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

Contexto: Durante muchos años, la detección del carcinoma prostático (CaP) y su manejo terapéutico se basó fundamentalmente en el antígeno prostático específico, el tacto rectal y la biopsia prostática. Sin embargo, estos parámetros poseen conocidas limitaciones. La resonancia magnética multiparamétrica (RMmp) prostática ha tenido en los últimos años un extenso desarrollo, aportando información morfológica y funcional. El objetivo es presentar una revisión actualizada de los alcances y las limitaciones de la RMmp prostática en relación con el CaP, en el marco de una visión multidisciplinaria. Adquisición de evidencia: Se realizó una revisión de la literatura en PubMed, de los artículos referidos a «RMmp/Estadificación/CaP/detección/vigilancia activa/planificación terapéutica/posterapeútica». Se incluyeron 4 revisiones sistemáticas y otros artículos publicados en revistas de alto factor de impacto dentro del área de Radiología y Urología. Síntesis de evidencia: La RMmp aporta información morfológica y funcional respecto al CaP. Esta información está integrada en el modelo de lectura Prostate Imaging Reporting and Data System, clasificándose la probabilidad de carcinoma clínicamente significativo en una escala del 1 al 5. Actualmente está establecida la utilidad de la RMmp en pacientes con antígeno prostático específico elevado y biopsia prostática previa negativa; estadificación tumoral en casos seleccionados; evaluación en los pacientes candidatos a vigilancia activa; planificación de tratamientos focales y evaluación de la persistencia o recurrencia tumoral. Conclusiones: La RMmp actualmente cumple un papel relevante en el diagnóstico y la toma de decisiones terapéuticas del CaP. El uso aún más extendido de la técnica requerirá una valoración coste/beneficio

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

Integral pharmacological management of bone mineral disorders in chronic kidney disease (part I): from treatment of phosphate imbalance to control of PTH and prevention of progression of cardiovascular calcification.

INTRODUCTION: Chronic kidney disease-mineral and bone disorders (CKD-MBD), involving a triad of laboratory and bone abnormalities, and tissue calcifications, are associated with dismal hard-outcomes. AREAS COVERED: In two comprehensive articles, we review contemporary and future pharmacological options for treatment of phosphate (P) imbalance (this part 1) and hyperparathyroidism (part 2), taking into account CKD-accelerated atheromatosis/atherosclerosis and/or cardiovascular calcification (CVC) processes. EXPERT OPINION: Improvements in CKD-MBD require an integral approach, addressing all three components of the CKD-MBD triad. Individualization of treatment with P-binders and combinations of anti-parathyroid agents may improve biochemical control with lower incidence of undesirable effects. Isolated biochemical parameters do not accurately reflect calcium or P load or bone activity and do not stratify high cardiovascular risk patients with CKD. Initial guidance is provided on reasonable therapeutic strategies which consider the presence of CVC. This part reflects that although there is not an absolute evidence, many studies point to the need to improve P imbalance while trying to, at least, avoid progression of CVC by restriction of Ca-based P-binders if economically feasible. The availability of new drugs (i.e. inhibitors of intestinal transporters), and studies including early CKD should ultimately lead to clearer and more cost/effective clinical targets for CKD-MBD.

Integral pharmacological management of bone mineral disorders in chronic kidney disease (part II): from treatment of phosphate imbalance to control of PTH and prevention of progression of cardiovascular calcification.

INTRODUCTION: Chronic kidney disease-mineral and bone disorders (CKD-MBD) are associated with costly complications and dismal hard-outcomes. AREAS COVERED: In two comprehensive articles we review contemporary and future pharmacological options for treatment of phosphate (P) imbalance (part 1) and hyperparathyroidism (this part 2), taking into account CKD-accelerated cardiovascular calcification (CVC) processes. EXPERT OPINION: Improvements in CKD-MBD require an integral approach, addressing all three components of the CKD-MBD triad. Here, initial guidance to control hyperparathyroidism is provided, taking into account the presence/absence of CVC. We include also measures for patients at risk of adynamic bone disease or suffering from calciphylaxis. Many epidemiological studies (relating to vitamin D) and thorough analyses of recent randomized clinical trials (of cinacalcet) point towards benefits of attempting to improve biochemical parameters while trying to, at least, avoid progression of CVC by more rational use of intestinal P-binders and low-dose vitamin D derivatives and/or calcimimetics. This approach does not seem to be far away from significantly improving hard-outcomes, at least in the dialysis population. The availability of new drugs and the performance of randomized clinical trials should ultimately lead to define earlier, clearer, and more cost-effective patient stratification and biochemical targets with consequent significant clinical improvements.

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.

Efectos de la rapamicina en los angiomiolipomas de pacientes con esclerosis tuberosa / Effects of rapamycin on angiomyolipomas in patients with tuberous sclerosis

Introducción: La esclerosis tuberosa (ET) es una enfermedad sistémica, de herencia autosómica dominante, ocasionada por mutaciones en dos genes (TSC1 y TSC2), que causan la aparición de tumores (angiolipomas [AML], angiofibromas, astrocitomas, etc.). La proliferación inadecuada y constante que existe en la ET puede ser bloqueada por inhibidores de la kinasa mTOR (mammalian target of rapamycin), como la rapamicina. Material y métodos: Se han incluido 17 pacientes afectados de ET y, al menos, un AML mayor de 2 cm de diámetro diagnosticado por resonancia magnética (RM). Han recibido tratamiento con rapamicina durante 12 meses. Los niveles plásmáticos se han mantenido entre 4 y 8 ng/dl. El tamaño del AML se ha monitorizado semestralmente mediante RM abdominal. Resultados: A los 12 meses de la inclusión, con la RM se ha objetivado una disminución del tamaño del AML en todos los pacientes incluidos, mostrando una reducción de, al menos, un 50% en el 82,4% (14/17; intervalo de confianza [IC] 95% [56,57%, 96,20%]). El porcentaje medio de reducción fue del 66,3% (IC95 [56,9%, 75,6%]; p <0,0001). Los principales efectos secundarios observados han sido: aftas orales (5/17); hipertrigliceridemia (3/17); microcitosis e hipocromía (3/17); diarrea (2/17); acné (1/17); pielonefritis aguda (1/17), y proteinuria (1/17). Conclusiones: Los datos clínicos preliminares sugieren que la rapamicina puede desempeñar un papel beneficioso en el tratamiento de la ET. Nuestra experiencia en 17 pacientes tratados durante 12 meses demuestra seguridad y eficacia en la reducción de AML (AU)

Background: Tuberous sclerosis (TS) is a systemic disease, with an autosomal dominant pattern of inheritance caused by mutations in two genes (TSC1 and TSC2) that cause tumours (angiomyolipomas [AML], angiofibromas, astrocytomas). Constant and inadequate proliferation occurring in TS may be blocked by mTOR inhibitors (mammalian target of rapamycin), such as rapamycin. Material and methods: At present, our study includes 17 patients with TS. All had at least one AML greater than 2cm in diameter diagnosed by MRI. They received rapamycin during 12 months. Plasma levels remained stable between 4-8ng/dl. The AML size was monitored every six months by abdominal MRI. Results: At 12 months of inclusion, MRI indicated a decrease in the size of AML in all patients showing at least a 50% reduction in 82.4% (14/17, 95% CI [56.57%, 96.20%]). The mean percent reduction was 66.3% (95% CI [56.9%, 75.6%], P<.0001). The major side effects observed were: oral aphthous ulcers (5/17); hypertriglyceridemia (3/17); microcytosis and hypochromia (3/17); diarrhea (2/17); acne (1/17); acute pyelonephritis (1/17); and proteinuria (1/17). Conclusions: These preliminary clinical data suggest that rapamycin can play a beneficial role in the treatment of TS. Our experience in 17 patients treated for 12 months demonstrates safety and efficacy in reducing AML volume (AU)

Virtual reality interoceptive exposure for the treatment of panic disorder and agoraphobia.

The efficacy of cognitive-behavioral therapy for panic disorder and agoraphobia (PDA) has been widely demonstrated. The exposure technique is the main component of these programs; interoceptive exposure also plays an important role. The virtual reality (VR) program for treating PDA developed by Botella's group can simulate physical sensations in a controlled manner while the user is immersed in the VR environments in the consultation room. These include audible effects, such as rapid heartbeat and panting, as well as visual effects, such as blurry vision, double vision and tunnel vision. This work examines the efficacy of the interoceptive exposure (IE) component in two treatment conditions: 1) VR Interoceptive Exposure Simultaneous Condition (VRIE-sim; N=14), and 2) Interoceptive Exposure Traditional Condition (IET; N=15). Results obtained showed that both treatment conditions significantly reduced the main clinical variables at post-treatment; these results were maintained or even improved at three month follow-up. Simultaneous VR interoceptive and VR external stimuli exposure is a new and effective way to apply PDA treatment.

Cardio- and cerebrovascular events in HIV-infected persons.

OBJECTIVE: Recent results from the D:A:D Study indicated that the incidence of myocardial infarction (MI) increased by 26% per year of exposure to combination antiretroviral treatment (CART). The present study was performed to investigate whether this risk was similar when including other cardio- and cerebro-vascular disease events (CCVE). DESIGN: D:A:D is an international collaboration of 11 cohorts, following 23 468 HIV-infected patients prospectively at 188 clinics in 21 countries situated in Europe, USA and Australia. METHODS: The end-point was the occurrence of a first CCVE during prospective follow-up, defined as the first of: acute MI, invasive cardiovascular procedures, stroke, or death from other cardiovascular disease. Relative rates (RR) for CCVE from Poisson regression models and 95% confidence intervals (CI) are reported. All models are adjusted for other risk factors for CCVE, including age, gender, ethnicity, family history, body mass index, and smoking status as well as cohort and HIV transmission group. RESULTS: Over 36 145 person-years of follow-up, 207 patients experienced at least one CCVE (23.7% fatal). The first event was MI in 126 patients, invasive cardiovascular procedure in 39 patients, stroke in 38 patients, and death from other cardiovascular disease in four patients. The incidence of first CCVE was 5.7 per 1000 person-years [95% confidence interval (CI) 5.0-6.5] and increased with longer exposure to CART (RR per year of exposure, 1.26; 95% CI, 1.14-1.38; P < 0.0001). CONCLUSION: CART increases the risk of CCVD, and this increase is comparable with how CART affects the risk of MI. This finding is consistent with the hypothesis that atherosclerosis is a side-effect of CART.

Lipid profiles in HIV-infected patients receiving combination antiretroviral therapy: are different antiretroviral drugs associated with different lipid profiles?

Levels of triglycerides (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), and high-density lipoprotein cholesterol (HDL-c), as well as the TC:HDL-c ratio, were compared in patients receiving different antiretroviral therapy regimens. Patients receiving first-line regimens including protease inhibitors (PIs) had higher TC and TG levels and TC : HDL-c ratios than did antiretroviral-naive patients; patients receiving 2 PIs had higher levels of each lipid. Ritonavir-containing regimens were associated with higher TC and TG levels and TC : HDL-c ratios than were indinavir-containing regimens; however, receipt of nelfinavir was associated with reduced risk of lower HDL-c levels, and receipt of saquinavir was associated with lower TC : HDL-c ratios. Patients receiving nonnucleoside reverse-transcriptase inhibitors had higher levels of TC and LDL-c than did antiretroviral-naive patients, although the risk of having lower HDL-c levels was lower than that in patients receiving a single PI. Efavirenz was associated with higher levels of TC and TG than was nevirapine.

Recursos necesarios en la mejora de la salud pública en obstetricia y ginecología / Resources required for the improvement of public health in obstetrics and ginecology

No disponible

Bioética y reproducción asistida / Bioethics and assisted reproduction

No disponible

[Utilization of thrombolytic drugs in Barcelona. Study Group on Secondary Prevention of Myocardial Infarction]. / Utilización de fármacos trombolíticos en Barcelona. Grupo de Estudio para la Prevención Secundaria del Infarto de Miocardio.

BACKGROUND: A number of clinical trials including more than 50,000 patients have shown the efficacy of thrombolytic therapy in reducing mortality associated with acute myocardial infarction (AMI). However, the results of some recently published drug utilization studies have shown that only one third of admitted patients with a diagnosis of AMI receive thrombolytic treatment. The aim of the present study was to quantify and characterize the use of thrombolytic drugs in three hospitals in Barcelona, Spain. PATIENTS AND METHODS: We collected retrospective information about some clinical variables and drug prescription of patients discharged with a diagnosis of AMI from three hospitals in Barcelona between January and June 1994. RESULTS: Three hundred and sixty-four patients (247 men, 68%) with a mean age of 68 years (SD 13) were included in the study. The median time from the beginning of clinical symptoms to hospital admission was 3 h (range 1 to 96). One hundred and two patients (28%) were prescribed thrombolytic drugs, and of these, 62%, received streptokinase. No one patient received any thrombolytic treatment before hospital admission. In a multivariate analysis the following variables were negatively associated with thrombolytic use: age over 75 years, more than three hours from the beginning of symptoms to hospital admission and an EKG with bundle-branch block, ST depression or normal. After excluding patients with limitations to thrombolytic use, 18% of all patients could be identified who did not receive any thrombolytic treatment they could have benefited from. CONCLUSIONS: Only one third of admitted patients with a diagnosis of AMI in the three study hospitals receive thrombolytic treatment. One fifth of the study population with AMI does not receive any thrombolytic therapy but could have benefited from it.

Binding of [3H]cytochalasin B to tumoral islet cells.

Tumoral pancreatic islet cells of the RINm5F line are equipped with two classes of [3H]cytochalasin B binding sites with respective Kd of 0.4 and 7 microM. The binding of the fungal metabolite and its dissociation from the binding sites display rapid time courses. The binding is inhibited by D-glucose, more than by L-glucose, by phlorizin and by cytochalasin E. These findings are considered in the light of the dual action of cytochalasin B upon hexose transport and motile activity in islet cells.

[Perinatal mortality and neonatal morbidity from 1974 till 1979]. / Mortalidad perinatal y mobilidad neonatal durante el quinquenio 1974-79.

PIP: To collect data on fetal and infant mortality in Spain 15,222 live births were investigated between 1974-1979 in a large metropolitan hospital. Perinatal mortality was 21.18/1000 in 1974, and 12.48/1000 in 1979, an average of 16.88/1000 over the 5-year period. Early fetal death was extremely high, 8.21/1000, possibly due to the fact that most women had never had any prenatal care. Mortality during delivery was 2.63/1000; early neonatal mortality was 6.04/1000; and late fetal mortality was 10.83/1000. Of the 15,222 newborns, 2381 (15.64%), needed special care: 2.14% needed intensive care, 4.41% needed average care, and 9.09% needed minimal care. Syndromes observed were: hypoxia (6.94%); low birth weight (4.16%); malformations; jaundice; and respiratory insufficiency.^ieng