Isquemia digital como forma de presentación de granulomatosis con poliangeítis / Digital ischemia as a presentation of granulomatosis with polyangiitis

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Granulomatosis de Wegener con anticuerpos anticitoplasma de neutrófilo frente a catepsina G / Wegener's granulomatosis with anti-neutrophil cytoplasmic antibodies against anti-cathepsin G antigen

La granulomatosis de Wegener pertenece al grupo de vasculitis de vaso pequeño asociadas a anticuerpos anticitoplasma de neutrófilo. Se caracteriza por inflamación granulomatosa y vasculitis necrosante que puede afectar a diversos órganos, principalmente cursa con afectación renal y de las vías respiratorias. Es una enfermedad rara en la infancia y el diagnóstico precoz es fundamental para el pronóstico a largo plazo de la enfermedad. La presencia de anticuerpos anticitoplasma de neutrófilo con patrón citoplasmático o de títulos elevados de anticuerpos antiproteinasa-3 ha sido actualmente incluida en los criterios diagnósticos de vasculitis en niños. En este artículo se presenta un caso de granulomatosis de Wegener en la infancia, con presencia de anticuerpos anticitoplasma de neutrófilo con patrón citoplasmático con ausencia de anticuerpos antiproteinasa-3 y presencia de niveles elevados de anticuerpos anticatepsina G, raramente asociados a granulomatosis de Wegener (AU)

Wegener’s granulomatosis belongs to the group of small vessel vasculitis associated with anti-neutrophil cytoplasmic antibodies characterized by granulomatous inflammation andnecrotising vasculitis in various organs with particular involvement of the upper and lower respiratory tracts and kidneys. Wegener’s granulomatosis is a rare disorder in childhood and early diagnosis of this disease is critical to the long-term prognosis of the disease. The presence of positive cytoplasmic antineutrophil cytoplasmic antibody staining or a high titre of proteinase 3 antibodies were added as new criteria of vasculitis in childhood. This article presents a case of Wegener’s granulomatosis, with the presence of anti-neutrophil cytoplasm antibodies with cytoplasmic pattern with absence of anti-proteinase 3 antibodies and presence of high levels of anti-cathepsin G antibodies, rarely described in Wegener’s granulomatosis (AU)

[Wegener's granulomatosis with anti-neutrophil cytoplasmic antibodies against anti-cathepsin G antigen]. / Granulomatosis de Wegener con anticuerpos anticitoplasma de neutrófilo frente a catepsina G.

Wegener's granulomatosis belongs to the group of small vessel vasculitis associated with anti-neutrophil cytoplasmic antibodies characterized by granulomatous inflammation and necrotising vasculitis in various organs with particular involvement of the upper and lower respiratory tracts and kidneys. Wegener's granulomatosis is a rare disorder in childhood and early diagnosis of this disease is critical to the long-term prognosis of the disease. The presence of positive cytoplasmic antineutrophil cytoplasmic antibody staining or a high titre of proteinase 3 antibodies were added as new criteria of vasculitis in childhood. This article presents a case of Wegener's granulomatosis, with the presence of anti-neutrophil cytoplasm antibodies with cytoplasmic pattern with absence of anti-proteinase 3 antibodies and presence of high levels of anti-cathepsin G antibodies, rarely described in Wegener's granulomatosis.

Estudio de la relación entre el tipo de Unidad de Cirugía Mayor Ambulatoria y los indicadores de calidad / No disponible

Objetivos: El objetivo de este trabajo es estudiar la repercusión que la estructura y la organización interna de la Unidad de Cirugía Mayor Ambulatoria del Complejo Hospitalario de Jaén han tenido en los indicadores clínicos de calidad en la cirugía de la herniainguinocrural. Material y métodos: Hemos estudiado 708 hernias inguinocrurales intervenidas desde el día 1 de enero de 2005 hasta el 1de marzo de 2007: 334 pacientes fueron intervenidos cuando la unidad era de tipo integrado y 374 en la unidad de tipo separado. Se han monitorizado cuatro indicadores: intervenciones suspendidas, ingresos, reintervenciones y reingresos. Se realizó un análisis estadístico para estudiar la posible asociación entre el tipo de unidad y los indicadores mediante el test de Chi-cuadrado. Resultados: Intervenciones suspendidas: la tasa de suspensiones fue del 3,2% en la unidad integrada y del 2,1% en la unidad de tipo separado. Ingresos: la tasa de ingresos en la unidad integrada fue 5,6 y del 4,8% en la de tipo separado. Reintervenciones: en la unidad integrada se reintervinieron 4 pacientes(1,2%), y dos en la unidad separada (0,5%). Reingresos: dos ingresos ocurrieron en la unidad integrada (0,6%) y uno en el tipo separado (0,27%).No se observó una asociación estadísticamente significativa entre el tipo de unidad y los indicadores clínicos de calidad estudiados. Conclusiones: 1. Los indicadores han mejorado en la unidad independiente respecto a la integrada. 2. No observamos asociación significativa entre el tipo de unidad y los indicadores de calidad (AU)

Objectives: The aim of this work is to study the effects on clinical quality indicators of changes in the structure and functional organisation of the Ambulatory Surgical Unit at the Complejo Hospitalario de Jaén, regarding the treatment of inguinal and femoralhernias. Material and methods: A series of 708 inguinal and femoralhernias undergoing surgery during 2005 –integrated unit (IntU),334 patients– and from January 2006 to March 2007 –independent unit (IndU), 374 patients– were studied. In these two sets of patients, four quality indicators were monitored (suspension of surgery, admission to Hospital, post-surgical re-operation, and readmissions).A statistical analysis was carried out to study the possible association between the type of Unit and quality indicators, using the Chi-square test. Results: Suspended surgery: suspension rate was 3.2% in the IntU and 2.1% in the IndU. Admission to hospital: admission rate was 5.6% in IntU and 4.8% in IndU. Re-operations: in IntU, four patients needed re-operation (1.2%) and only two (0.5%) in IndU. Readmission: two patients (0.6%) were readmitted in IntU and only one (0.27%) in IndU. There were no statistically significant associations between unit type and the studied clinical qualityindicators. Conclusions: 1. Quality indicators have shown an improvement from the integrated to the independent unit. 2. However, there is no statistically significant association between unit type and quality indicators (AU)

[Expression of receptors of estrogens and androgens in the testicular appendices]. / Expresión de receptores de estrógenos y andrógenos en los apéndices testiculares.

INTRODUCTION: The appendices or hidátides of the testicle are structures that are considered an embryonic rest. In testicular hidátide estrogen receivers have been demonstrated but in the epididimys the results vary. Has been theorized that the elevation of the estrogen levels in the puberty can produce an inflammation and torsion of hidátide, nevertheless, in the epididimys in which the estrogen expression is not clear (and also they are twisted) the theory is put in doubt. This controversy takes us to the accomplishment of this work. MATERIAL AND METHOD: A prospective study is made in 20 testicular appendices, of which 7 from the epididimys are extirpated of patients to whom an escrotal exploration is made in the development of surgery of processes of the inguino-escrotal channel (hidroceles, hernias). Optical microscopy and inmunohistoquímical study are analyzed by means of using prediluted monoclonales antibodies, for receivers of estrogens, androgens and proliferative index. The results were proceed and analyzed by means of SPSS statistical program. RESULTS: All hidátides, testicular and from the epididimarys expressed receivers for estrogens without significant difference among them, not existing differences as far as the location of receiving sayings within the three compartments of hidátide. The number of estrogen receivers was in relation to the age of the patient. Only hidátides from the epididimys fundamentally expressed receivers of located androgens and at level of ductus. We have not found significant relation between the proliferative index and the expression of estrogen receivers. The proliferative index was more elevated at level of ductus. CONCLUSIONS: 1) As much the testicular appendices as those from the epididimays expressed receivers of estrogens at level of the three compartments. It makes think about a same embryonic origin, although only the epididimal ones expressed androgen receivers. 2) the observation of estrogen receivers in both types of hidátides, as well as the relation of the number of such with the age of the patient, makes think that the increase of estrogens in the puberty can participate in patogénia of the torsion of these appendices.

Estudio de los indicadores de calidad en el tratamiento de la hernia inguinocrural en cirugía mayor ambulatoria / No disponible

Objetivos: El objetivo de este trabajo es estudiar los indicadores clínicos de calidad en el tratamiento de la hernia inguinocrural en la Unidad de Cirugía Mayor Ambulatoria del Complejo Hospitalario de Jaén. Material y métodos: Se han monitorizado de forma prospectiva cinco indicadores clínicos: intervenciones suspendidas, ingresos, complicaciones postoperatorias, reintervenciones y reingresos, en una serie de 655 hernias inguinocrurales intervenidas entre los años 2005 y 2006. El 89% de los pacientes fueron varones. Edad media: 52 años. Tipo de hernia: unilateral 554 casos,38 bilaterales, recidivadas 37 y múltiple 75. Riesgo ASA: ASA I55%, ASA II 38%, ASA III 7%.Resultados: Intervenciones suspendidas: el índice de suspensiones es del 2,5%, siendo la causa más frecuente la aparición de procesos intercurrentes y los problemas organizativos. Ingresos: la tasa de ingresos fue del 5%, con una estancia media de 36,6 horas. La causa más frecuente fue el incumplimiento del protocolo de cuidados postoperatorios. Morbilidad: treinta y cinco pacientes presentaron complicaciones (5%), que pueden clasificarse como menores todas, excepto un caso de infección respiratoria, que precisó reingreso. Reintervenciones: fueron reintervenidos 6 pacientes (0,9%). Reingresos: la tasa de reingresos fue del 0,4% (3 pacientes).Conclusiones:1. Los indicadores estudiados (excepto el índice de ingresos)se encuentran en los estándares de calidad aceptados.2. Los indicadores han mejorado en el año 2006 respecto a2005 (AU)

Objectives: The aim of this work is to study clinical quality indicators related to the treatment of inguinal and femoral hernias in the Ambulatory Surgical Unit at the Complejo Hospitalario de Jaén, Spain. Material and methods: Five clinical indicators were prospectively recorded (suspensions of surgery, admissions to hospital, postoperative complications, re-operations and re-admissions)in a series of 655 groin hernias operated on between 2005and 2006. 89% of the patients were males. Mean age: 52 years. Type of hernia: 554 cases were unilateral, 38 bilateral, 37 recurrent and 75 multiple. ASA risk: ASA I, 55%, ASA II, 38%, ASAIII, 7%.Results: Suspended surgeries: suspension rate was 2.5%,the most frequent cause was other accompanying processes and organizational problems. Hospital admissions: 5% of the patients were admitted with a mean stay in the hospital of 36.6 hours. The most frequent cause was not following protocols of post-surgical care. Morbidity: thirty-five patients presented some complication (5%), usually minor, with the exception of one patient who developed respiratory infection and was readmitted to the hospital. Reoperation:6 patients needed a new surgical procedure (0.9%).Re-admissions: the rate of re-admission was 0.4% (3 patients).Conclusions:1. All the indicators studied (with the exception of the rate of admission) are within the accepted standard criteria.2. Quality indicators have improved from 2005 to 2006 (AU

[Nitric oxide in malignant astrocytes]. / El monóxido de nitrógeno en los astrocitomas malignos.

INTRODUCTION: One of the different molecules involved in the development of astrocytomas is nitric oxide (NO), a gaseous radical that, depending on the cell type and the experimental paradigm selected in the pathology, can play either a cytotoxic or a cytoprotective role. DEVELOPMENT: During the development of an astrocytoma NO acts as a tumouricidal agent, although it can also alter vascular reactivity and lead to neovascularisation, thereby contributing to the invasive capacity (aggressiveness) of the tumour. One of the mechanisms of tumoural progression consists in the protein inactivation resulting from the NO nitration of tyrosine from proteins coded for by tumour-suppressing genes, such as p53. Furthermore, in malignant astrocytes, nitrosoglutathione, a natural NO-donor, has been seen to play a role in the chemoresistance displayed against nitrosourea derivatives. The NO excreted by irradiated astrocytoma cells also appears to be involved in the resistance to the radiotherapy shown by non-irradiated cells. CONCLUSIONS: The molecular mechanisms behind the complex and paradoxical activity of NO in glioblastoma multiforme have still not been fully explained and its implications in vivo are even further from being completely understood.

El monóxido de nitrógeno en los astrocitomas malignos / Nitric oxide in malignant astrocytes

Introducción. Entre las diferentes moléculas implicadas en el desarrollo de los astrocitomas se encuentra el monóxido de nitrógeno (NO), un radical gaseoso que, según el tipo celular y el paradigma experimental seleccionado en patología, puede ejercer un papel citotóxico o citoprotector. Desarrollo. Durante el desarrollo de un astrocitoma, el NO presenta actividad tumoricida, aunque también puede alterar la reactividad vascular y conducir a la neo-vascularización; contribuye, de este modo, a la capacidad invasiva (agresividad) del tumor. Entre los mecanismos de progresión tumoral se encuentra la inactivación proteica derivada de la síntesis de NO, a través de la nitración de residuos de tirosina de las proteínas codificadas por genes supresores de tumores, como la p53. Además, también se ha detectado en los astrocitomas malignos la participación del nitrosoglutatión, un reservorio natural de NO, en la quimiorresistencia frente a los derivados de la nitrosourea, así como la implicación del NO excretado por las células irradiadas de astrocitoma en la resistencia a la radioterapia de células no irradiadas. Conclusión. Los mecanismos moleculares de la compleja y paradójica actividad del NO en el glioblastoma multiforme todavía no se han dilucidado del todo y, menos todavía, sus implicaciones in vivo

Introduction. One of the different molecules involved in the development of astrocytomas is nitric oxide (NO), a gaseous radical that, depending on the cell type and the experimental paradigm selected in the pathology, can play either a cytotoxic or a cytoprotective role. Development. During the development of an astrocytoma NO acts as a tumouricidal agent, although it can also alter vascular reactivity and lead to neovascularisation, thereby contributing to the invasive capacity (aggressiveness) of the tumour. One of the mechanisms of tumoural progression consists in the protein inactivation resulting from the NO nitration of tyrosine from proteins coded for by tumour-suppressing genes, such as p53. Furthermore, in malignant astrocytes, nitrosoglutathione, a natural NO-donor, has been seen to play a role in the chemoresistance displayed against nitrosourea derivatives. The NO excreted by irradiated astrocytoma cells also appears to be involved in the resistance to the radiotherapy shown by non-irradiated cells. Conclusions. The molecular mechanisms behind the complex and paradoxical activity of NO in glioblastoma multiforme have still not been fully explained and its implications in vivo are even further from being completely understood

[Fibroepithelial polyp of the urethra in a young woman]. / Pólipo fibroepitelial de uretra en mujer joven.

OBJECTIVE: We present the case of a fibroepithelial polyp from the uretra of a young female, analysing the factors that make this an interesting case. MATERIAL AND METHODS: A case-report of a fibrous polyp from the urethra of a young female, an analysis of its differential diagnosis and a review of the literature. RESULTS AND CONCLUSIONS: The fibrous polyp of the urethra (fibroepithelual polyp, simple polyp, pedunculated polyp) is a rare benign epithelial tumour, more frequently encountered in males and in the posterior urethra. When it appears in females it is usually located in the external meatus and normally asymptomatic, although it can also present with a mictional syndrome, terminal hematuria or urethral hemorrhage. The differential diagnosis includes other benign epithelial tumours of the urethra, such as the caruncula, mainly the granulomatous, very difficult to differentiate, the squamous papilloma and the acuminated chondiloma. A clinical examination and histological study are necessary for a correct diagnosis, and treatment consists of surgical resection.

Pólipo fibroepitelial de uretra en mujer joven / Fibroepithelial polyp of the urethra in a young female

OBJETIVO: Aportación de un caso de pólipo fibroepitelial de uretra femenina en mujer joven. Análisis de los factores que lo convierten en un caso interesante. MATERIAL Y MÉTODOS: Exposición de un caso clínico de pólipo fibroso de uretra femenina en mujer joven, estudio de los diferentes diagnósticos diferenciales y revisión de la literatura. RESULTADO Y CONCLUSIONES: El pólipo fibroso de uretra (pólipo fibroepitelial, pólipo simple, pólipo pedunculado), es una rara tumoración epitelial benigna, más frecuente en varones y en la uretra posterior. Cuando aparece en la mujer suele asentar en el meato externo y ser asintomático, aunque también puede debutar como síndrome miccional, hematuria terminal o uretrorragia. El diagnóstico diferencial incluye otros tumores epiteliales benignos de la uretra, como la carúncula, fundamentalmente la granulomatosa, de la que puede ser muy difícil de diferenciar el papiloma escamoso y el condiloma acuminado. Para su diagnóstico son necesarias la exploración clínica y el estudio histológico, y el tratamiento consiste en la extirpación (AU)

[Synchronous prostatic carcinosarcoma: report of 2 cases and review of the literature]. / Carcinosarcoma prostático sincrónico: presentación de dos casos y revisión de la literatura.

OBJECTIVE: Carcinosarcoma of the prostate is a biphasic tumor containing adenocarcinoma and recognisable sarcomatous components. It is a rare neoplasm with less than 40 reported cases. We describe two additional examples showing carcinosarcoma in the initial pathologic material (synchronous presentation). METHODS AND RESULTS: The patients were 71 and 78 year-old, respectively. The primary prostatic tumour in case one was composed of adenocarcinoma admixed with a neoplastic mesenchymal component that displayed foci of chondrosarcoma, rhabdomyosarcoma and angiosarcoma. The adenocarcinoma in the second case was admixed with spindle cell sarcoma and chondrosarcoma. Both patients died of disease after surgery, 3 and 9 months respectively. CONCLUSION: Synchronous carcinosarcoma of the prostate is a highly malignant neoplasm that may need an aggressive therapy.

Nuclear volume estimates in prostatic intraepithelial neoplasia.

OBJECTIVE: Prostatic intraepithelial neoplasia (PIN), the most likely precursor of prostatic adenocarcinoma, is divided into two grades, low and high. Pathologists may encounter difficulties in applying these criteria in daily practice. In view of the clinical significance of high grade PIN as strong predictor of carcinoma, the separation of low and high grade PIN plays an important role in patient management. The aim of the present study was to evaluate three-dimensional nuclear size estimation in normal prostatic glands, low and high grade PIN, and prostatic adenocarcinoma as an element in their classification. STUDY DESIGN: We studied 31 formalin-fixed, paraffin-embedded, whole-mounted radical prostastectomy specimens that contained foci of normal prostatic glands, low and high grade PIN, and prostatic adenocarcinoma. Hematoxylin-eosin-stained sections were selected for the stereologic estimation of volume-weighted mean nuclear volume by the "point-sampled intercepts" method. On each focus, an average of six fields of vision were systematically chosen. RESULTS: The quantitative results indicate a significant increase in nuclear volume from normal prostatic glands (mean, 209.0 micron 3; SD, 64.6 micron 3) to low grade PIN, high grade PIN and prostatic adenocarcinoma with increments of 49%, 88% and 109%, respectively (F = 29.1, P < .001). Two-group comparisons (Duncan procedure) showed differences between low and high grade PIN and prostatic adenocarcinoma (P < .01). The difference between high grade PIN and prostatic adenocarcinoma was not significant. CONCLUSION: Three-dimensional estimates of nuclear size discriminate low and high grade PIN. Lack of stereologic differences between high grade PIN and prostatic adenocarcinoma further supports high grade PIN as a precursor of prostatic adenocarcinoma.

Carcinosarcoma prostático sincrónico: presentación de dos casos y revisión de la literatura / Synchronous carcinosarcoma of the prostate: report of two cases and review of the literature

OBJETIVO: El carcinosarcoma prostático es un tumor bifásico que contiene adenocarcinoma y componentes sarcomatosos reconocibles. Es una neoplasia muy poco frecuente, de la que se han comunicado menos de 40 casos. Describimos dos ejemplos adicionales que muestran carcinosarcoma en el primer material anatomopatológico (presentación sincrónica). MÉTODOS Y RESULTADOS: Los pacientes tenían edades de 71 y 78 años. El tumor prostático primario en el Caso 1 estaba constituido por adenocarcinoma mezclado con un componente mesenqui-mal que mostraba focos de condrosarcoma, rabdomiosarcoma y angiosarcoma. El adenocarcinoma en el Caso 2 estaba mezclado con sarcoma fusocelular y condrosarcoma. Ambos pacientes murieron a causa de la enfermedad, tras cirugía, a los 3 y 9 meses respectivamente. CONCLUSIÓN: El carcinosarcoma prostático sincrónico es una neoplasia altamente maligna que puede precisar una terapia agresiva (AU)

Nuclear volume estimates in prostatic atypical adenomatous hyperplasia.

OBJECTIVE: To investigate nuclear volume estimates by the point-sampled intercepts method in atypical adenomatous hyperplasia (AAH) as compared with nodular hyperplasia and well-differentiated prostatic adenocarcinoma. STUDY DESIGN: The study group consisted of 27 formalin-fixed, paraffin-embedded, whole-mounted radical prostatectomy specimens that contained foci of nodular hyperplasia, atypical adenomatous hyperplasia and well-differentiated adenocarcinoma (Gleason pattern 1 and 2). Representative sections were selected for stereologic estimation of volume-weighted mean nuclear volume by the point-sampled intercepts method. On each focus, an average of five fields of vision were systematically chosen. RESULTS: The quantitative results indicate an increase in nuclear volume from nodular hyperplasia (209 +/- 65 micron 3) to AAH (237 +/- 85 micron 3) and prostate adenocarcinoma (436 +/- 106 micron 3). Significant differences were found (F = 39.0, P < .001) with two group comparisons (Scheffe's procedure) between prostate cancer and AAH (P < .001) or nodular hyperplasia (P < .001). The difference between AAH and benign hyperplasia was not signifcant. CONCLUSION: The results indicate that three-dimensional estimates of the nuclear size discriminate AAH and nodular hyperplasia from well-differentiated prostate adenocarcinoma. These findings suggest that AAH is probably a histologic variant of benign prostatic hyperplasia the exact relationship of which to prostatic adenocarcinoma remains to be determined.

When is a biopsy justified in a case of relapsing polychondritis?

Relapsing polychondritis (RP) is a relatively rare rheumatic condition of unknown aetiology. It is characterized by recurrent episodic inflammation of cartilaginous structures (nose, ear and trachea). The clinical diagnosis of polychondritis can frequently be made with confidence in the absence of histological confirmation. A 61-year-old diabetic man, with bilateral relapsing aural inflammation, left ear deafness with tinnitus and pain at the sternocostal junctions is reported. After clinical diagnosis of relapsing polychondritis steroid therapy was started. An ear cartilage biopsy was performed confirming the clinical diagnosis. Subsequently soft tissue infection occurred at the operation site. The abscess was drained and oral ciprofloxacin was given with complete resolution of the infection over 30 days. As the infection is the main cause of death in these patients, we analyse whether biopsy is absolutely necessary for the diagnosis of RP in some patients.