Androgen deprivation therapy in patients with localized disease: Comparison with curative intent treatments and time to castration resistance. Results of the Spanish Prostate Cancer Registry

BACKGROUND

The effect of primary androgen deprivation therapy (ADT) in patients with localized prostate cancer (PCa) has not been well documented. The objective of the present study was to analyze the outcome of tumors treated with ADT as primary therapy in the Spanish Prostate Cancer Registry (19.4% of the series).

PATIENTS AND METHODS

Patients were classified in three groups: 1) with low/intermediate risk clinically localized tumors; 2) with high risk and locally advanced (T3-4) tumors; 3) with metastatic tumors. Time to castration resistance and overall cancer-specific survival were analyzed. In non-metastatic tumors, survivals in patients treated with ADT were compared with data from patients who underwent local treatments from the Spanish Prostate Cancer Registry.

RESULTS

703 cases were analyzed. There were significant differences in the time to castration resistance, which was lower in the group of metastatic tumors. During follow-up, there were 179 deaths (25.5%) of which 89 (12.6%) were due to PCa. After 3 years of ADT, only 14.6% of patients in group 1 had died (1% due to PCa), 20.5% in group 2 and 46.8% in group 3 (9.2% and 31.3% due to PCa, respectively). Cancer-specific survival was significantly worse in group 1 using ADT than radical prostatectomy or radiotherapy. In high-risk and locally advanced tumors, ADT also had a lower cancer-specific survival than local treatments.

CONCLUSION

A longer time until the castration resistance was observed in patients with well- and intermediate-risk localized tumors treated with ADT. Patients with metastatic tumors showed the shortest time to castration resistance.

Have there been changes in the application of mechanical ventilation in relation to scientific evidence? A multicenter observational study in Mexico

OBJECTIVE

The main study objectives were to describe the practice of mechanical ventilation over an 18-year period in Mexico, and estimate changes in mortality among critical patients subjected to invasive mechanical ventilation (IMV).

DESIGN

A retrospective subanalysis of a prospective observational study conducted in 1998, 2004, 2010 and 2016 was carried out.

SETTING

Intensive Care Units (ICUs) in Mexico.

PARTICIPANTS

Adult patients consecutively enrolled in the ICU during one month and who underwent IMV for more than 12hours or noninvasive mechanical ventilation for more than one hour. Follow-up was performed up to a maximum of 28 days after inclusion.

INTERVENTIONS

None.

PRINCIPAL VARIABLES OF INTEREST

Age, sex, severity upon admission as estimated by SAPS II, parameters of daily arterial blood gases, treatment and complication variables, date and status at discharge from the ICU and from hospital.

RESULTS

A total of 959 patients were included in 81 ICUs. Tidal volume (vt) decreased significantly both in patients with acute respiratory distress syndrome (ARDS) criteria (estimated 8.5ml/kg b.w. in 1998 to 6ml/kg in 2016; P<0.001) and in patients without ARDS (estimated 9ml/kg b.w. in 1998 to 6ml/kg in 2016; P<0.001). The ventilatory protective strategy (defined as vt < 6ml/kg or < 8ml/kg and a plateau pressure < 30cmH₂O) was: 19% in 1998, 44% in 2004, 58% in 2010 and 75% in 2016 (P<0.001). The adjusted mortality rate in ICU over the 4 periods was: in 2004, odds ratio (OR) 1.05 (95% confidence interval, 95%CI: 0.73-1.72; P=0.764); in 2010, OR 1.68 (95%CI: 1.13-2.48; P=0.009); in 2016, OR 0.85 (95%CI: 0.60-1.20; P=0.368).

CONCLUSIONS

The clinical practice of IMV in Mexican ICUs has been modified over a period of 18 years. The most significant change is the ventilatory strategy based on low vt. These changes have not been associated with significant changes in mortality.

Stickler syndrome. Epidemiology of retinal detachment

OBJECTIVE

A review was performed on all patients with Stickler syndrome that had been treated in our Centre since it was diagnosed, in order to evaluate the risk of suffering a retinal detachment (RD).

METHODS

A total of 14 patients, diagnosed by clinical criteria, were included. The following variables were evaluated: age, gender, ocular background, follow-up, initial and final visual acuity (VA), optical prescription, prophylactic treatment, surgery and techniques performed. The risk age to suffer a RD, as well as cataracts, was determined by using the Kaplan-Meier survival curve analysis.

RESULTS

From a total of 5 men and 9 women, the median initial VA was 0.35, which was the same as the final VA. The median optical prescription was -9.5 D myopia. The median of follow-up was 7 years. Ocular background was 4 RD cases and 2 Lasik surgeries. The operations performed were 8 RD, 12 cataract, 2 glaucoma, 2 macular hole, and one endotropia. The median age of RD was 20 years and cataract 34 years. As regards surgical tecnique, 4 scleral buckle cases, and 4 scleral buckle+pars plana vitrectomy cases were formed. The prophylactic treatments performed were: one scleral buckle case, 4 endolaser photocoagulation, and one cryotherapy. Two of which presented with RD.

CONCLUSION

In the series presented, retinal detachment in Stickler syndrome mainly occurs in the second decade of life, with cataracts mainly developing in the fourth decade.

Intensive care practices in brain death diagnosis and organ donation

We conducted a multicentre study of 1844 patients from 42 Spanish intensive care units, and analysed the clinical characteristics of brain death, the use of ancillary testing, and the clinical decisions taken after the diagnosis of brain death. The main cause of brain death was intracerebral haemorrhage (769/1844, 42%), followed by traumatic brain injury (343/1844, 19%) and subarachnoid haemorrhage (257/1844, 14%). The diagnosis of brain death was made rapidly (50% in the first 24 h). Of those patients who went on to die, the Glasgow Coma Scale on admission was ≤ 8/15 in 1146/1261 (91%) of patients with intracerebral haemorrhage, traumatic brain injury or anoxic encephalopathy; the Hunt and Hess Scale was 4-5 in 207/251 (83%) of patients following subarachnoid haemorrhage; and the National Institutes of Health Stroke Scale was ≥ 15 in 114/129 (89%) of patients with strokes. Brain death was diagnosed exclusively by clinical examination in 92/1844 (5%) of cases. Electroencephalography was the most frequently used ancillary test (1303/1752, 70.7%), followed by transcranial Doppler (652/1752, 37%). Organ donation took place in 70% of patients (1291/1844), with medical unsuitability (267/553, 48%) and family refusal (244/553, 13%) the main reasons for loss of potential donors. All life-sustaining measures were withdrawn in 413/553 of non-donors (75%).

Continuously evaluating performance in deceased donation: the Spanish quality assurance program

The Spanish Quality Assurance Program applied to the process of donation after brain death entails an internal stage consisting of a continuous clinical chart review of deaths in critical care units (CCUs) performed by transplant coordinators and periodical external audits to selected centers. This paper describes the methodology and provides the most relevant results of this program, with information analyzed from 206,345 CCU deaths. According to the internal audit, 2.3% of hospital deaths and 12.4% of CCU deaths in Spain yield potential donors (clinical criteria consistent with brain death). Out of the potential donors, 54.6% become actual donors, 26% are lost due to medical unsuitability, 13.3% due to refusals to donation, 3.1% due to maintenance problems and 3% due to other reasons. Although the national pool of potential donors after brain death has progressively decreased from 65.2 per million population (pmp) in 2001 to 49 pmp in 2010, the number of actual donors after brain death has remained at about 30 pmp. External audits reveal that the number of actual donors could be 21.6% higher if all potential donors were identified and preventable losses avoided. We encourage other countries to develop similar comprehensive approaches to deceased donation performance.

Microwave Assisted Synthesis of Iron(III) Oxyhydroxides/Oxides Characterized Using Transmission Electron Microscopy, X-ray Diffraction, and X-ray Absorption Spectroscopy

Microwave assisted synthesis of iron oxide/oxyhydroxide nanophases was conducted using iron(III) chloride titrated with sodium hydroxide at seven different temperatures from 100 degrees C to 250 degrees C with pulsed microwaves. From the XRD results, it was determined that there were two different phases synthesized during the reactions which were temperature dependent. At the lower temperatures, 100 degrees C and 125 degrees C, it was determined that an iron oxyhydroxide chloride was synthesized. Whereas, at higher temperatures, at 150 degrees C and above, iron(III) oxide was synthesized. From the XRD, we also determined the FWHM and the average size of the nanoparticles using the Scherrer equation. The average size of the nanoparticles synthesized using the experimental conditions were 17, 21, 12, 22, 26, 33, 28 nm, respectively for the reactions from 100 degrees C to 250 degrees C. The particles also had low anisotropy indicating spherical nanoparticles, which was later confirmed using TEM. Finally, XAS studies show that the iron present in the nanophase was present as iron(III) coordinated to six oxygen atoms in the first coordination shell. The higher coordination shells also conform very closely to the ideal or bulk crystal structures.

Adenoma of the nonpigmented ciliary epithelium

PURPOSE

To report the clinicopathologic features of an adenoma of the nonpigmented ciliary epithelium.

DESIGN

Single interventional case report. METHODS. A nonpigmented iris and ciliary body tumor was diagnosed in a 66-year-old woman who complained of blurred vision related to a unilateral cataract. A combined cataract surgery and partial lamellar sclerouvectomy was performed.

RESULTS

Histopathologic findings disclosed an adenoma of the nonpigmented ciliary epithelium.

CONCLUSIONS

Unilateral cataract in an adult patient can be rarely related to a tumor growing from the ciliary epithelium. Adenoma of the non pigmented ciliary epithelium may mimic an amelanotic melanoma. Partial lamellar sclerouvectomy is an effective method to manage this condition and to confirm the diagnosis.

Tumor VEGF expression and serum VEGF levels are independent prognostic factors in curatively resected gastric cancer patients

4021

Background: Increased serum and/or tumor vascular endothelial growth factor (VEGF) and urokinase-type plasminogen activator (uPA) have been shown to predict poor survival in several neoplasms, but their prognostic value in gastric cancer (GC) remains unknown. Methods: Serum VEGF (S-VEGF) and uPA concentrations were measured by commercially available ELISA in 20 healthy controls and 97 GC patients (70% I-II stages) before an R0 gastric resection. Tumor expression of VEGF and uPA were assessed by immunohistochemistry. Additional variables, including demographic, histological and therapeutic data were also evaluated. Univariate (Kaplan-Meier, log-rank test) and multivariate (Cox regression) analyses were performed to select prognostic factors regarding survival and tumor recurrence. Results: S-VEGF, but not uPA levels were significantly higher in GC patients than in controls. After a mean follow-up of 47 ± 3 months, the probability of cancer-related survival at 2, 5, and 10 years was 86%, 69% and 59%, respectively. Univariate analysis identified tumor VEGF expression (p=0.001) and high (> 289 pg/ml) S-VEGF levels (p=0.045), along with pTMN stage, grade of curability, perineural invasion, lymph node ratio, and extent of lymphadenectomy as variables associated with cancer-related survival. The mean disease-free survival was 20 ± 3 months, the probability of tumor recurrence being 78%, 62% and 62% at 2, 5 and 10 years, respectively. Prognostic variables for recurrence were the same as those identified for survival. Multivariate analysis identified tumor VEGF expression and high S-VEGF levels as independent prognostic survival factors. Conclusions: After a long follow-up, tumor VEGF expression and S-VEGF levels are independent prognostic factors for recurrence and survival in curatively resected gastric cancer patients. Such markers for increased angiogenic activity might help to identify patients at high risk of recurrence that could mostly benefit from adjuvant therapies. It is tempting to speculate that trials assessing the potential benefit of a.ntiangiogenic agents might be particularly warranted in patients with resected GC and a highly angiogenic phenotype.

No significant financial relationships to disclose.

Pronóstico de los enfermos con enfermedad pulmonar obstructiva crónica reagudizada que precisan ventilación mecánica

OBJECTIVE

To determine the variables associated with prognosis for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in mechanically ventilated patients.

DESIGN

Prospective cohort study with retrospective analysis.

LOCATION

361 Intensive Care Units (ICU) in 20 countries.

PATIENTS AND METHODS

There were included in the study 522 patients who required mechanical ventilation for more than 12 hours due to an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). In order to determine those variables associated with mortality, there was performed a recursive partition analysis in which the following variables were included: demographics, arterial blood gas prior to intubation, complications arising during mechanical ventilation (barotrauma, acute respiratory distress syndrome, ventilator-associated pneumonia, sepsis), organ dysfunction (cardiovascular, renal, liver, coagulation) and duration of ventilatory support.

INTERVENTIONS

None. VARIABLES OF PRIME IMPORTANCE: ICU mortality.

RESULTS

ICU and hospital mortality rates were 22% and 30%, respectively. Variables associated with mortality were cardiovascular dysfunction, renal dysfunction and duration of ventilatory support > 18 days. Median durations were as follows: mechanical ventilatory support, 4 days (P25: 2, P75: 6); weaning from ventilatory support, 2 days (P25: 1, P75: 5); stay in intensive care unit, 8 days (P25: 5, P75: 13); stay in hospital, 17 days (P25: 10, P75: 27).

CONCLUSIONS

Mortality in the studied cohort of patients with AECOPD was associated with cardiovascular dysfunction, renal dysfunction and prolonged mechanical support.

[Coordination and donation]

The progressive incorporation of organ transplants as a therapeutic resource resulted in organisational adaptation and overall transplant management, leading to the emergence of the figure of the transplant coordinator in the mid-1980s. In Spain, the National Organisation of Transplants (Organización Nacional de Transplantes - ONT) was created, establishing a system - called the "Spanish model" - based on a network of coordinators at three levels: national, the autonomous community and the hospital. This organisational structure is a point of reference at the world level. The prevalence of the Intensive Medicine specialisation amongst hospital transplant coordinators is remarkable. The majority of organs proceed from brain-dead patients with beating hearts and this requires the infrastructure offered by intensive care units. The functions of the coordinator can be summarised in guaranteeing a synchrony of all the elements and teams that come together in an organisational chain that has come to be called the "process of donation". Schematically, the crucial points that the hospital coordinator develops are the following: - Detection of the potential donor. - Maintenance of the donor. - Diagnosis of brain death. - Family consent. - Preparation of the hospital logistics. - Helping the relatives. - Direct involvement in the Program of Guarantee of Quality. - Person of reference in any activity related to the transplant. It would be desirable to achieve the creation of transplant coordination teams, with univocal messages, professionalism and a permanent input of the so-called "human factor", which is so necessary and also so close to the transplant world.

[Poisoning by foodstuffs, plants and mushrooms]

Food poisoning is defined as poisoning caused by any foodstuff or alimentary product that causes poisoning because it contains toxic substances, germs, metals, additives, hormones, etc. It forms an important part of Clinical Toxicology, although in the majority of statistics, alimentary toxic infections provoked by bacteria, protozoa and viruses are not classified as poisonings, since they are caused by germs, and are classified as infections. Reference is made within this subject to all types of pathologies due to food, with special emphasis given to botulism. The clinical picture of botulism is discussed in its different clinical forms, but above all in its adult form which is contracted through the consumption of undercooked or badly preserved foods; poisoning by fish and seafood. Also described are the toxicological pictures that can be caused by the consumption of plants containing toxic substances, framed by the different symptomologies they produce; finally, poisonings by mushrooms are set out according to the period of incubation and possible confusions.

The patentability of human genes: an ethical debate in the European Community

The European Parliament rejected in 1995 the European Commission proposal to harmonize legal protection of biotechnological inventions. Although it did not seem initially the most contentious of the many issues involved in the current legal and ethical debate around biomedicine and genetics, patenting is now focusing bioethics in Europe.

[Treatment of acute myocardial infarction with rt-PA in 60 minutes. Cooperative study]

Thrombolytic therapy (TT) modifies the natural history of acute myocardial infarction (AMI) diminishing morbi-mortality rate. In recent studies, modification of infusion velocity, decreased the mortality 10 percentage points.

OBJECTIVE

Test if rt PA administration over an hour is safe and practical.

MATERIAL AND METHODS

A prospective, cooperative trial during 3 years, included patients with AMI with less than 6 hours of the onset of symptoms that received rt-PA therapy. Initially 10 mg bolus and then 90 mg over 60 minutes period. Together with the administration of rt-PA, 5000 units of heparin was given, followed by 1000 units per hour adjusted to keep PTT at 1.5 to 2 times normal. All patients received aspirin and according of the evolution adjuvant therapy. We defined bleeding complications and/or cerebrovascular accident related to thrombolytic therapy.

RESULTS

We included 225 patients who received rt-PA. Average age was 57.1 +/- 22.2 years, 78.7% males and 21.3% females. Arrival time at hospital was 2.93 +/- 1.7 hours. 82.2% were in class I-II by NYHA. 59.2% had anterior wall location and 32.4% posterior-inferior wall 80% had reperfusion criteria. Only 7.1% required transfusion and 0.4% presented CNS bleeding. The survival rate was 95.2%. The mortality had no relation with bleeding.

CONCLUSION

Fast infusion is an effective and safe method. Transfusion requirements are no greater, and CNS bleeding was noted in 0.4% of the cases.

[Kikuchi-Fujimoto disease associated with acute infection by herpesvirus 6]

The histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto disease is a very rare entity in Spain. We present a 34-year-old arabic male admitted to hospital because one-month story of asthenia, anorexia, weight loss, fever and lymphadenopathies in all palpable sites. Analytic studies were all within normal limits except LDH levels and globular sedimentation rate, both raised. After cervical lymph node biopsy performance high grade Non-Hodgkin lymphoma was initially diagnosed. During admission he complained from pain in both shoulders and an erythematous desquamative eruption in trunk appeared. Some days later, a second lymph node biopsy was performed and Kikuchi-Fujimoto disease was diagnosed. Serologic tests for human herpes virus 6 were positive demonstrating active associated infection. He begun treatment with indomethicin, fever and general symptoms disappeared one week later discontinuing treatment. Two months after discharge, all lymphadenopathies had disappeared. A review on epidemiological, clinical, pathological and differential diagnosis issues is made.

[Down's dyndrome and congenital heart disease (author's transl)]

Out of a group of 113 cases of Down's syndrome 50 were associated with congenital heart disease, confirmed by haemodynamic, angiographic and surgical means. The mean age was 36.6 months. Twelve were cyanotic, six of them because of an inverted previous left-toright shunt. The endocardial cushion defect, alone or in association, accounted for 40% of these anomalies, and ventricular septal defect for 26%. If the cases with right ventricle outflow obstruction are excluded, 50% presented pulmonary pressures over 70 mmHg. In addition, 80% of endocardial cushion defects presented pulmonary hypertension, being the three fourths under one year of life. On the basis of the data presented, authors remark the need of an early approach to specialized diagnosis of these children, in order to allow an earlier surgical correction or palliation than in children without Down syndrome.

[Role of the ballon of intraaortic contrapulsation in a patient with stenosis of the main left branch and renovascular hypertension]

A 34 year old patient with prolonged unstable angina pectoris who did not respond to medical treatment is presented. In the course of three days he developed acute subendocardial infarction complicated by severe ventricular arrhythmias and cardiac arrest. Previously renovascular arterial hypertension due to important stenosis of the right renal artery had been diagnosed by renal arteriography. The precordial pain did not disappear with acute myocardial infarction. He presented acute postinfarction angina which required the use of vasodilator and beta-adrenergic blocking agents which did not alleviate his symptoms completely. Coronary arteriography performed a month after acute myocardial infarction demonstrated 99% stenosis of the left main coronary artery and 70% stenosis of the left anterior descending artery. During three days before surgery intraaortic ballon pumping was employed and the patient did not present precordial pain. The patient became asymptomatic after placing two aortocoronary vein grafts to the left anterior descending and circumflex arteries, and three months later blood pressure fell to normal after placing a right aorto renal graft. The poor prognosis of critical stenosis of the main left branch, its medical treatment and better evolution after surgery is discussed. The indications for intra-aortic ballon pumping in this type of patients and its use before surgery so as to be able to suspend beta-adrenergic blocking agents without risks are specified. Finally the surgical indications for renovascular hypertension are discussed.