'Button type' bipolar plasma vaporisation of the prostate compared with standard transurethral resection: a systematic review and meta-analysis of short-term outcome studies.

OBJECTIVE: To evaluate the surgical morbidity and effectiveness in improving symptoms of benign prostatic hyperplasia (BPH), comparing 'button-type' bipolar plasma vaporisation (BTPV) vs transurethral resection of the prostate (TURP). METHODS: We conducted a literature search of published articles until November 2014. Only prospective and randomised studies with comparative data between BTPV and conventional TURP (mono- or bipolar) were included in this review. RESULTS: Six articles were selected for the analyses. In the 871 patients evaluated, 522 underwent TURP and 349 BTPV. There was a tendency for a higher transfusion rate in the TURP group, with two BTPV cases (0.006%) and 16 TURP cases (0.032%) requiring transfusions (P = 0.06). The number of complications was similar between the groups (odds ratio 0.33, 95% confidence interval [CI] 0.8-1.31; P = 0.12; I(2) = 86%). When subdivided by severity, 10.7% (14/131) and 14.6% (52/355) of complications were classified as severe (Clavien 3 or 4) in patients who underwent BTPV and TURP, respectively (P = 0.02). The average duration of indwelling catheterisation was significantly less in patients who underwent BTPV (standardised mean difference [SMD] -0.84; 95% CI -1.54 to 0.14; P = 0.02; I(2) = 81%). Both treatments significantly improved symptoms and the postoperative International Prostate Symptom Score was similar in both groups (SMD 0.09, 95% CI -1.56 to 1.73; P = 0.92). CONCLUSION: BTPV is an effective and safe treatment for BPH. The improvement of urinary symptoms and overall complications are comparable to conventional TURP. However, BTVP appears to be associated with a lower rate of major complications and duration of indwelling catheterisation.

Prospective randomized study of treatment of large proximal ureteral stones: extracorporeal shock wave lithotripsy versus ureterolithotripsy versus laparoscopy.

PURPOSE: The best treatment modalities for large proximal ureteral stones are controversial, and include extracorporeal shock wave lithotripsy, ureterolithotripsy, percutaneous nephrolithotripsy, laparoscopic ureterolithotomy and open surgery. To the best of our knowledge extracorporeal shock wave lithotripsy, semirigid ureterolithotripsy and laparoscopic ureterolithotomy have not been previously compared for the treatment of large proximal ureteral stones. Therefore, we compared these modalities for the treatment of large proximal ureteral stones. MATERIALS AND METHODS: A total of 48 patients with large proximal ureteral stones (greater than 1 cm) were prospectively randomized and enrolled in the study at a single institution between 2008 and 2010. Eligible patients were assigned to extracorporeal shock wave lithotripsy, semirigid ureterolithotripsy or laparoscopic ureterolithotomy. RESULTS: Extracorporeal shock wave lithotripsy had a 35.7% success rate, semirigid ureterolithotripsy 62.5% and laparoscopic ureterolithotomy 93.3%. Stone-free rates showed a statistically significant difference among the groups (p = 0.005). Patients treated with laparoscopic ureterolithotomy vs semirigid ureterolithotripsy vs extracorporeal shock wave lithotripsy required fewer treatment sessions (mean ± SD 1.9 ± 0.3 vs 2.2 ± 0.6 vs 2.9 ± 1.4, p = 0.027). Neither major nor long-term complications were observed. CONCLUSIONS: Proximal ureteral stone treatment requires multiple procedures until complete stone-free status is achieved. Laparoscopic ureterolithotomy is associated with higher success rates and fewer surgical procedures, but with more postoperative pain, longer procedures and a longer hospital stay. Although it is associated with the highest success rates for large proximal ureteral calculi, laparoscopic ureterolithotomy remains a salvage, second line procedure, and it seems more advantageous than open ureterolithotomy. At less well equipped centers, where semirigid ureterolithotripsy or extracorporeal shock wave lithotripsy is not available, it remains a good treatment option.

Dynamic sentinel node biopsy for inguinal lymph node staging in patients with penile cancer: a systematic review and cumulative analysis of the literature.

BACKGROUND: Dynamic sentinel node biopsy (DSNB) is used to evaluate the nodal status of patients with clinically node-negative penile carcinoma. Its use is not widespread, and the majority of patients with clinically node-negative disease undergo an elective inguinal lymph node dissection (ILND). However, a prophylactic bilateral ILND is a procedure with approximately 50% of morbidity. The purpose of this review is to evaluate the accuracy of DSNB in penile cancer. METHODS: This is a systematic review and cumulative analysis of studies published between 1966 and 2010. The Medline, Embase, Cancerlit, and American Society of Clinical Oncology abstract databases were searched for published studies on penile cancer and DSNB. The outcomes assessed were: sensitivity, specificity, likelihood ratios, and summary receiver operating characteristics (ROC) curves. RESULTS: Ten articles covering 519 participants were included in the cumulative analysis. The pooled sensitivities and specificities for sentinel node biopsy for detection of metastasis were 77.1 and 100% versus ILND and 87.9 and 100% versus wait and see program. The false-negative rate founded was 3.1% in the ILND group and 3.5% in the wait and see group. CONCLUSIONS: The use of dynamic sentinel lymph node biopsy to detect lymph node metastasis in specialized centers appears to be justified. Addiction of other techniques to DSNB to reduce false-negative results is awaited and must be confirmed by future studies.

Her-2/neu expression in prostate adenocarcinoma: a systematic review and meta-analysis.

PURPOSE: HER-2/neu has been linked to the clinical progression of hormone independent prostate cancer. We performed a meta-analysis to investigate the prognostic impact of HER-2/neu over expression in patients with prostate adenocarcinoma, and its correlation with other pathological and clinical variables. MATERIALS AND METHODS: We searched the MEDLINE, Embase, CancerLit and ASCO abstract databases for published studies of HER-2/neu protein expression in primary prostate cancer tissue with a median followup of greater than 2 years and data on survival in patients with and without HER-2/neu over expression. We separately analyzed studies reporting HER-2/neu soluble receptor levels in patients with prostate cancer. RESULTS: We included 38 articles with a total of 5,976 patients. The overall RR of death in those with HER-2/neu over expression in the primary tumor was 1.63 (95% CI 1.47-1.82, p <0.0001). In the presence of over expression the recurrence RR was 1.87 (95% CI 1.59-2.21, p <0.0001). High HER-2/neu extracellular domain levels also correlated with death (RR 2.01, 95% CI 1.21-3.35, p = 0.007) and recurrence (RR 1.74, 95% CI 1.41-2.15, p <0.0001). CONCLUSIONS: There is a consistent association of HER-2/neu over expression and Gleason less than 7 with a higher RR of death and recurrence in patients with prostate cancer. Further clinical trials should test the hypothesis that HER-2/neu is a marker of a clinically worse outcome in patients with prostate cancer and a potential target for therapy.

Percentage of excess BMI lost correlates better with improvement of metabolic syndrome after Roux-en-Y gastric bypass in morbidly obese subjects: anthropometric indexes and gastric bypass.

BACKGROUND: The metabolic syndrome (MS) is a complex disorder characterized by a number of cardiovascular risk factors usually associated with central fat deposition and insulin resistance. Many different medical treatments are available for MS, including bariatric surgery, which improves all risk factors. The present study aimed to evaluate, at the Clinic of Gastroenterology and Obesity Surgery (Brazil), the accuracy of different anthropometric indexes and their correlation with improvement of the MS factors in the postoperative (6-month) period. METHODS: This was a retrospective study of 140 patients who had undergone gastric bypass. Most of the patients were women (79.3%). The mean body mass index was 44.17 kg/m(2). We evaluated the weight of the subjects, the presence of diabetes mellitus and hypertension as co-morbidities, and the biochemical parameters. The anthropometric indexes tested included the percentage of excess weight loss, amount lost in kilograms, difference in the body mass index, percentage of initial weight lost, percentage of excess body mass index lost (%EBL), and percentage of initial fat mass lost. RESULTS: The %EBL had a Spearman's correlation coefficient of 0.55 (P <.0001) for the difference between the MS factors before and after Roux-en-Y gastric bypass. The receiver operating characteristic curve for the %EBL resulted in an area under the curve of 0.846 (P = 0.0001) and a sensitivity and specificity of 100% and 61.29%, respectively, for a cutoff value of 64.55%. CONCLUSION: The %EBL was the best method to report weight loss and the improvement in MS in morbidly obese subjects after Roux-en-Y gastric bypass.

Predictive performance of 12 equations for estimating glomerular filtration rate in severely obese patients.

OBJECTIVE: Considering that the Cockcroft-Gault formula and the equation of diet modification in renal disease are amply used in clinical practice to estimate the glomerular filtration rate, although they seem to have low accuracy in obese patients, the present study intends to evaluate the predictive performance of 12 equations used to estimate the glomerular filtration rate in obese patients. METHODS: This is a cross-sectional retrospective study, conducted between 2007 and 2008 and carried out at a university, of 140 patients with severe obesity (mean body mass index 44 ± 4.4 kg/m2). The glomerular filtration rate was determined by means of 24-hour urine samples. Patients were classified into one or more of the four subgroups: impaired glucose tolerance (n = 43), diabetic (n = 24), metabolic syndrome (n = 76), and/or hypertension (n = 66). We used bias, precision, and accuracy to assess the predictive performance of each equation in the entire group and in the subgroups. RESULTS: In renal disease, Cockcroft-Gault's formula and the diet modification equation are not precise in severely obese patients (precision: 40.9 and 33.4, respectively). Sobh's equation showed no bias in the general group or in two subgroups. Salazar-Corcoran's and Sobh's equations showed no bias for the entire group (Bias: -5.2, 95% confidence interval (CI) = -11.4, 1.0, and 6. 2; 95%CI = -0.3, 12.7, respectively). All the other equations were imprecise for the entire group. CONCLUSION: Of the equations studied, those of Sobh and Salazar-Corcoran seem to be the best for estimating the glomerular filtration rate in severely obese patients analyzed in our study.

Liver markers, prevalence of the metabolic syndrome abnormalities and effect of Roux-en-Y gastric bypass in morbidly obese subjects.

OBJECTIVES: To evaluate the relations between liver markers (GGT, ALT and AST) and the metabolic syndrome (and its components) in morbidly obese subjects, and to determine the response of these metabolic factors and hepatic enzymes after weight loss induced by Roux-en-Y gastric bypass. METHODS: This study was carried out at a university hospital, in Santo André (SP), Brazil. We evaluated 140 morbidly obese subjects aged from 18 to 60 years submitted to a Roux-en-Y gastric bypass, who were followed for a mean period of 8 months. Patients with a history of heavy drinking, type 1 diabetes, and/or liver disease were excluded. RESULTS: Liver markers, most notably GGT, were strongly associated with metabolic abnormalities, mainly hyperglycemia. The prevalence of type 2 diabetes significantly increased with increasing levels of GGT (highest versus lowest quartile GGT: odds ratio 3.89 [95%CI: 1.07-14.17]). Liver markers significantly decreased 8 months after the Roux-en-Y gastric bypass and the reduction of GGT levels were associated with the reduction of glucose levels (Pearson r = 0.286; p = 0.001). CONCLUSIONS: Elevated levels of liver markers, principally GGT, in morbidly obese subjects are associated with metabolic abnormalities. In addition to the well-known benefits of bariatric surgery, Roux-en-Y gastric bypass, reduced the levels of liver markers to the normal range.

Impact of plasmatic lipids in glycemic control and its influence in the cardiometabolic risk in morbidly obese subjects.

OBJECTIVES: To evaluate whether biochemical parameters are associated with a good glycemic control and to identify the occurrence of cardiometabolic risk variables. MATERIAL AND METHODS: One hundred forty Brazilians were evaluated. The subjects were characterized with regard to glycemic control as good, fair and poor and were divided into tertiles by TG and HbA(1c). We use the ROC curve to determine which variables were predicted of poor glycemic control and the factor analyses to identify the domains that segregated among the risk variables. RESULTS: Fasting glucose and insulin levels, TG level, VLDL-C and HOMA-IR increased significantly across HbA(1c) tertiles. The best marker for identification of poor glycemic control was triglycerides. The presence of cardiometabolic abnormalities did not alter the glycemic control, but HOMA-IR was significantly higher in subjects with abnormalities. CONCLUSION: The use of TG levels offers a reasonable degree of clinical utility. In morbidly obese subjects insulin resistance is associated with individual cardiometabolic factors.

Marcadores hepáticos, prevalência de alterações da síndrome metabólica e efeito do bypass gástrico com reconstrução em Y-de-Roux em pacientes obesos mórbidos / Liver markers, prevalence of the metabolic syndrome abnormalities and effect of Roux-en-Y gastric bypass in morbidly obese subjects

Objectives: To evaluate the relations between liver markers (GGT, ALT and AST) and the metabolic syndrome (and its components) in morbidly obese subjects, and to determine the response of these metabolic factors and hepatic enzymes after weight loss induced by Roux-en-Y gastric bypass. Methods: This study was carried out at a university hospital, in Santo André (SP), Brazil. We evaluated 140 morbidly obese subjects aged from 18 to 60 years submitted to a Roux-en-Y gastric bypass, who were followed for a mean period of 8 months. Patients with a history of heavy drinking, type 1 diabetes, and/or liver disease were excluded. Results: Liver markers, most notably GGT, were strongly associated with metabolic abnormalities, mainly hyperglycemia. The prevalence of type 2 diabetes significantly increased with increasing levels of GGT (highest versus lowest quartile GGT: odds ratio 3.89 [95%CI: 1.07-14.17]). Liver markers significantly decreased 8 months after the Roux-en-Y gastric bypass and the reduction of GGT levels were associated with the reduction of glucose levels (Pearson r = 0.286; p = 0.001). Conclusions: Elevated levels of liver markers, principally GGT, in morbidly obese subjects are associated with metabolic abnormalities. In addition to the well-known benefits of bariatric surgery, Roux-en-Y gastric bypass, reduced the levels of liver markers to the normal range.

Objetivos: Avaliar as relações entre os marcadores hepáticos (GGT, ALT e TGO) e a síndrome metabólica (e seus componentes) em indivíduos com obesidade mórbida, e determinar a resposta desses fatores metabólicos e enzimas hepáticas após a perda de peso induzida pelo bypass gástrico em Y-de-Roux. Métodos: Estudo realizado em um hospital universitário, localizado em Santo André (SP). Foram avaliados 140 indivíduos com obesidade mórbida, entre 18 e 60 anos de idade, submetidos ao bypass gástrico em Y-de-Roux, acompanhados por um período médio de 8 meses. Pacientes com história de alcoolismo pesado, diabetes tipo 1 e/ou doença hepática foram excluídos. Resultados: Os marcadores hepáticos, principalmente GGT, foram fortemente associados a alterações metabólicas, principalmente hiperglicemia. A prevalência de diabetes tipo 2 aumentou significativamente com a elevação dos níveis de GGT [quartil superior versus inferior: odds ratio 3,89 (IC95%: 1,07-14,17)]. Os marcadores hepáticos diminuíram significativamente 8 meses após o bypass em Y-de-Roux e a redução dos níveis de GGT estava associada à redução dos níveis de glicose (Pearson r = 0,286; p = 0,001). Conclusões: Níveis elevados de marcadores hepáticos, principalmente GGT, em pacientes com obesidade mórbida, estavam associados a alterações metabólicas. Além dos já conhecidos benefícios da cirurgia bariátrica, o bypass gástrico em Y-de-Roux reduziu os níveis dos marcadores hepáticos a valores normais.

Desempenho preditivo de 12 equações para estimativa da taxa de filtração glomerular em pacientes gravemente obesos / Predictive performance of 12 equations for estimating glomerular filtration rate in severely obese patients

Objective: Considering that the Cockcroft-Gault formula and the equation of diet modification in renal disease are amply used in clinical practice to estimate the glomerular filtration rate, although they seem to have low accuracy in obese patients, the present study intends to evaluate the predictive performance of 12 equations used to estimate the glomerular filtration rate in obese patients. Methods: This is a cross-sectional retrospective study, conducted between 2007 and 2008 and carried out at a university, of 140 patients with severe obesity (mean body mass index 44 ± 4.4 kg/m2). The glomerular filtration rate was determined by means of 24-hour urine samples. Patients were classified into one or more of the four subgroups: impaired glucose tolerance (n = 43), diabetic (n = 24), metabolic syndrome (n = 76), and/or hypertension (n = 66). We used bias, precision, and accuracy to assess the predictive performance of each equation in the entire group and in the subgroups. Results: In renal disease, Cockcroft-Gault's formula and the diet modification equation are not precise in severelyobese patients (precision: 40.9 and 33.4, respectively). Sobh's equation showed no bias in the general group or in two subgroups. Salazar- Corcoran's and Sobh's equations showed no bias for the entire group (Bias: -5.2, 95% confidence interval (CI) = -11.4, 1.0, and 6. 2; 95%CI = -0.3, 12.7, respectively). All the other equations were imprecise for the entire group. Conclusion: Of the equations studied, those of Sobh and Salazar-Corcoran seem to be the best for estimating the glomerular filtration rate in severely obese patients analyzed in our study.

Objetivo: Considerando que a fórmula de Cockcroft-Gault e a equação de modificação da dieta em doença renal são amplamente utilizadas na prática clínica para estimar a taxa de filtração glomerular, de aparente baixa acurácia em pacientes obesos, o presente estudo procura avaliar o desempenho preditivo de 12 equações utilizadas para estimar a taxa de filtração glomerular em pacientes obesos. Métodos: Estudo transversal, retrospectivo, realizado entre 2007 e 2008 em uma universidade, com 140 pacientes com obesidade grave (índice de massa corpórea médio de 44 ± 4,4 kg/m2). A taxa de filtração glomerular foi determinada por meio de amostras de urina de 24 horas. Os pacientes foram classificados em um ou mais dos quatro subgrupos: intolerância à glicose (n = 43), diabéticos (n = 24), síndrome metabólica (n = 76) e/ou hipertensos (n = 66). Viés, precisão e acurácia foram usados para avaliar o desempenho preditivo de cada equação no grupo como um todo e nos subgrupos. Resultados: A fórmula de Cockcroft-Gault e a equação de modificação da dieta em doença renal são imprecisas em pacientes gravemente obesos (precisão de 40,9 e 33,4, respectivamente). A equação de Sobh não apresentou viés no grupo geral e em dois subgrupos. As equações de Salazar- Corcoran e Sobh não apresentaram viés em todo o grupo (viés: -5,2, intervalo de confiança (IC) 95% = -11,4, 1,0 e 6,2; IC95% = -0,3, 12.7, respectivamente). Todas as outras equações foram imprecisas no grupo como um todo. Conclusão: Das equações estudadas, a de Sobh e a de Salazar-Corcoran parecem ser as melhores para estimar a taxa de filtração glomerular em pacientes gravemente obesos analisados no estudo.

Impact of plasmatic lipids in glycemic control and its influence in the cardiometabolic risk in morbidly obese subjects / Impacto dos lipídios plasmáticos no controle glicêmico e sua influência no risco cardiometabólico em pacientes obesos mórbidos

OBJECTIVES: To evaluate whether biochemical parameters are associated with a good glycemic control and to identify the occurrence of cardiometabolic risk variables. MATERIAL AND METHODS: One hundred forty Brazilians were evaluated. The subjects were characterized with regard to glycemic control as good, fair and poor and were divided into tertiles by TG and HbA1c. We use the ROC curve to determine which variables were predicted of poor glycemic control and the factor analyses to identify the domains that segregated among the risk variables. RESULTS: Fasting glucose and insulin levels, TG level, VLDL-C and HOMA-IR increased significantly across HbA1c tertiles. The best marker for identification of poor glycemic control was triglycerides. The presence of cardiometabolic abnormalities did not alter the glycemic control, but HOMA-IR was significantly higher in subjects with abnormalities. CONCLUSION: The use of TG levels offers a reasonable degree of clinical utility. In morbidly obese subjects insulin resistance is associated with individual cardiometabolic factors.

OBJETIVOS: Avaliar o quanto os lipídios plasmáticos, o IMC e a glicemia de jejum estão associados com um bom controle glicêmico e identificar a ocorrência de variáveis do risco cardiometabólico. MÉTODO: Cento e quarenta brasileiros foram avaliados. Os pacientes foram caracterizados, de acordo com o controle glicêmico, como tendo bom controle, moderado controle e controle ruim e foram divididos em tercis de TG e HbA1c. Utilizou-se a curva ROC para determinar quais variáveis predizem um controle glicêmico inadequado e a análise fatorial para identificar os domínios que segregam as diferentes variáveis. RESULTADOS: A glicemia de jejum e os níveis de insulina, os níveis de TG, VLDL-C e HOMA-IR aumentaram significativamente de acordo com os tercis de HbA1c. O melhor marcador para identificação de indivíduos com um controle glicêmico ruim foi o triglicérides. A presença de anormalidades cardiometabólicas não alterou significativamente o controle glicêmico, mas o HOMA-IR foi significativamente maior nestes indivíduos. CONCLUSÃO: O uso dos níveis de TG oferece uma boa utilidade clínica. Em pacientes obesos mórbidos, a resistência à insulina esta associada com fatores de risco cardiometabólico.

Comorbidades e sinais de alerta da pneumonia adquirida na comunidade: análise de pacientes com mais de 50 anos / Comorbidities and warning signals of community acquired pneumonia: analysis of patients over 50 years old

Introdução: a pneumonia adquirida na comunidade (PAC) é a maior causa de morte por doenças infecciosas no mundo, principalmente em idosos. São Caetano do Sul, São Paulo, demonstra um aumento de população idosa (28%), devido ao aumento da expectativa de vida. Assim, o número de casos em pacientes ≥ 50 anos aumentou drasticamente. Dos 567 casos notificados em São Caetano Sul, de maio a dezembro de 2005 e de março a setembro de 2006, 70% correspondiam a idosos. Objetivo: analisar as comorbidades relacionadas à PAC em pacientes ≥ 50 anos e os sinais de alerta que estes apresentam no início do tratamento ambulatorial em São Caetano do Sul. Casuística e métodos: foram analisados 41 casos de PAC em pacientes ≥ 50 anos que apresentavam o quadro clínico compatível com infecção respiratória aguda, achado de infiltrado pulmonar novo ao raio X de tórax, associado à pelo menos um dos itens: desidratação, febre ≥ 38 ºC e tosse produtiva. Os critérios de exclusão foram a presença de doenças pulmonares e portadores de HIV. Resultados e conclusões: analisou-se o quadro de PAC em 41 pacientes com ≥ 50 anos, com sinais e sintomas característicos aos exames no Pronto Socorro. Devido à particularidade da amostra estudada, não se podem generalizar os resultados. Houve prevalência do sexo feminino, sendo a idade média dos pacientes de 69 anos Das comorbidades analisadas, a insuficiência cardíaca congestiva teve maior prevalência (50%), seguida pela insuficiência renal (25%). Dos pacientes analisados, 24% apresentavam uréia > 40 mg/dL e 18% apresentavam taquipnéia.

Introduction: the Community acquired pneumonia (CAP) is the major cause of death by infectious diseases in the world, especially among the elderly. Sao Caetano do Sul, São Paulo, shows a growth of the elderly population (28%), due to the rise of the life expectancy. Therefore, the number of cases in patients older than 50 years old rose drastically. From the 567 cases related in São Caetano do Sul, from May to December of 2005 and from March to September of 2006, 70% were related to elders. Objective: analyze the comorbidities related to CAP in patients older than 50 years, and the alert signs shown by them in the beginning of the ambulatory treatment in São Caetano do Sul. Subjectives and methods: 41 cases of CAP were analyzed in patients older than 50 years which presented clinical situation compatible with deep breathing infection, new pulmonary infiltrate discovered in the X-Ray exam of the chest, which is related to at least one of the following items: dehydration, fever and productive cough. The exclusion criteria were the diagnosis of lung diseases and HIV. Results and conclusions: the CAP scenes of 41 patients older then 50 years were analyzed, with signs and symptoms that are characteristics of the Emergency Medical Services exams. Due to the particularity of the sample studied, the result cannot be generalized. Females prevailed; the average age of the patients was 69 years. From all the comorbidities analyzed, the congestive cardiac insufficiency prevailed at most (50%), followed by the renal insufficiency (25%). Among the patients analyzed, 24% presented urea > 40 mg/dL and 18% presented shortpnea.