Manejo de masas renales en receptores de trasplante renal. Revisión colaborativa de los grupos de trabajo de trasplante renal y cáncer renal de la sección de jóvenes urológos (YAU) de la Asociación Europea de Urología (EAU) / How to manage renal masses in kidney transplant recipients? A collaborative review by the EAU-YAU kidney transplantation and renal cancer working groups

Introducción: Los receptores de trasplante renal (TR) tienen al menos cuatro veces más riesgo de desarrollar neoplasias renales que la población general. Dado que estos pacientes suelen albergar tumores bilaterales o multifocales, el tratamiento de las masas renales sigue siendo un tema controvertido. Objetivo Explorar el tratamiento actual de las masas renales en riñones nativos de pacientes con TR. Adquisición de la evidencia Se realizó una búsqueda bibliográfica en la base de datos Medline/PubMed y se incluyeron 34 estudios en la presente revisión. Síntesis de la evidencia La vigilancia activa es una opción terapéutica factible en pacientes frágiles con masas renales menores de 3 cm. Dado que la cirugía conservadora de nefronas no está justificada en el caso de masas en el riñón nativo, la nefrectomía radical es el tratamiento estándar para los tumores renales en riñones nativos de receptores de TR, con técnicas laparoscópicas asociadas a tasas de complicaciones perioperatorias significativamente menores en comparación con el abordaje abierto. La realización de nefrectomía bilateral de riñón nativo y TR en el mismo acto puede ser una opción terapéutica en pacientes con masa renal y enfermedad poliquística renal, particularmente ante la ausencia de diuresis residual. Los pacientes con enfermedad localizada y nefrectomía radical satisfactoria no requieren ajuste del tratamiento inmunosupresor. En los casos con metástasis, los agentes mTOR pueden garantizar una respuesta antitumoral eficaz, manteniendo a la vez el tratamiento inmunosupresor adecuado para proteger el injerto. Conclusiones El cáncer renal en riñones nativos postrasplante es un acontecimiento frecuente. La nefrectomía radical es el tratamiento de elección en masas renales localizadas. Aún no se ha implementado una estrategia de cribado estandarizada y ampliamente aprobada para las neoplasias malignas en las unidades renales nativas. (AU)

Introduction: Kidney transplant (KT) recipients have a four-times higher risk of renal malignancies compared to general population. As these patients frequently harbor bilateral or multifocal tumors, the management of renal masses is still under debate. Objective To explore the current management of the native kidney masses in KT patients.Acquisition of evidenceWe performed a literature search on MEDLINE/PubMed database. A number of 34 studies were included in the present review. Synthesis of evidence In frail patients with renal masses below 3 cm, active surveillance is a feasible alternative. Nephron-sparing surgery is not justified for masses in the native kidney. Radical nephrectomy is the standard treatment for post-transplant renal tumors of the native kidneys in KT recipients, with laparoscopic techniques leading to significantly less perioperative complication rates as compared to the open approach. Concurrent bilateral native nephrectomy at the time of transplantation can be considered in patients with renal mass and polycystic kidney disease, especially if no residual urinary output is present. Patients with localized disease and successful radical nephrectomy do not require immunosuppression adjustment. In metastatic cases, mTOR agents can ensure efficient antitumoral response, while maintaining proper immunosuppression in order to protect the graft. Conclusions Post-transplant renal cancer of the native kidneys is a frequent occurrence. Radical nephrectomy is most frequently performed for localized renal masses. A standardized and widely-approved screening strategy for malignancies of native renal units is yet to be implemented. (AU)

Actualización en carcinoma diferenciado de tiroides refractario a radioyodo / Update on iodine-refractory differentiated thyroid carcinoma

La terapia con radioyodo constituye un pilar fundamental en la terapia adyuvante de rutina de los pacientes con carcinoma diferenciado de tiroides de alto riesgo. Sin embargo, un porcentaje no despreciable de estos pacientes desarrollaran un estado de refractariedad a este tratamiento, mostrando un peor pronóstico, disminuyendo la supervivencia y la esperanza de vida, lo que demuestra una clara necesidad de explorar distintos abordajes terapéuticos. El tratamiento de los pacientes refractarios al radioyodo sigue siendo un desafío, disponiendo en la actualidad de distintas opciones terapéuticas novedosas que deben ser conocidas por las distintas especialidades relacionadas con el carcinoma diferenciado de tiroides (CDT). El objetivo del presente trabajo es hacer una revisión del CDT refractario al tratamiento con yodo radiactivo, centrándose especialmente en la definición de yodorrefractariedad, destacando su importancia por su elevada mortalidad, e introducir las diferentes opciones terapéuticas disponibles para estos pacientes (AU)

Radioiodine therapy represents a fundamental pillar in the routine adjuvant therapy of patients with high-risk differentiated thyroid carcinoma. However, a non-negligible percentage of these patients will develop iodine refractoriness, showing a worse prognosis, as well a lower survival, which demonstrates a clear need to explore different therapeutic approaches. Iodine refractory patient treatment continues to be a challenge, currently having different novel therapeutic options that should be known by the different specialties related to differentiated thyroid carcinoma (DTC). The aim of this work is to review iodine refractory thyroid carcinoma treatment, focusing especially on the definition of iodine refractoriness, highlighting its importance due to its high mortality, and introducing the different therapeutic options available for these patients (AU)

Update on iodine-refractory differentiated thyroid carcinoma.

Radioiodine therapy represents a fundamental pillar in the routine adjuvant therapy of patients with high-risk differentiated thyroid carcinoma. However, a non-negligible percentage of these patients will develop iodine refractoriness, showing a worse prognosis, as well a lower survival, which demonstrates a clear need to explore different therapeutic approaches. Iodine refractory patient treatment continues to be a challenge, currently having different novel therapeutic options that should be known by the different specialties related to differentiated thyroid carcinoma (DTC). The aim of this work is to review iodine refractory thyroid carcinoma treatment, focusing especially on the definition of iodine refractoriness, highlighting its importance due to its high mortality, and introducing the different therapeutic options available for these patients.

Estadificación ganglionar tras terapia sistémica primaria en mujeres con cáncer de mama y afectación ganglionar al diagnóstico / Lymph node staging after primary systemic therapy in women with breast cancer and lymph node involvement at diagnosis

Objetivo: El objetivo principal de este estudio es analizar la eficacia del marcaje ganglionar combinado (clip y biopsia de ganglio centinela (BGC)) para la estadificación axilar en pacientes con tratamiento sistémico primario (TSP) y cáncer de mama con ganglios positivos confirmados patológicamente en el momento del diagnóstico. El objetivo secundario es determinar el impacto del marcaje ganglionar en la supresión de la linfadenectomía axilar (LA) en el grupo a estudio. Métodos: Estudio prospectivo en el que se realizó la estadificación ganglionar mediante la localización con alambre metálico (arpón) de los ganglios afectados y una BGC con doble trazador. Todas las pacientes sin afectación metastásica del ganglio centinela (GC) o del ganglio marcado con clip/alambre no realizaron una LA. El comité multidisciplinar acordó el tratamiento axilar de las pacientes con afectación ganglionar. Resultados: Ochenta y un pacientes cumplieron los criterios de inclusión. Identificamos y extirpamos el ganglio marcado con clip/alambre en 80 de 81 pacientes (98,8%), y la BGC se realizó con éxito en el 88,9% de los pacientes. El GC y el nódulo marcado con arpón coincidieron en el 78,9% de las pacientes. El 76,2% de las pacientes no se sometieron a LA. Conclusiones: El marcaje axilar combinado (clip y BGC) en pacientes con ganglios metastásicos al diagnóstico y TSP ofrece una alta tasa de identificación (98,8%) y una alta correlación entre el ganglio marcado con arpón y el GC (78,8%). Este procedimiento ha permitido la supresión de la LA en el 76,2% de las pacientes incluidas en el estudio. (AU)

Objective: The main objective of this study is to analyze the efficacy of combined axillary marking (lymph node clipping and sentinel lymph node biopsy (SLNB)) for axillary staging in patients with primary systemic treatment (PST) and pathologically confirmed node-positive breast cancer at diagnosis. The secondary objective is to determine the impact of lymph node marking in the suppression of axillary lymph node dissection (ALND) in the study group. Methods: We conducted a prospective study in which lymph node staging was performed using wire localization of positive lymph nodes and a SLNB with dual tracer. All patients who presented no metastatic involvement of the sentinel lymph node (SLN) or clip/wire-marked lymph node were spared an ALND. The multidisciplinary committee agreed on axillary treatment for patients with lymph node involvement. Results: Eighty one patients met the inclusion criteria. We identified and extirpated the clip/wire-marked node in 80 of 81 patients (98.8%), with SLNB performed successfully in 88,9% of patients. The SLN and wire-marked node matched in 78.9% of patients; 76.2% of patients did not undergo ALND. Conclusions: The combined axillary marking (clip and SLNB) in patients with metastatic lymph node at diagnosis and PST offers a high identification rate (98.8%%) and a high correlation between the wire-marked lymph node and the SLN (78.9%%). This procedure has enabled the suppression of ALND in 76.2% of patients. (AU)

How to manage renal masses in kidney transplant recipients? A collaborative review by the EAU-YAU kidney transplantation and renal cancer working groups.

INTRODUCTION: Kidney transplant (KT) recipients have a four-times higher risk of renal malignancies compared to general population. As these patients frequently harbor bilateral or multifocal tumors, the management of renal masses is still under debate. OBJECTIVE: To explore the current management of the native kidney masses in KT patients. ACQUISITION OF EVIDENCE: We performed a literature search on MEDLINE/PubMed database. A number of 34 studies were included in the present review. SYNTHESIS OF EVIDENCE: In frail patients with renal masses below 3 cm, active surveillance is a feasible alternative. Nephron-sparing surgery is not justified for masses in the native kidney. Radical nephrectomy is the standard treatment for post-transplant renal tumors of the native kidneys in KT recipients, with laparoscopic techniques leading to significantly less perioperative complication rates as compared to the open approach. Concurrent bilateral native nephrectomy at the time of transplantation can be considered in patients with renal mass and polycystic kidney disease, especially if no residual urinary output is present. Patients with localized disease and successful radical nephrectomy do not require immunosuppression adjustment. In metastatic cases, mTOR agents can ensure efficient antitumoral response, while maintaining proper immunosuppression in order to protect the graft. CONCLUSIONS: Post-transplant renal cancer of the native kidneys is a frequent occurrence. Radical nephrectomy is most frequently performed for localized renal masses. A standardized and widely-approved screening strategy for malignancies of native renal units is yet to be implemented.

Lymph node staging after primary systemic therapy in women with breast cancer and lymph node involvement at diagnosis.

OBJECTIVE: The main objective of this study is to analyze the efficacy of combined axillary marking (lymph node clipping and sentinel lymph node biopsy (SLNB)) for axillary staging in patients with primary systemic treatment (PST) and pathologically confirmed node-positive breast cancer at diagnosis. The secondary objective is to determine the impact of lymph node marking in the suppression of axillary lymph node dissection (ALND) in the study group. METHODS: We conducted a prospective study in which lymph node staging was performed using wire localization of positive lymph nodes and a SLNB with dual tracer. All patients who presented no metastatic involvement of the sentinel lymph node (SLN) or clip/wire-marked lymph node were spared an ALND. The multidisciplinary committee agreed on axillary treatment for patients with lymph node involvement. RESULTS: Eighty one patients met the inclusion criteria. We identified and extirpated the clip/ wire-marked node in 80 of 81 patients (98.8%), with SLNB performed successfully in 88,9% of patients. The SLN and wire-marked node matched in 78.9% of patients; 76.2% of patients did not undergo ALND. CONCLUSIONS: The combined axillary marking (clip and SLNB) in patients with metastatic lymph node at diagnosis and PST offers a high identification rate (98.8%) and a high correlation between the wire-marked lymph node and the SLN (78.9%). This procedure has enabled the suppression of ALND in 76.2% of patients.

The second Mexican consensus on hepatocellular carcinoma. Part II: Treatment.

Hepatocellular carcinoma (HCC) is more frequently manifesting as one of the main complications of cirrhosis of the liver, its principal risk factor. There have been modifications in its incidence over the past decade, related to an epidemiologic transition in the etiology of cirrhosis, with a decrease in the prevalence of hepatitis C and an increase in nonalcoholic fatty liver disease (NAFLD) as a cause, as well as the development of HCC in the non-cirrhotic liver due to NAFLD. Genetic markers associated with the disease have been identified, and surveillance and diagnosis have improved. Regarding treatment, surgical techniques, in both resection and transplantation, have advanced and radiologic techniques, at the curative stage of the disease, have enhanced survival in those patients. And finally, there have been radical changes in the systemic approach, with much more optimistic expectations, when compared with the options available a decade ago. Therefore, the Asociación Mexicana de Hepatología decided to carry out the Second Mexican Consensus on Hepatocellular Carcinoma, which is an updated review of the available national and international evidence on the epidemiology, risk factors, surveillance, diagnosis, and treatment of the disease, to offer the Mexican physician current information on the different topics regarding hepatocellular carcinoma. In this second part of the document, the topics related to the treatment of HCC are presented.

Integrative Systemic Supervision: Promoting Supervisees' Theoretical Integration in Systemic Therapy.

Integrative systemic therapy (IST) is a meta-theoretical perspective, grounded in systemic theory and integration, that transcends therapy models in individual, couple, and family therapy. To foster supervisees' theoretical integration and systemic thinking, two of IST's primary tools-the essence diagram and blueprint-are described and applied to inform an integrative, systemic meta-perspective for supervision. Recommendations, specific guiding questions, and examples are provided to operationalize these tools in the multi-level supervision system (i.e., supervisor-supervisee-client system). IST supervisors and other supervisors who are interested in integrative, systemic training can use these tools to guide the process of supervision and strengthen supervisees' ability to hypothesize, plan, converse, and read clients' feedback in relation to the various tasks of therapy. The essence diagram and blueprint are applied to facilitate case consultation and cultivate the development of supervisees' clinical competencies. Particularly, the problem-solving focus of IST has been adapted to include a competency-based and professional growth-oriented dimension for supervision to better promote supervisees' development. Lastly, the advantages and challenges of IST-influenced supervision are discussed.

La terapia sistémica integral (TSI) es una perspectiva metateórica basada en la teoría sistémica y la integración, que trasciende los modelos de terapia en la terapia individual, de pareja y familiar. Para fomentar la integración teórica de los supervisados y el pensamiento sistémico, se describen y se aplican dos de las herramientas principales de la TSI-el diagrama del eje y el diseño- a fin de respaldar una metaperspectiva integradora y sistémica de la supervisión. Se ofrecen recomendaciones, preguntas orientadoras específicas y ejemplos para poner en funcionamiento estas herramientas en el sistema de supervisión multinivel (p. ej.: sistema supervisor-supervisado-paciente). Los supervisores de la TSI y otros supervisores que estén interesados en la capacitación integradora y sistémica pueden usar estas herramientas para guiar el proceso de supervisión y fortalecer la capacidad de los supervisados para plantear hipótesis, planificar, conversar y leer los comentarios de los pacientes en relación con las diferentes tareas de la terapia. El diagrama del eje y el diseño se aplican para facilitar la consulta de casos y cultivar el desarrollo de las competencias clínicas de los supervisados. Particularmente, se ha adaptado el eje de resolución de problemas de la TSI para incluir una dimensión basada en competencias y orientada al crecimiento profesional a fin de que la supervisión promueva mejor el desarrollo de los supervisados. Por último, se comentan las ventajas y las dificultades de la supervisión influida por la TSI.

Encontros e desencontros: o casal e suas motivações para adoção / Encounters and mismatches: the couple and their motivations for adoption

O tema central do presente trabalho trata das diversas motivações que impulsionam os casais pretendentes à adoção a ingressarem com o processo de habilitação no Juizado da Infância e Juventude. Tem como objetivo abordar os principais motivos, mostrando a importância de compreender o desejo do casal enquanto projeto de família e os desejos objetivos e subjetivos de cada membro para a adoção. Para tal, são feitas reflexões à luz da teoria e de situações da prática clínica, salientando os aspectos relativos à sintonia entre o casal e a pertinência destes motivos em relação ao seu contexto de vida e às demandas de uma criança que está à espera de uma família. Em face das diferentes motivações, apresentamos considerações quanto à contribuição da abordagem da terapia sistêmica de casal na compreensão e intervenção nas questões que emergem e interferem no projeto de adoção.

The central theme of this work deals with the various motivations that impel couples seeking adoption to join the process of qualification in the Court of Childhood and Youth. It aims to address the main reasons, showing the importance of understanding the couple's desire as a family project and the objective and subjective desires of each member. For this, reflections are made, in the light of theory and clinical practice situations. They address aspects related to the harmony between the couple and the relevance of these reasons in relation to their life context and the demands of a child who is waiting for a family. In view of the different motivations, we present considerations regarding the contribution of the systemic couple therapy approach to the understanding and intervention in the issues that emerge and interfere in the adoption project.

Caracterização da clientela da clínica-escola de um instituto de terapia relacional sistêmica / Characterization of the clinic-school clientele of a system of relational systemic therapy

Este estudo teve por objetivo caracterizar o perfil clínico e sociodemográfico da clientela de uma clínica-escola de um instituto de Terapia Relacional Sistêmica, localizado na região Sul do Brasil. Foram analisadas 315 fichas de triagem dos atendimentos que ocorreram entre janeiro de 2016 e dezembro de 2017. Os dados foram analisados através de estatística descritiva por meio do programa SPSS. Os resultados mostraram que houve predomínio de atendimentos individuais, pessoas do gênero feminino, com ensino superior completo, solteiros e com idade entre 20-29 anos. As famílias que procuraram psicoterapia estavam na fase do ciclo de vida denominada família com filhos pequenos e os casais encontravam-se na faixa etária entre 30-39 anos. As principais queixas foram: dificuldades nas relações familiares, sintomas depressivos e ansiedade, as quais somaram 44,4% do total. Este estudo permitiu refletir sobre o planejamento dos serviços de psicologia e a adequação das ações voltadas às especificidades da clientela.

This study aimed to characterize clinical and demographic profile of clients of a Psychology Clinic School of an institute of Relational Systemic Therapy, located in the South region of Brazil. A number of 315 files was analyzed from the screening process occurred between January 2016 and December 2017. Data were analyzed through descriptive statistics through the SPSS program. The results showed that there was a predominance of individual patients, female, with higher education, single and age 20-29 years old. The families that searched for psychotherapy were in the stage of family with children in life cycle and couples were in the age group between 30-39 years old. The main complaints were: difficulties in family relationships, depressive and anxiety symptoms, which accounted for 44.4% of the total. This study allows reflecting about the planning of the Psychology Services and the adequacy of actions to the specifics of the clients.

Micro-fenomenología de la subjetividad del psicoterapeuta sistémico / Micro-phenomenology of the subjectivity of the systemic psychotherapist / Micro-fenomenologia da subjetividade do psicoterapeuta sistêmico

La terapia psicológica sistémica acontece en un contexto relacional, donde interactúan las subjetividades de los consultantes y los terapeutas. Las investigaciones tradicionales han focalizado más las características de los consultantes, que la subjetividad del terapeuta. De ahí que hayan privilegiado perspectivas de "tercera persona". Los pocos estudios que indagan la subjetividad del terapeuta recurren a metodologías introspectivas, interpretativas y prescriptivas. ¿Cómo acceder a la subjetividad del terapeuta desde perspectivas distintas a las que ofrecen la observación en "tercera persona" y la introspección en "primera persona"? El propósito del artículo es explorar, mediante el método micro-fenomenológico, cómo se muestra la subjetividad del terapeuta en la primera impresión de un consultante. Para ello, se realizaron entrevistas a seis terapeutas. Los resultados evidencian que la emocionalidad en-activa aparece como una invariante de la subjetividad del terapeuta; y que esta invariante opera como una "motivación inteligente", la cual entra "en acción" en el trascurso de la relación intersubjetiva misma y, permanentemente, monitorea y orienta el proceso terapéutico. Los resultados permiten considerar, por un lado, que las investigaciones tradicionales han subvalorado la importancia de la emocionalidad en-activa en el proceso terapéutico; y, por otro, que el mejoramiento cualitativo de la terapia implica no sólo reconocer esta invariante, sino también cultivarla.

Systemic psychological therapy takes place in a relational context, where the subjectivities of the consultants and the therapists interact. Traditional research has focused more on the characteristics of the consultants than on the subjectivity of the therapist. Hence, "third person" perspectives have been privileged. The few studies that investigate the subjectivity of the therapist resort to introspective, interpretive and prescriptive methodologies. How to access the subjectivity of the therapist from different perspectives than those offered by "third person" observation and "first person" introspection? The purpose of the article is to explore, through the micro-phenomenological method, how the subjectivity of the therapist is shown in the first impression of a consultant. To do this, interviews were conducted with six therapists. The results show that en-active emotionality appears as an invariant of the therapist's subjectivity; and that this invariant operates as an "intelligent motivation", which enters "into action" in the course of the intersubjective relationship itself and permanently monitors and guides the therapeutic process. The results allow us to consider, on the one hand, that traditional research has undervalued the importance of en-active emotions in the therapeutic process; and, on the other, that the qualitative improvement of therapy implies not only recognizing this invariant, but also cultivating it.

A terapia psicológica sistêmica ocorre em um contexto relacional, onde as subjetividades das pessoas que consultam interagem. A pesquisa tradicional se concentrou mais nas características das pessoas que consultam do que na subjetividade do terapeuta. Portanto, as perspectivas da "terceira pessoa" foram privilegiadas. Os poucos estudos que investigam a subjetividade do terapeuta recorrem a metodologias introspectivas, interpretativas e prescritivas. Como acessar a subjetividade do terapeuta sob perspectivas diferentes daquelas oferecidas pela observação em "terceira pessoa" e introspecção em "primeira pessoa"? O objetivo do artigo é explorar, através do método micro-fenomenológico, como a subjetividade do terapeuta é mostrada na primeira impressão de um consultor. Para isso, foram realizadas entrevistas com seis terapeutas. Os resultados mostram que a emocionalidade em-ativa aparece como um invariante da subjetividade do terapeuta; e que esse invariante opera como uma "motivação inteligente", que entra em "ação" no curso da própria relação intersubjetiva e monitora e guia permanentemente o processo terapêutico. Os resultados permitem considerar, por um lado, que a pesquisa tradicional subvalorizou a importância das emoções em-ativas no processo terapêutico; e, por outro lado, que a melhoria qualitativa da terapia implica não apenas reconhecer esse invariável, mas também cultivá-lo.

The Milan Approach, History, and Evolution.

The two authors intend to underline the continuities and discontinuities that organize the Milan Approach, after the splitting from Selvini Palazzoli and Prata; they intend to tell the teachings of Luigi Boscolo and Gianfranco Cecchin from the beginning of training in 1978 till nowadays. After having spoken of some important stages in the work till the death of the two masters, the article underlines two major new aspects. 1. We speak about the corporeal turn: embodied experience as preconceptual know-how from which concepts are structured. We speak about the connections between bodies and social issues that enact forms of knowledge and understanding. 2. In this period of war, violence, and tyranny, we speak about epistemology and ontology as complementary stances: the need to let others disclose themselves, by allowing them to speak their own terms of engagement. The therapeutic effort is one of deactivating the dangers of one's own presuppositions and prejudices that limit one's capacity to describe and make hypothesis. There are social ontologies, communities with strong moral intensity, historical and social realities that need therapists to take position, since they need to take side and be aware of the categories they utilize. Historical and social ontology deals with the continuous change of symptoms in connection to the continuous change of the social panorama in the context we live in. We live by the bodies we are.

Los dos autores se proponen subrayar las continuidades y las discontinuidades que organizan la terapia sistémica de Milán después de la separación de Selvini Palazzoli y Prata, y comunicar las enseñanzas de Luigi Boscolo y Gianfranco Cecchin desde el comienzo de la formación en 1978 hasta la actualidad. Después de haber hablado de algunas etapas importantes en el trabajo hasta la muerte de los dos maestros, el artículo subraya dos aspectos nuevos e importantes. 1. Hablamos acerca del giro corpóreo: la experiencia personificada como conocimiento preconceptual desde el cual se estructuran los conceptos. Hablamos acerca de las conexiones entre los cuerpos y los problemas sociales que representan formas de conocimiento y comprensión. 2. En este periodo de guerra, violencia y tiranía hablamos acerca de la epistemología y la ontología como posturas complementarias: la necesidad de dejar que los demás se den a conocer permitiéndoles comunicar sus propias condiciones de participación. El esfuerzo terapéutico es el de desactivar los peligros de las presuposiciones y los prejuicios propios que limitan la capacidad de una persona para describir y elaborar hipótesis. Hay antologías sociales, comunidades con una intensidad moral fuerte, realidades históricas y sociales que necesitan que los terapeutas adopten una postura, ya que deben tomar partido y ser conscientes de las categorías que utilizan. La ontología histórica y social se ocupa del cambio continuo de síntomas en relación con el cambio continuo del panorama social en el contexto en que vivimos. Vivimos según los cuerpos que somos.

How is Systemic and Constructionist Therapy Change Process Narrated in Retrospective Accounts of Therapy? A Systematic Meta-synthesis Review.

Despite the considerable potential of qualitative approaches for studying the systemic and constructionist therapy process due to shared theoretical and epistemological premises, to date there is lack of a comprehensive qualitative synthesis of how change process is experienced and conceptualized by clients and therapists. To address this evidence gap, we performed a systematic meta-synthesis review of 30 studies reporting clients' and therapists' retrospective narratives of change process across systemic and constructionist models and across a range of client configurations, including individuals, couples, families, and groups. The studies were identified following a systematic search in PsycINFO and MEDLINE resulting in 2,977 articles, which were screened against eligibility criteria. Thematic analysis led to the identification of four main themes: (1) navigating through differences, (2) toward nonpathologizing construction of problems, (3) navigating through power imbalances, and (4) toward new and trusting ways of relating. Findings illustrate the multifaceted aspects of systemic and constructionist change process, the importance for their reflexive appraisal, and the need for further research contributing to the understanding of the challenges inherent in the systemic and constructionist therapeutic context.

A pesar del potencial considerable de los enfoques cualitativos para estudiar el proceso de la terapia sistémica y construccionista debido a premisas teóricas y epistemológicas compartidas, hasta la fecha hay una escasez de síntesis cualitativas completas de cómo los pacientes y los terapeutas viven y conceptualizan el proceso de cambio. Para abordar esta falta de datos, realizamos una revisión sistemática de la metasíntesis de 30 estudios que informan historias retrospectivas de los pacientes y los terapeutas del proceso de cambio entre modelos sistémicos y construccionistas y entre una variedad de configuraciones de pacientes, entre ellas, individuos, parejas, familias y grupos. Los estudios se identificaron después de una búsqueda sistemática en PsycINFO y MEDLINE, de donde se obtuvieron 2,977 artículos, que se analizaron según los criterios de elegibilidad. El análisis temático condujo a la identificación de cuatro temas principales: 1) orientarse entre las diferencias, 2) hacia una construcción no patologizante de los problemas, 3) orientarse entre los desequilibrios de poder, 4) hacia formas nuevas y confiables de relacionarse. Los resultados ilustran los aspectos multifacéticos del proceso de cambio sistémico y construccionista, la importancia para su valoración reflexiva y la necesidad de más investigaciones que contribuyan a la comprensión de los desafíos inherentes en el contexto terapéutico sistémico y construccionista.

The Discursive Performance of Change Process in Systemic and Constructionist Therapies: A Systematic Meta-Synthesis Review of In-Session Therapy Discourse.

Despite the emphasis of systemic and constructionist approaches on discourse and interaction, to date there has been no comprehensive overview of how change process is performed within in-session therapeutic dialogue. In this paper, we present a qualitative meta-synthesis of 35 articles reporting systemic and constructionist therapy process data from naturally occurring therapeutic dialogue. The studies were selected following the screening against eligibility criteria of a total sample of 2,977 studies identified through a systematic search of PsycINFO and MEDLINE databases. Thematic analysis of the 35 studies' findings identified four main themes depicting change process performance: (a) shifting to a relational perspective, (b) shifting to non-pathologizing therapeutic dialogue, (c) moving-forward dialogue, and (d) the dialogic interplay of power. Findings highlight the interactional and discursive matrix within which systemic and constructionist change process occurs. Findings illuminate the value of qualitative research studies sampling naturally occurring therapeutic discourse in bringing this matrix forth, particularly when utilizing discursive methodologies like conversation or discourse analysis.

A pesar del énfasis de los enfoques sistémicos y construccionistas sobre el discurso y la interacción, hasta ahora no se ha hecho una descripción general completa de cómo se lleva a cabo el proceso de cambio dentro del diálogo terapéutico en la sesión. En este artículo presentamos una metasíntesis cualitativa de 35 artículos que informan datos del proceso de terapia sistémica y construccionista obtenidos del diálogo terapéutico que se produce naturalmente. Los estudios se eligieron siguiendo los criterios de evaluación por elegibilidad de una muestra total de 2977 estudios detectados mediante una búsqueda sistemática en las bases de datos PsycINFO y MEDLINE. El análisis temático de los resultados de los 35 estudios identificó cuatro temas principales que describen la representación del proceso de cambio; (a) el cambio a una perspectiva relacional, (b) el cambio a un diálogo terapéutico no patologizante, (c) el diálogo de avance, y (d) la interacción dialógica del poder. Los resultados destacan la matriz interactiva y discursiva dentro de la cual se produce el proceso de cambio sistémico y construccionista. Los resultados ilustran el valor de los estudios de investigación cualitativa que muestrean el discurso terapéutico producido naturalmente a la hora de presentar esta matriz, particularmente cuando se utilizan metodologías discursivas, como el análisis de la conversación o el discurso.

Clear-cell carcinoma with sarcomatoid pattern, associated with gingival metastasis. Case report and review of the literature.

ANTECEDENTES: El carcinoma renal con diferenciación sarcomatoide confiere un pronóstico sombrío por su evolución metastásica; a mucosa oral corresponde menos del 1%. CASO CLÍNICO: Mujer de 66 años, tumor dependiente de riñón izquierdo con reporte de patología de carcinoma renal de células claras patrón sarcomatoide, tumor gingival en maxilar izquierdo, biopsia con metástasis de células claras sarcomatoide. Recibió radioterapia local. Progresó con metástasis a sistema nervioso central, pulmonar, mediastinal y suprarrenal. CONCLUSIONES: La presentación clínica de tumores renales en la mucosa oral es rara. La presencia de diferenciación sarcomatoide implica un reto terapéutico por la respuesta a las terapias sistémicas existentes. Los avances en fármacos con actividad inmunitaria podrían mejorar las tasas de respuesta. BACKGROUND: The renal carcinoma with sarcomatoid differentiation confers a poor prognosis due to its metastatic evolution, less than 1% corresponds to oral mucosa. CASE REPORT: 66 year old female, left kidney tumor, with pathology report clear cell renal carcinoma, with sarcomatoid pattern, gingival tumor in the left maxilla, biopsy with sarcomatoid metastases, received local radiotherapy. It progressed with metastases to the central nervous system, pulmonary, mediastinal and adrenal. ­. CONCLUSIONS: The clinical presentation of kidney tumors in oral mucosa is rare, the presence of sarcomatoid differentiation implies a therapeutic challenge due to the response to existing systemic therapies, advances in drugs with immunological activity could improve response rates.

Comparing Cognitive Behavioral Therapy and Systemic Therapy for Social Anxiety Disorder: Randomized Controlled Pilot Trial (SOPHO-CBT/ST).

This randomized controlled trial (RCT) aimed to pilot the newly developed manualized and monitored systemic therapy (ST) for social anxiety disorder (SAD), as compared to manualized and monitored cognitive behavioral therapy (CBT). We conducted a prospective multicenter, assessor-blind pilot RCT on 38 outpatients (ICD F40.1; Structured Clinical Interview for DSM (SCID); Liebowitz Social Anxiety Scale, LSAS-SR >30). The primary outcome was level of social anxiety (LSAS-SR) at the end of treatment. A total of 252 persons were screened, and 38 patients were randomized and started therapy (CBT: 20 patients; ST: 18 patients; age: M = 36 years, SD = 14). Within-group, simple-effect intent-to-treat analyses (ITT) showed significant reduction in LSAS-SR (CBT:d = 1.04; ST:d = 1.67), while ITT mixed-design ANOVA demonstrated the advantage of ST (d = 0.81). Per-protocol analyses supported these results. Remission based on reliable change indices also demonstrated significant difference (LSAS-SR: 15% in CBT; 39% in ST;h: 0.550), supported by blind diagnosticians' ratings of those who completed therapy (SCID; 45% in CBT, 78% in ST,p = .083). No adverse events were reported. CBT and ST both reduced social anxiety, supporting patient improvement with the newly developed ST for SAD; this has yet to be verified in a subsequent confirmatory RCT.

Este ensayo controlado aleatorizado tuvo como finalidad probar la terapia sistémica (TS) estandarizada y monitoreada recientemente desarrollada para el trastorno de ansiedad social en comparación con la terapia cognitivo-conductual (TCC) estandarizada y monitoreada. Realizamos un ensayo controlado aleatorizado prospectivo, multicentro y con enmascaramiento para el evaluador en 38 pacientes ambulatorios (CIE F40.1; Entrevista Clínica Estructurada para los trastornos del DSM (SCID); Escala de Ansiedad Social de Liebowitz, LSAS-SR > 30). El resultado principal fue el nivel de ansiedad social (LSAS-SR) al final del tratamiento. Se evaluó a un total de 252 personas, 38 pacientes fueron aleatorizados y comenzaron la terapia (TCC: 20 pacientes; TS: 18 pacientes; edad: promedio= 36 años, desviación estándar = 14). Los análisis intragrupales, de efecto simple, con intención de tratar demostraron una reducción significativa del LSAS-SR (TCC: d = 1.04; TS: d = 1.67), mientras que el análisis de varianza de diseño mixto con intención de tratar demostró la ventaja de la TS (d = 0.81). Los análisis por protocolo respaldaron estos resultados. La remisión basada en los índices de cambio fiable también demostró una diferencia significativa (LSAS-SR: 15% en la TCC; 39% en la TS; h: 0.550), respaldada por diferencias casi significativas en las valoraciones con enmascaramiento para los evaluadores de aquellos que completaron la terapia (SCID; 45% en la TCC, 78% en la TS, p = 0.083). No se informaron efectos adversos. Tanto la TCC como la TS reducen la ansiedad social y respaldan la mejora de los pacientes con la terapia sistémica recientemente desarrollada para los trastornos de ansiedad social; esto aun debe verificarse en un ensayo controlado aleatorizado confirmatorio posterior.

Cuidados inconsistentes durante a infância e relações de apego na adolescência: um estudo de caso / Inconsistent childhood care and adolescent attachment relationships: a case study

O presente trabalho consiste em um estudo de caso clínico de uma adolescente, realizado em um serviço de atendimento psicológico. Ao longo da terapia sistêmica individual foram abordados aspectos da história da paciente, como negligência, perdas, adoção intrafamiliar e apego inseguro. O processo terapêutico considerou a paciente no contexto da sua história, rede de relacionamentos e experiências, enfatizando os significados que ela atribuía a esses eventos. Assim, dentro das particularidades do caso, trabalhou-se para compreender o impacto na relação entre o tipo de cuidado recebido na infância e o apego na adolescência e construção de self. Entende-se que esse estudo pode contribuir para se pensar em estratégias de intervenção sistêmica que auxiliem a mudança na visão de pais ou cuidadores com relação ao apego de adolescentes.

This work consists in a clinical case study of a female teenager, held in a psychological service. Throughout the individual systemic therapy aspects of the patient's history were addressed, such as negligence, losings, intra-family adoption and insecure attachment. The therapeutic process considered the patient in the context of her history, relationships' network and experiences, emphasizing the meanings that she attributed to these events. Thus, within the particularities of the case, the clinical work aimed to understand the impact on the relationship between the type of care received in childhood, attachment in adolescence and self-construction. This study may contribute to elaborate strategies of strategies of systemic intervention that help change the vision of parents or caregivers with regard to attachment of adolescents.

Problemas de comportamento infantil no contexto da família em crise conjugal: contribuições da terapia sistêmica / Problems of children's behavior in the family context: contributions from systemic therapy

O presente artigo pretende articular elementos de um atendimento clínico familiar à luz do referencial sistêmico, buscando entender as influências do sistema familiar, especificamente do subsistema conjugal, para o surgimento e a perpetuação de sintomas desafiadores infantis. O estudo caracteriza-se como qualitativo e utiliza a abordagem metodológica do estudo de caso clínico, descrevendo o processo de terapia sistêmica familiar da criança de cinco anos identificada como Maiara. Foram oferecidos sete atendimentos, mas a família só compareceu em quatro deles. Os resultados evidenciam que a criança, através de suas crises convulsivas e de suas atitudes desafiadoras, expressa uma dificuldade do grupo familiar, mais especificamente uma crise conjugal que vinha se agravando após a chegada dos filhos. Considera-se que as sessões realizadas auxiliaram a família nas mudanças que necessitava realizar, evitando a sobrecarga emocional de seus membros, bem como a somatização da paciente identificada.

The present article aims to articulate elements of a clinical family service using the systemic referential. The aim is to understand the influences of the family system, specifically the conjugal subsystem, for the outbreak of and perpetuation of children's challenging symptoms. This qualitative study uses the methodological approach of the clinical case study, it describes the process of systemic family therapy of the five-year-old child identified as Maiara. Seven appointments were offered, but the family only attended four of them. The results show that the child, with her convulsive crisis and challenging attitudes, expresses a difficulty of the family group, more specifically a marital crisis that was getting worse after the arrival of the children. It is considered that the sessions performed helped the family to deal with the necessary changes in their lives and this avoided the emotional overload of the family members, as well as the somatization of the identified patient.

A importância do pai no tratamento sistêmico da anorexia nervosa / The importance of father in systemic treatment of anorexia nervosa

Este artigo visa a tratar dos aspectos relacionados à função paterna na anorexia nervosa e da sua potencial importância dentro da terapia familiar sistêmica, após uma breve contextualização no desenvolvimento histórico do seu conceito nosológico, bem como relacionar com a figura e a função paterna na literatura científica. Há bastante informação teórica a respeito das relações intrafamiliares na anorexia, porém análises específicas da função paterna são escassas, prevalecendo os aspectos da relação mãe-filha. Abordaremos também um exemplo de caso da paciente R., diagnosticada com anorexia nervosa e tratada no grupo de Transtornos Alimentares no Centro de Atenção Psicossocial da Infância (CAPSi) do Hospital de Clínicas de Porto Alegre (HCPA), vinculado à Universidade Federal do Rio Grande do Sul (UFRGS), no qual consideramos o papel desempenhado pelo pai como fundamental para uma recuperação mais rápida e eficaz.

This article aims to address the issues related to the paternal function in anorexia nervosa and its potential importance within its systemic treatment, after a brief background on the historical development of its nosological concept and relate it to the image and the role of the father in the scientific literature. There is a lot of information about the intra-family relationships in anorexia, but specific analysis of the paternal role are scarce, prevailing aspects of the mother-daughter relationship. We will also explore the case example of patient "R"., diagnosed with anorexia nervosa and treated in the Eating Disorders Group in the Center for Psychosocial Care for Children (CAPSi) of Porto Alegre Clinical Hospital (HCPA), linked to the Federal University of Rio Grande do Sul (UFRGS), where we consider the role of the father as a main instrument in her quick recovery.

African American Couples in the 21st Century: Using Integrative Systemic Therapy (IST) to Translate Science into Practice.

The complexity of the African American community in the United States continues to evolve. The growing number of professional African Americans who grew up in the postcivil rights era combined with the persistent reminders of inequity paints a complex backdrop for understanding African American relationships. The majority of our knowledge about African American couples disproportionately comes from nonclinical social science fields such as sociology and demography. Unfortunately, the scholarly literature on how to work with African American couples is relatively scant. This paper seeks to add to this limited literature by providing clinicians and scholars with a proposed set of issues to consider when conceptualizing and treating African American couples. In particular, the complexity and nuance needed to work with African American couples are best done by using an integrative model. Thus, this paper will discuss how the Integrative Systemic Therapy (IST) model is particularly well suited for working with African American couples. This paper will summarize the science on African American marriages with a focus on salient factors such as gender, SES, and trust, which will then be translated into clinical practice by utilizing a case example. The case example will be of a middle-class couple in order to delineate the challenges and the growing heterogeneity of African Americans. The article will conclude with a commentary on the evolving heterogeneity of African Americans, which sheds light on how an integrative perspective is important for disentangling and embracing the growing complexity of African American couples.

La complejidad de la comunidad afroamericana de los Estados Unidos continúa evolucionando. El número cada vez mayor de afroamericanos profesionales que crecieron en la era posterior a los derechos civiles combinado con los recordatorios constantes de inequidad pinta un telón de fondo complejo para comprender las relaciones afroamericanas. La mayoría de nuestro conocimiento acerca de las parejas afroamericanas proviene desproporcionadamente de ámbitos de las ciencias sociales no clínicas, como la sociología y la demografía. Desafortunadamente, la bibliografía científica sobre cómo trabajar con parejas afroamericanas es relativamente escasa. Este artículo tiene como finalidad incrementar esta bibliografía limitada proporcionando a los clínicos y a los académicos un conjunto de asuntos propuestos para tener en cuenta al conceptualizar y tratar a las parejas afroamericanas. En particular, la complejidad y los matices necesarios para trabajar con las parejas afroamericanas se logran mejor usando un modelo integrativo. Por lo tanto, en este artículo se debatirá cómo el modelo de terapia sistémica integrativa (TSI) (Pinsof et al., 2017) se adapta perfectamente para trabajar con parejas afroamericanas. En este artículo se resumirá la ciencia sobre los matrimonios afroamericanos haciendo hincapié en factores prominentes, como el género, el nivel socioeconómico y la confianza, que luego se trasladarán a la práctica clínica utilizando un caso ilustrativo. El caso ilustrativo será de una pareja de clase media a fin de describir los desafíos y la heterogeneidad creciente de los afroamericanos. El artículo concluye con un comentario sobre la creciente heterogeneidad de los afroamericanos, donde se aclara cómo una perspectiva integrativa es importante para desenmarañar y aceptar la complejidad creciente de las parejas afroamericanas.