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BMJ Case Rep ; 11(1)2018 Dec 03.
Artigo em Inglês | MEDLINE | ID: mdl-30567185


Patent foramen ovale (PFO) is a congenital abnormality present in 25%-30% of healthy adults and rarely leads to any sequelae. 1 2 It is associated with a left-to-right shunt which usually does not lead to any haemodynamic compromise. Occasionally, the shunt can get reversed; that is, right-to-left shunt occurs due to worsening pulmonary hypertension and can lead to persistent hypoxia. It is rare for the shunt reversal to happen in the absence of pulmonary hypertension. Here, we present an exceedingly rare case in a 61-year-old man presenting with hypoxia, was found to have shunt reversal due to unilateral diaphragmatic paralysis. He was successfully treated with PFO closure. The purpose of this report is to consider rare possibilities of PFO shunt reversal when the right-sided heart pressure is normal and to highlight that a simple chest X-ray can be a clue to the diagnosis.

Forame Oval Patente/diagnóstico , Paralisia Respiratória/diagnóstico , Adulto , Diagnóstico Diferencial , Ecocardiografia Transesofagiana , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/cirurgia , Humanos , Hipertensão Pulmonar/etiologia , Hipóxia/etiologia , Masculino , Paralisia Respiratória/complicações , Paralisia Respiratória/diagnóstico por imagem , Paralisia Respiratória/cirurgia
Clin Genitourin Cancer ; 16(4): e751-e760, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29551583


BACKGROUND: Upper tract urothelial carcinoma (UTUC) accounts for approximately 5% of all urothelial cancers. Because of similarities in morphology and histology between UTUC and urothelial carcinoma of the bladder, most treatment guidelines used for UTUC are extrapolated from the urothelial bladder carcinoma setting. With the emergence of new treatment modalities, such as immunotherapy, UTUC-specific prognostic and predictive models are needed. PATIENTS AND METHODS: A retrospective study of 454 UTUC patients who received surgery at Cleveland Clinic (1995-2014) was conducted. Univariable and multivariable analysis (MVA) was used to identify independent predictors of progression-free survival (PFS) and overall survival (OS). RESULTS: Two hundred eighty-six patients with invasive UTUC were identified with pT1, pT2, pT3, and pT4 in 93 (33%), 51 (18%), 126 (44%), and 16 (6%), respectively. Most patients (76%) had laparoscopic nephroureterectomy, 14% had positive invasive surgical margins, and 22% had multifocal tumors. All patients had urothelial carcinoma as primary histology, 93 of 183 (51%) with available follow-up data had disease recurrence. Estimated median PFS was 17.2 months (95% confidence interval [CI], 13.1-39.3). In MVA, pT stage (P = .0005), positive margins (P = .04), and age older than 70 years (P = .002) independently correlated with PFS. Overall, 101 patients (37%) of 272 patients with available data died with estimated median OS of 64.5 months (95% CI, 39.3-107.4); median follow-up was 39.5 (range, 0.3-186) months in patients alive and recurrence-free at last follow-up. In MVA, lymphovascular invasion (P = .005), tumor size (P = .0005), age (P = .005), and pT stage (P = .03) independently predicted OS. Using these factors, 3 prognostic groups for PFS and 2 for OS were identified. CONCLUSION: Clinical-pathological parameters can be prognostic in UTUC and might inform clinical trial design and decision-making.

Carcinoma de Células de Transição/cirurgia , Laparoscopia/métodos , Recidiva Local de Neoplasia/epidemiologia , Nefroureterectomia/métodos , Neoplasias Urológicas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Resultado do Tratamento