Kidney cancer focal cryoablation trend: does location or approach matter?

PURPOSE: We evaluated the current indications and surgical and survival outcomes for cryoablation (CA) using either a percutaneous (PCA) or a laparoscopic approach (LCA). We also investigated the ability of the PADUA score to predict the risk of complications and local recurrence. METHODS: A retrospective analysis was performed at two European tertiary referral centers. Parameters analyzed included size, location, approach, operative time, hospital stay, complications, and functional and oncologic outcomes. Univariate and multivariate analyses were performed. An ROC analysis was conducted to evaluate the accuracy of the PADUA score. RESULTS: Eighty patients were included. Mean tumor size was 2.6 cm. PCA was more often performed in posterior (95 vs. 60 %), inferior (72 vs. 32 %), and lateral (87 vs. 55 %) tumors. The global complication rate was 8.75 %, although proximity to the renal sinus resulted in a higher rate (30 vs. 4 %). Mean follow-up was 34 and 23 months for LCA and PCA, respectively. The 5-year recurrence-free survival was 76 and 90 % for LCA and PCA, respectively. Multivariate analysis showed that tumor involvement of the collecting system was predictive of recurrence. Under ROC analysis, PADUA score was a mild predictor for complications (AUC = 0.601) and a good predictor for recurrence (AUC = 0.723); PADUA ≥8 was identified as a cutoff for patients to a higher risk of recurrence. CONCLUSIONS: The percutaneous approach is confirmed to be the preferred CA technique for posterior and lateral tumors. CA in deeper renal lesions and tumors with PADUA score ≥8 might entail a higher risk of recurrence, and closer follow-up should be considered in these patients.

Incidence and risk factors for incomplete HBV DNA suppression in HIV/HBV-co-infected patients initiating tenofovir-based therapy.

Suppression of hepatitis B virus (HBV)-DNA to undetectable levels is an important goal for HIV/HBV-co-infected patients receiving anti-HBV-active antiretroviral therapy (ART), and current guidelines recommend that this outcome should be reached by 1 year of treatment. However, the proportion of patients that fail to achieve an undetectable HBV DNA at this time point and its determinants remain unknown in clinical practice. The objective of this study was to determine the incidence and risk factors for incomplete HBV suppression following 1 year of tenofovir-based ART. We performed a cohort study among tenofovir-treated HIV/HBV-co-infected patients. Patients had HBV viraemia, initiated tenofovir-based ART and had HBV DNA measured at 1 year of therapy. The primary outcome was incomplete HBV suppression (HBV DNA ≥2.6 log IU/mL) at 1 year. Logistic regression determined odds ratio (ORs) of incomplete HBV suppression for risk factors of interest. Among 133 patients, 54% (95% CI, 46-63%) had incomplete HBV suppression at 1 year. Incomplete suppression was associated with higher baseline HBV DNA (OR, 1.46 per log IU/mL increase; 95% CI, 1.1-1.94) and detectable HIV viraemia at 1 year (OR, 2.52; 95% CI, 1.19-5.32). Among 66 patients with suppressed HIV RNA at 1 year, 28 (42%) failed to achieve an undetectable HBV DNA. Failure to suppress HBV DNA by 1 year occurred in a sizeable proportion of tenofovir-treated HIV/HBV-co-infected patients. Higher HBV DNA and detectable HIV viraemia were risk factors for incomplete HBV suppression.

Cloning, characterization and functional expression of Taenia solium 17 beta-hydroxysteroid dehydrogenase.

The 17ß-hydroxysteroid dehydrogenases (17ß-HSD) are key enzymes involved in the formation (reduction) and inactivation (oxidation) of sex steroids. Several types have been found in vertebrates including fish, as well as in invertebrates like Caenorhabditis elegans, Ciona intestinalis and Haliotis diversicolor supertexta. To date limited information is available about this enzyme in parasites. We showed previously that Taenia solium cysticerci are able to synthesize sex steroid hormones in vitro when precursors are provided in the culture medium. Here, we identified a T. solium 17ß-HSD through in silico blast searches in the T. solium genome database. This coding sequence was amplified by RT-PCR and cloned into the pcDNA 3.1(+) expression vector. The full length cDNA contains 957bp, corresponding to an open reading frame coding for 319 aa. The highest identity (84%) at the protein level was found with the Echinococcus multilocularis 17ß-HSD although significant similarities were also found with other invertebrate and vertebrate 17ß-HSD sequences. The T. solium Tsol-17ßHSD belongs to the short-chain dehydrogenase/reductase (SDR) protein superfamily. HEK293T cells transiently transfected with Tsol17ß-HSD induced expression of Tsol17ß-HSD that transformed 3H-androstenedione into testosterone. In contrast, 3H-estrone was not significantly transformed into estradiol. In conclusion, T. solium cysticerci express a 17ß-HSD that catalyzes the androgen reduction. The enzyme belongs to the short chain dehydrogenases/reductase family and shares motifs and activity with the type 3 enzyme of some other species.

BRILMA block for costal cartilage excision: Case report. / Bloqueo BRILMA para extirpación de cartílago costal: caso clínico.

The block of the lateral branches of the intercostal nerves in the middle axillary line (BRILMA) is an interfascial ultrasound-guided block for analgesia in thoracic wall and upper abdominal surgery, presenting as an adequate alternative to neuraxial techniques. We present the case of a 49-year-old female scheduled for idiopathic subglottic stenosis repair with a costal cartilage graft from the 10th rib and tracheotomy. At the end of the surgery, unilateral ultrasound-guided BRILMA block with 20ml of ropivacaine 0.2% was performed at the level of the 6th rib, uneventfully. Postoperatively, the patient referred a maximum level of pain of 3/10. There was no opioid consumption after the 2nd postoperative day, although a subcostal incision may produce considerable pain. BRILMA is a superficial block, easily reproducible in most patients. It diminishes the number of punctures needed in the thoracic wall, as well as the risk for pneumothorax and local anesthetic toxicity.

Gonadectomy inhibits development of experimental amoebic liver abscess in hamsters through downregulation of the inflammatory immune response.

Incidence of amoebic liver abscess (ALA) in human males is considerably higher than in females, suggesting a role for sex hormones in this parasite infection. We describe here the effect of hamster gonadectomization on the development of ALA. After monitoring the decrease of oestradiol in females and testosterone in males to undetectable levels by ELISA and Radio Immuno Assay (RIA) in serum, hamsters were intraportally infected with Entamoeba histolytica trophozoites and killed 7 days later. ALA was absent in 50% of male and 15% of female gonadectomized (Gdx) hamsters, in comparison with 100% infection in non-Gdx controls. This protection against ALA in Gdx hamsters was concomitant to a comparatively scarce inflammatory infiltrate and necrosis surrounding clusters of trophozoites in the liver tissue, as well as to a lack of response of spleen cells to Con A, evaluated in proliferation assays. As tissue damage in ALA has been associated with a local inflammatory Th1 response, we determined the profile of response in hamsters by immunohistochemistry on liver sections. In contrast to strong Th1 responses in non-Gdx animals, Gdx females and males exhibited Th2 and Th3 profiles of cytokines, respectively, suggesting that protection against ALA following gonadectomization, could be related to downregulation of liver Th1 response during amoebic infection.

[Urothelial carcinoma in a woman with autosomal dominant polycystic kidney disease: description of a case and review of the literature]. / Carcinoma urotelial renal en una paciente con enfermedad renal poliquística autosómico dominante: presentación de un caso y revisión de la literatura.

We describe a case of urothelial carcinoma of renal pelvis in a 48 years old woman affected of autosomal dominant polycystic kidney disease (ADPKD). We discuss the difficulty of the radiological diagnostic and we revise the incidence of renal tumors in this entity. Association between urothelial carcinoma and ADPKD is highly infrequent and without apparently causal relation.

Questions and answers on prostate multiparameter magnetic resonance imaging: Everything a urologist should know. / Preguntas y respuestas sobre resonancia magnética multiparamétrica prostática: todo lo que el urólogo debe conocer.

CONTEXT: For many years, the detection of prostate cancer (PC) and the management of its therapy have been based primarily on prostate-specific antigen, rectal examination and prostate biopsy. However, these parameters have known limitations. Multiparametric magnetic resonance imaging (mpMRI) for prostate cancer has undergone extensive development in recent years, providing morphological and functional information. The aim of this study is to present an updated review of the scope and limitations of prostatic mpMRI for PC, in the framework of a multidisciplinary vision. ACQUISITION OF EVIDENCE: We conducted a literature review (in PubMed) of articles referencing "mpMRI/staging/ PC/detection/active surveillance/therapy planning/post-therapy". We included 4 systematic reviews and other articles published in high impact-factor journals within the field of radiology and urology. SUMMARY OF THE EVIDENCE: MpMRI provides morphological and functional information concerning PC. This information is integrated into the Prostate Imaging Report and Date System, classifying the probability of clinically significant carcinoma on a scale from 1 to 5. The usefulness of mpMRI is currently being established for patients with high prostate-specific antigen levels and prior negative prostate biopsy; tumour staging in selected cases; assessment of patients who are candidates for active surveillance; the planning of focal treatments; and the assessment of tumour persistence and recurrence. CONCLUSIONS: MpMRI currently fills a relevant role in the diagnosis and therapeutic decision-making of PC. More widespread use of the technique requires a cost/benefit analysis.

G proteins are involved in the suppression of collagen alpha 1 (I) gene expression in cultured rat hepatic stellate cells.

We analyse the role of the G proteins in regulating collagen gene expression by measuring collagen alpha 1(I) mRNA levels in cultured hepatic stellate cells in basal conditions and after stimulating or inhibiting the major intracellular signalling pathways. Stimulation of Gs protein and adenylyl cyclase or the addition of 8Br-cAMP to the cells led to a decrease in collagen alpha 1(I) mRNA levels, while blocking protein kinase A abolished this effect. Blocking Gi protein, phospholipase A2 and C, calcium channels and calmodulin resulted in a significant increase in collagen mRNA levels. PKC stimulation led to a marked decrease in these levels. These results suggest that collagen gene expression is inhibited by a number of intracellular pathways. A Gs and a pertussis toxin-sensitive G protein seem to initiate cellular response. Transcription factors, acting in these pathways, must be identified. However, it seems that they do not need to be synthesised.

Endourological management is better in early-onset ureteral stenosis in kidney transplantation.

INTRODUCTION: The incidence of ureteral stenosis in kidney transplant recipients is 3%-8%. The treatment of ureteral stenosis has been traditionally operative reconstruction, although such intervention is associated with high rates of serious complications, including graft loss and even perioperative mortality. More recently, endourological treatment has been proposed due to its low morbidity. OBJECTIVE: The objective of this study was to assess the usefulness of balloon percutaneous dilatation as a treatment technique for ureteral stenosis in kidney transplant recipients. PATIENTS AND METHODS: Among 1000 kidney transplantations performed between 1980 and 2004, the coexistence of high creatinine values and urinary tract dilatation in the postoperative period, after discarding concomitant causes, was managed with a percutaneous nephrostomy. Once renal function recovered, antegrade pyelography was performed to confirm the presence and determine the location of ureteral stenosis. Ureteral dilatation was performed using a 5-French balloon-fitted angioplasty catheter. RESULTS: Fifty-six patients were diagnosed with ureteral stenosis during follow-up, an incidence of 5.6%. Transluminal balloon dilatation was the first therapeutic option in 45 cases, whereas surgery was performed directly on 11 patients. Disappearance of the stenosis as well as maintenance of an improved creatinine level was verified in 45% of cases (20 patients). Two patients experienced graft loss. Both a short time to diagnosis after transplantation (P = .06) and the presence of a previous acute rejection episode (P < .05) were good prognosis factors for the endourologic solution of a ureteral stricture. CONCLUSIONS: Balloon dilatation may be considered the definitive procedure for treatment of ureteral stenosis in selected cases. Percutaneous nephrostomy should be used for initial diagnosis and improvement in the renal function before attempting an open procedure.

Percutaneous management of transplant ureteral fistulae is feasible in selected cases.

INTRODUCTION: Ureteral fistulae in renal transplants may develop as a consequence of compromised ureteral vascularity or from a technical factor related to the ureteroneocystostomy, the latter typically developing within the first 72 hours posttransplant. Recently, percutaneous nephrostomy drainage has been used with increasing frequency for the initial management. It alone can lead to resolution of the fistula in at least some patients. The aim of the study was the evaluation of endourological management of ureteral fistulae in renal transplants. MATERIAL AND METHODS: Between August 1981 and February 2004, 1000 adult recipients underwent renal transplantation. Sixteen out of 29 patients who developed ureteral fistulae were managed endourologically; 13, open surgery. The items recorded on these patients included the type of ureteroneocystostomy, the time to fistula diagnosis, the image technique, the type of ureteral stents, and the clinical evolution. RESULTS: The 13 patients who underwent open surgery did well. Endourological management of ureteral fistula was successfully performed in 10 of 16 cases. In all of them percutaneous nephrostomy drainage with stenting of the ureter with a double-J catheter did not prove any advantage to no stent (66.6% vs 57%). In 13 of these 16 patients in which the passage of contrast into the bladder was demonstrated, the fistula resolved in 10 cases (77%), while none of the three cases with no flow into the bladder were helped by this approach. CONCLUSION: Percutaneous techniques can provide definitive management for 62% of renal allograft patients who develop ureteral fistula beyond 72 hours after renal transplant.

Prospective study of ultrasound-guided percutaneous renal cryotherapy: case selection as an optimization factor for a technique.

OBJECTIVE: To evaluate the technical and oncological effectiveness of ultrasound-guided percutaneous renal cryotherapy (PRC) in a selected group of patients with renal cancer. MATERIAL AND METHODS: We conducted a prospective study of 28 patients with posterior-facing T1a renal tumors with middle and inferior external borders. All patients underwent ultrasound-guided PRC. Follow-up was conducted with computed tomography at 1 month and then every 6 months, with a good result defined as the total absence of contrast incorporation. We performed a descriptive and survival study using the Kaplan-Meier estimator. RESULTS: The 28 patients had a mean age (SD) of 68.3 (10.1) years, and the group underwent 28 procedures. The mean (SD) size of the tumors was 25.5 (7.5) mm, the mean nephrometry score was 1.41 (0.52) and the mean preoperative creatinine level was 133.5 (144.1) mmol/L. There were no intraoperative complications. In terms of postoperative complications, there was only 1 case (3.5%) of a skin lesion resulting from treating a tumor in a transplanted kidney (Clavien II). The median follow-up was 25 months, and the mean (SD) postoperative creatinine level was 135.5 (110.3) mmol/L. Two cases presented radiological recurrence (93% efficacy), with a mean time to recurrence of 12 and 19 months, respectively. There were no tumor-related deaths. CONCLUSIONS: Our series (the largest on PRC in our country to date) shows that, with an appropriate selection of tumors, PRC is a safe technique with minimal morbidity. Ultrasonography enables the controlled performance of the procedure and saves the patient from radiation and reduces costs.

Pelvic MRI findings in relapsed prostate cancer after radical prostatectomy.

PURPOSE/OBJECTIVE: Little is known about the clinical impact of using multiparametric MRI to plan early salvage radiotherapy after radical prostatectomy. We aimed to evaluate the incidence and location of recurrence based on pelvic multiparametric MRI findings and to identify clinical variables predictive of positive imaging results. MATERIALS AND METHODS: We defined radiological criteria of local and lymph node malignancy and reviewed records and MRI studies of 70 patients with PSA recurrence after radical prostatectomy. We performed univariate and multivariate analysis to identify any association between clinical, pathological and treatment-related variables and imaging results. RESULTS: Multiparametric MRI was positive in 33/70 patients. We found local and lymph node recurrence in 27 patients and 7 patients, respectively, with a median PSA value of 0.38 ng/ml. We found no statistically significant differences between patients with positive and negative multiparametric MRI for any variable. Shorter PSADT was associated with positive lymph nodes (median PSADT: 5.12 vs 12.70 months; p: 0.017). CONCLUSIONS: Nearly half the patients had visible disease in multiparametric MRI despite low PSA. Positive lymph nodes incidence should be considered when planning salvage radiotherapy, particularly in patients with a short PSADT.

Sp family of transcription factors is involved in iron-induced collagen alpha1(I) gene expression.

The purpose of this study was to identify the cis-acting elements and the trans-acting factors involved in the iron-induced expression of the collagen alpha1(I) (COL1aI) gene. Rat hepatic stellate cells were cultured in the presence of 50 microM ferric chloride, 50 microM ascorbic acid, and 250 microM citric acid (Fe/AA/CA), and the effects on collagen gene expression and the binding of nuclear proteins to the COL1aI promoter were measured. The Fe/AA/CA treatment induced a time- and dose-dependent increase in the cellular levels of COL1aI mRNA that was abrogate by pretreating cells with cycloheximide, antioxidants, and inhibitors of aldehyde-protein adduct formation. Transient transfection experiments showed that Fe/AA/CA exerted its effect through regulatory elements located between -220 and -110 bp of the COL1aI promoter. Gel retardation assays showed that Fe/AA/CA increased the binding of nuclear proteins to two elements located between -161 and -110 bp of the COL1aI promoter. These bindings were blocked by unlabeled consensus Sp1 oligonucleotide and supershifted with Sp1 and Sp3 antibodies. Finally, Fe/AA/CA increased cellular levels of the Sp1 and Sp3 proteins and Sp1 mRNA. Treatment with Fe/AA/CA stimulates COL1aI gene expression by inducing the synthesis of Sp1 and Sp3 and their binding to two regulatory elements located between -161 and -110 bp of the COL1aI promoter.

Collagen alpha1(I) gene contains an element responsive to tumor necrosis factor-alpha located in the 5' untranslated region of its first exon.

The aims of the present study were to identify the cis-acting element through which tumor necrosis factor-alpha (TNFalpha) inhibits collagen alpha1(I) gene transcription and the trans-acting factors involved in this effect in cultured hepatic stellate cells. Deletion analysis of the collagen alpha1(I) promoter demonstrated that TNFalpha inhibited gene expression through an element located between -59 and + 116 bp relative to the transcription start site. DNase I protection assays revealed a footprint between +68 and +86 bp of the collagen first exon, the intensity of which decreased when the DNA probe was incubated with nuclear protein from TNFalpha-treated hepatic stellate cells. This footprint contained a G+C-rich box. Transfection experiments demonstrated that mutations in this G+C-rich element abrogated the inhibitory effect of TNFalpha on the collagen alpha1(I) promoter. Gel retardation experiments using a radiolabeled oligonucleotide containing sequences of this region confirmed that TNFalpha treatment decreased the formation of two complexes between nuclear proteins and DNA. These complexes were efficiently blocked with an oligonucleotide containing an Spl-binding site and were supershifted with specific Spl and Sp3 antibodies. These results suggest that TNFalpha inhibits collagen alpha1(I) gene expression by decreasing the binding of Spl to a G+C-rich box in the 5' untranslated region of its first exon.

Ultrasound-guided needle aspiration in prostatic abscess.

OBJECTIVES: To review the clinical presentation of prostatic abscess and to assess the usefulness of ultrasound-guided needle aspiration as a treatment option for this condition. METHODS: Between October 1984 and November 1997, prostatic abscess was diagnosed in 31 patients. The average age was 60 years (range 29 to 79). Prostate ultrasound was performed using either a hypogastric or transrectal approach. Initial therapy included ultrasound-guided needle aspiration in 24 (77.4%), transurethral resection of prostate (TURP) in 5 (16.1%), or conservative management with antibiotic therapy. During follow-up, ultrasound examinations and urine cultures were performed on an outpatient basis. RESULTS: Past medical history most often included previous urinary infection (15 patients, 48%) and bladder outlet obstruction (13 patients, 42%). Sixty-one percent of patients presented with irritative voiding symptoms at the time of diagnosis. Ultrasound-guided needle aspiration resolved 83.3% of cases; 2 patients needed a second procedure. Three patients required TURP for drainage and 2 to remove an obstruction after abscess resolution. CONCLUSIONS: A high degree of suspicion is needed to diagnose prostatic abscess clinically. Transrectal ultrasound is necessary for the differential diagnosis. Transrectal ultrasound-guided needle aspiration is a technically simple and effective therapeutic procedure with no morbidity and, in case of failure, may be repeated or a drainage TURP may be undertaken.

Carbohydrate epitopes of Entamoeba histolytica cell surface glycoproteins are major targets of the human humoral response.

The antigens of Entamoeba histolytica recognized by antibodies in 11 individual sera from patients treated for amebic liver abscess were determined both by immunoprecipitation of metabolically-radiolabeled whole trophozoite proteins and by immunoblotting.Collectively, twenty-s even antigens ranging from 167 to 21 kDa were detected in immunoblots of whole trophozoite extracts; eight of these were recognized by all tested patient sera. Immunoprecipitation studies also revealed a complex amebic antigenic profile. Of a total of twenty immunoprecipitated polypeptides (from 200 to 24 kDa), seventeen were uniquely recognized by the patient sera. Eight of these seventeen antigens were immunoprecipitated by most immune sera. The cellular localization of trophozoite antigens was determined by analyzing plasma membrane and soluble cytosol fractions. Plasma membranes contained virtually as many antigenic moieties as the total trophozoite extract; in contrast, the soluble fraction was antigenically less complex. Mild periodate oxidation of plasma membrane antigens indicated that surface glycoproteins are highly immunogenic for the human host and that antibodies to their carbohydrate epitopes are a major component of the total response of most patients.

Neurobehavioral deficits after low level lead exposure in neonates: the Mexico City pilot study.

Gestation age and ability of the baby to self-quiet and to be consoled during the first 30 days of life decrease when mother's blood lead levels rise from 36 weeks of pregnancy to birth of child. These effects appear to be independent of the absolute lead levels of mother and child (N = 42). Since pre- and perinatal stress predicts higher maternal birth lead, further work could determine the relative contributions of undetected stress during pregnancy and elevated lead levels upon subsequent development. Several cases, not included in the statistical analyses, showed associations between cord leads greatly elevated over maternal leads and poor outcome.

Host cells in the spiral canal of Taenia solium (Cestoda) cysticerci.

The presence of host inflammatory cells inside the spiral canal of all viable Taenia solium cysts obtained from naturally infected pigs is described. Cells can penetrate into the vicinity of suckers and rostellum, although most appear damaged, suggesting that conditions in the canal are deleterious for them. These observations extend the localization of host inflammatory infiltrate to this intricate microniche, which may offer new approaches for the treatment of cysticercosis, based on a scolex-targeted action. The presence of host cells in the canal of cysts also poses the problem of the resulting contamination with host materials in studies using cysts extracts. As an example, host DNA contamination is readily detectable in genomic DNA isolated from T. solium and Taenia taeniaeformis cysts, as demonstrated by polymerase chain reaction amplification and subsequent sequencing of a segment of the 18S ribosomal gene.

[The evaluation of the efficacy of a multidisciplinary treatment in a group of obese patients with a BMI > or = 35 and a change in lung function]. / Valoración de la eficacia de un tratamiento multidisciplinario en un grupo de pacientes obesos con IMC > o = 35 y alteración de la función pulmonar.

OBJECTIVE: To assess the efficacy of an interdisciplinary protocol for treating obesity in a group of patients with BMI > or = 35 and with altered respiratory function that was not necessarily related to obesity or not. PATIENTS AND METHOD: Forty obese individuals between 18 and 60 years of age with altered respiratory function were enrolled. Spirometric values, plethysmograph volumes, arterial blood gases, and nighttime respiratory polygraphs were recorded. Following psychological and nutritional evaluation, the patients commenced year-long treatment for obesity involving a personalized diet and psychological counseling. Follow-up was weekly and individualized at first; in later sessions, patients were grouped. Lung function tests were repeated after loss of 5 kg. Sleep polygraphy was repeated after loss of 10 kg. RESULTS: Weight loss over 15 kg was achieved by 48.6% of the patients. Respiratory function variables: FVC, FEV1, RV, ERV, PaO2 and SatO2 after treatment changed significantly from initial levels. Significant differences were also seen in the severity of sleep apnea and pressures needed for continuous positive airway pressure. Uric acid, glucose and triglyceride blood levels became normal in 89%, 61% and 50% of the patients, respectively, after weight loss. No characteristic psychological profile was identified for severe obesity, although levels of anxiety, eating behavior, marital adjustment and perception of body image were aspects that were fundamentally altered. CONCLUSIONS: In the difficult group of obese patients with BMI > or = 35, interdisciplinary treatment has proven effective for achieving substantial weight loss, while improving respiratory function and severity of sleep disorder. This therapy, which is at present viable for few centers, deserves consideration in the interest of benefiting the increasing number of obese patients.