como la movilización y la nutrición precoz, se relacionan directamente con la disminución de las complicaciones postoperatorias y de la estancia hospitalaria. En la actualidad se presentan diversos retos en el campo del tratamiento del DAP, que precisarán de nuevos enfoques y nuevas alternativas terapéuticas. Los protocolos analgésicos específicos para cada tipo de intervención quirúrgica, adaptados al contexto organizativo y de práctica clínica hospitalaria, son una garantía para individualizar los tratamientos y responder adecuadamente a las demandas analgésicas de cada paciente. Entre las recomendaciones de las recientes Guías del manejo del Dolor Agudo Postoperatorio de la American Pain Society (APS) destacamos: el uso de la analgesia multimodal, la analgesia regional y epidural en procedimientos específicos, las mínimas dosis de opioides y la preferencia de la vía oral frente a la intravenosa, y la modalidad de PCA. Ante la epidemia de consumo de opioides, las recomendaciones actuales se basan en minimizar la dosis de opioide postoperatorio, aplicar pautas multimodales y retirarlos precozmente cuando puedan ser sustituidos por otros analgésicos. En los programas de cirugía fast-track, el inicio precoz de la deambulación, de la fisioterapia o de la rehabilitación son factibles con un nivel moderado de dolor. Pretender eliminar totalmente el dolor en estos programas de fast-track puede asociarse a inmovilidad del paciente o a efectos secundarios de los analgésicos que retrasen la recuperación. Se han desarrollado nuevos dispositivos de administración de opioides no invasivos o «needel-free», con el fin de eliminar las desventajas de la morfina intravenosa. Las ventajas teóricas se basan en una mayor movilidad y satisfacción del paciente, en la autoadministración y en un mejor perfil farmacológico. Son opioides de inicio rápido y acción prolongada, sin metabolitos activos, por lo que teóricamente tienen un perfil farmacológico más eficaz y seguro. Estas nuevas alternativas podrían sustituir a la administración de la PCA de morfina a bolos en la cirugía mayor laparoscópica o en la cirugía de columna vertebral, entre otras. También podrían jugar un papel de analgesia de transición, en la retirada precoz de los catéteres epidurales o paravertebrales en cirugía torácica o en cirugía vascular (AU)

Effective control of postoperative pain, as well as other factors such as early mobilization and nutrition, are directly related to the reduction of postoperative complications and hospital stay, and have become an essential part of perioperative care There are actually several challenges in the field of the treatment of DAP, which require new approaches and therapeutic alternatives. The specific analgesic protocols for each type of surgery, adapted to the organizational context and clinical practice, are a guarantee to individualize the treatments and appropriately respond to the analgesic demands of any patient. Among the recommendations of the recent Guidelines for the Management of Acute Postoperative Pain of the American Pain Society (APS), we highlight: the use of Multimodal Analgesia, Regional and Epidural Analgesia in specific procedures, the minimum possible doses of opioids, the preference of the oral versus intravenous route, and PCA modality. Faced with the epidemic use of opioids, the current recommendations are based on minimizing the dose of postoperative opioids, together with, applying multimodal guidelines and early withdrawing, when they can be replaced by other analgesics. In fast-track surgery programs, the early onset of ambulation, physical therapy and/or rehabilitation are feasible with a moderate level of pain. Attempting to eliminate completely the pain in these fast-track programs can be associated with patients immobility, or analgesic side effects that may delay patients recovery. New devices for administering non-invasive opioids or «needel-free» have been developed in order to eliminate the disadvantages of intravenous morphine. The theoretical advantages are based on greater mobility and patient satisfaction, self-administration and a better pharmacological profile. They are fast onset opioids with a prolonged action and without active metabolites, which offer a theoretically more effective and safe pharmacological profile. These new alternatives could replace the administration of morphine PCA to boluses, in major laparoscopic surgery or in spinal surgery, among others. They may also play a role in the transition analgesia, in situations such as early withdrawal of epidural or paravertebral catheters in thoracic or vascular surgery (AU)

El transfer de URG/BQ a UCIP, ¿cómo debe hacerse? / No disponible

No disponible

Effectiveness and safety of ombitasvir, paritaprevir, ritonavir ± dasabuvir ± ribavirin: An early access programme for Spanish patients with genotype 1/4 chronic hepatitis C virus infection.

Over the last 5 years, therapies for hepatitis C virus (HCV) infection have improved significantly, achieving sustained virologic response (SVR) rates of up to 100% in clinical trials in patients with HCV genotype 1. We investigated the effectiveness and safety of ombitasvir/paritaprevir/ritonavir±dasabuvir in an early access programme. This was a retrospective, multicentre, national study that included 291 treatment-naïve and treatment-experienced patients with genotype 1 or 4 HCV infection. Most patients (65.3%) were male, and the mean age was 57.5 years. The mean baseline viral load was 6.1 log, 69.8% had HCV 1b genotype, 72.9% had cirrhosis and 34.7% were treatment-naïve. SVR at 12 weeks posttreatment was 96.2%. Four patients had virological failure (1.4%), one leading to discontinuation. There were no statistical differences in virological response according to genotype or liver fibrosis. Thirty patients experienced serious adverse events (SAEs) (10.3%), leading to discontinuation in six cases. Hepatic decompensation was observed in five patients. Four patients died during treatment or follow-up, three of them directly related to liver failure. Multivariate analyses showed a decreased probability of achieving SVR associated with baseline albumin, bilirubin and Child-Pugh score B, and a greater probability of developing SAEs related to age and albumin. This combined therapy was highly effective in clinical practice with an acceptable safety profile and low rates of treatment discontinuation.

Topical EMLA for pain control during extracorporeal shock wave lithotripsy: prospective, comparative, randomized, double-blind study.

Patient collaboration in external shock wave lithotripsy (ESWL) is critical for its correct application, making proper analgesic selection indispensable. The aim of this study was to evaluate the efficacy of combined application of EMLA and intravenous (i.v.) pethidine compared with pethidine plus placebo cream in patients undergoing ESWL for ureteral and/or renal lithiasis. Prospective, controlled, randomized, double-blind study was conducted in patients receiving ESWL for renal and/or ureterolithiasis. The patients were randomly assigned to receive i.v. pethidine plus either EMLA cream (group A) or placebo hydrating cream (group B). Evaluated were type, location, and size of lithiasis, patient's sex, age, body mass index, comorbidity, Visual Analogue Scale (VAS) score of pain, and degree of lithiasis fragmentation. EMLA cream provided significantly better pain relief and lithiasis fragmentation and more completed ESWL treatment. Topical application of EMLA cream combined with i.v. pethidine improved VAS scores and lithiasis fragmentation and decreased the rate of withdrawal from ESWL procedure versus i.v. pethidine plus placebo therapy.

[Radiofrequency ablation as an alternative treatment for organ confined renal tumor]. / Ablación con radiofrecuencia como alternativa de tratamiento para el tumor renal localizado.

INTRODUCTION: We report our early clinical experience associated with radiofrequency (RF) ablation in patients with renal cell carcinoma (RCC) and evaluate the efficacy, tolerability and complications. MATERIAL AND METHODS: Retrospective review of patients treated in our hospital with kidney ecoguide RF. All of them diagnosed with renal tumor and not candidates for surgery because of bilateral tumor, significant comorbidity or refusal to surgical treatment. We use an Amitech® 220 Watts generator with an electrode tip 3 cm. Straight knitting needles and hooks. Controls were performed with axial tomography at 24h, 7 days, 1, 3 and 6 months and every 6 months thereafter. RESULTS: 11 tumors, 9 patients. The mean age was 76 years (63-85 years). The average tumor size was 3.5 cm (2.2-5.8 cm). In 2 tumors was needed prior chemoembolization. In other two new RF session was needed. 9 tumors with treatment considered effective. Mean follow-up was 17.5 months (3-52 months). One patient had local recurrence at 14 months and needed a laparoscopic radical nephrectomy and two patients developed lung metastases 41.5 months after RF. There were no clinically relevant complications. CONCLUSIONS: In our experience, we believe that RF is considered an alternative treatment for renal tumors with clinical stage T1 or T2 very symptomatic in patients in whom surgery is not possible, with acceptable results in the medium term, a good tolerance, reduced consumption of hospital resources and low complication rate.

Ablación con radiofrecuencia como alternativa de tratamiento para el tumor renal localizado / Radiofrequency ablation as an alternative treatment for organ confined renal tumor

Introducción: Presentamos nuestra serie inicial de tumores renales tratados mediante radiofrecuencia (RF) continua percutánea y evaluamos la eficacia, la tolerabilidad y las complicaciones de la técnica. Material y métodos: Revisión retrospectiva de los pacientes tratados en nuestro hospital con RF renal ecoguiada. Todos diagnosticados de tumor renal y no candidatos a cirugía por tumor bilateral, comorbilidad importante o rechazo al tratamiento quirúrgico. Utilizamos un generador Amitech® de 220W con una punta de electrodo de 3 cm, agujas de punta recta y en gancho. Los controles fueron realizados mediante una tomografía computarizada toracoabdominopélvica a las 24h, a los 7 días, al mes, a los 3 meses y a los 6 meses, y cada 6 meses después. Resultados: Se hallaron 11 tumores en 9 pacientes. La media de edad fue de 76 años (63–85). La media de tamaño tumoral fue de 3,5cm (2,2–5,8). En 2 tumores se necesitó de quimioembolización previa y en otros dos se necesitó una nueva sesión de RF. Hubo 9 tumores con tratamiento considerado como eficaz. La media de seguimiento fue de 17,5 meses (3–52). Un paciente tuvo persistencia de enfermedad a los 3 meses con necesidad de nefrectomía radical laparoscópica y otros dos tuvieron metástasis pulmonares a los 26,5 meses de media. No hubo complicaciones relevantes clínicamente. Conclusiones: En nuestra experiencia, estimamos que la RF es un tratamiento considerado como una alternativa para los tumores renales de estadio clínico T1 o T2 muy sintomáticos, en pacientes en los que no es posible la cirugía, con unos resultados aceptables a medio plazo, una buena tolerancia, un escaso consumo de recursos hospitalarios y un bajo índice de complicaciones (AU)

Introduction: We report our early clinical experience associated with radiofrequency (RF) ablation in patients with renal cell carcinoma (RCC) and evaluate the efficacy, tolerability and complicactions. Material and methods: Retrospective review of patients treated in our hospital with kidney ecoguide RF. All of them diagnosed with renal tumor and not candidates for surgery because of bilateral tumor, significant comorbidity or refusal to surgical treatment. We use an Amitech® 220 Watts generator with an electrode tip 3cm. Straight knitting needles and hooks. Controls were performed with axial tomography at 24h, 7 days, 1, 3 and 6 months and every 6 months thereafter.Results11 tumors, 9 patients. The mean age was 76 years (63–85 years). The average tumor size was 3.5cm (2,2–5,8cm). In 2 tumors was needed prior chemoembolization. In other two new RF session was needed. 9 tumors with treatment considered effective. Mean follow-up was 17.5 months (3–52 months). One patient had local recurrence at 14 months and needed a laparoscopic radical nephrectomy and two patients developed lung metastases 41.5 months after RF. There were no clinically relevant complications. Conclusions: In our experience, we believe that RF is considered an alternative treatment for renal tumors with clinical stage T1 or T2 very symptomatic in patients in whom surgery is not possible, with acceptable results in the medium term, a good tolerance, reduced consumption of hospital resources and low complication rate (AU)