Infección urinaria febril en hombres: rentabilidad del tactorectal para el diagnóstico de prostatitis aguda en urgencias / Acute prostatitis in men with urinary tract infection and fever: diagnostic yield of rectal examination findings in the emergency department

Objetivo: El diagnóstico de prostatitis aguda bacteriana (PAB) en hombres con infección del tracto urinario febril (ITUF) se basa en la presencia de una próstata dolorosa al tacto rectal (TR). Se evaluó la sensibilidad (S), especificidad (E), valores predictivos positivo y negativo (VPP y VPN) y los coeficientes de probabilidad positivo y negativo (CPPy CPN), del TR en el diagnóstico de PAB en hombres con ITUF. Método: Se incluyó de forma prospectiva 48 hombres con ITUF comunitaria. La valoración clínica inicial incluyó la realización del TR y la determinación del control prostático específico total (PSAt) que se consideró la prueba de referencia. Resultados: Veintitrés (47,9%) pacientes tenían una próstata dolorosa al TR y 30(62,5%) niveles elevados de PSAt. Trece (27,1%) de los pacientes presentaron una puñopercusión lumbar positiva, 9 (30,7%) de ellos con valores elevados de PSAt. El TR tuvo una S del 63,3%, una E del 77,7%, un VPP del 82,6%, un VPN del 56%, un CPP del 2,85 y un CPN del 0,47 en el diagnóstico de PAB. Conclusiones: La demostración de una próstata dolorosa al TR en hombres con ITUF es un dato altamente sugestivo de PAB, pero debido a la baja S y VPN del TR, la ausencia de dolor no la descarta por lo que los hombres con una ITUF deberían ser tratados como una PAB (AU)

Objective: The diagnosis of acute bacterial prostatitis (ABP) in men with a urinary tract infection (UTI) and fever is based on a finding of a painful prostate on rectal examination. This study aimed to assess the sensitivity, specificity, positive and negative predictive values (PPV and NPV), and positive and negative likelihood ratios of rectal examination findings in the diagnosis of ABP associated with UTI and fever. Methods: We prospectively included 48 men with community-acquired UTI with fever. Clinical evaluation included a rectal examination and prostate-specific antigen (PSA) determination which was considered ten reference test for ABP. Results: Twenty-three patients (47.9%) had a painful prostate on rectal examination and 30 (62.5%) had elevated PSA levels. Thirteen (27.1%) had a positive lumbar fist percussion; PSA was elevated in 9 (30.7%) of those patients. The sensitivity of rectal examination findings for a diagnosis of ABP was 63.3%; specificity, 77.7%; PPV, 82.6%; NPV, 56%; positive likelihood ratio, 2.85; and negative likelihood ratio, 0.47.Conclusions: A finding of painful prostate on rectal examination in men with UTI with fever strongly suggests a diagnosis of acute bacterial prostatitis. The low sensitivity and NPV of this finding means that an absence of pain does not rule out a diagnosis of ABP. Therefore men with UTI with fever should be treated as if they had ABP (AU)

[Role of radiotherapy in the XXI century]. / Papel de la radioterapia en el siglo XXI.

In the last twenty years the extraordinary rise of information technology has made possible key technological developments at the service of precision in radiotherapy treatments: in obtaining three-dimensional images, in systems planning and in radiation units. Thus in less than two decades there progress has been made from radiotherapy in two dimensions (RT 2D) to 3D conformal radiotherapy (3DCRT) and to modulation of intensity modulated radiotherapy for maximum conformation (IMRT). High precision in radiation delivery adjusts the prescribed dosage to the white volume, better preserving the adjacent healthy tissue. It is thus possible to aspire to improving the therapeutic index in two respects, either reducing late toxicity when this is a problem of sufficient scale, or scaling the dosage in the white volume in order to increase tumour control without provoking further toxicity. A final component in reaching the present state of radiotherapy is of capital importance: the guided image which makes it possible to direct the beams of radiation, adapting them to the possible changes of position of the white volume before or during treatment.

[The clinical application of intensity-modulated radiation therapy]. / Aplicación clínica de la radioterapia de intensidad modulada.

Intensity-modulated radiation therapy (IMRT) represents one of the greatest technical innovations in modern radiotherapy. Its capacity of achieving treatments with the dose conforming largely to the irradiated area makes it possible to treat volumes close to organs at risk with great safety These characteristics make it an ideal technique for studies, whether for reducing toxicity in organs at risk, or for intensifying dosages to improve the control of the disease. The first part of the article considers what is understood by IMRT and its peculiar dosimetric characteristics, as well the types of IMRT; the second part deals with the clinical evidence in some localisations such as tumours of the head and neck, prostate and breast.

[Clinical impact of image guided radiotherapy]. / Radioterapia guiada por imagen. Impacto clínico.

Image guided radiotherapy (IGR) is a concept that encompasses the most modern way of administering radiotherapy treatment. The aim is to maximise the dose deposited in the target volume, minimising the dose in healthy organs. This would not be possible without the continuous development of technology and software, above all in the following areas: deformable image registration, replanning new treatments, real time image and calculation of accumulated dose. While the clinical impact is evident, little is said about the impact on the reorganisation of the Radiotherapy Oncology services. IGR supposes training all team members involved, with a training and a starting period. With the experience acquired, the time dedicated to each patient (in all stages of treatment: simulation, planning, starting out, systems for verifying position, on-line, off-line corrections, replanning, periodic clinical controls) is far higher than that required in conventional radiotherapy, which gives rise to new responsibilities and roles.

[Radiotherapy of mobile tumors]. / Radioterapia en tumores móviles.

In this article we detail some questions related to managing the treatment of mobile tumors, that is, those tumors that shift with respiratory movements, integrating movement into the plan of treatment. This fact complicates the administration of high doses of radiotherapy since, in such cases, the radiation margin must be wider than that required by the tumor itself, representing a greater risk to surrounding healthy tissue. However, the new technologies offer an alternative in these cases, such as tracking and respiratory gating in radiotherapy (RT), that is, the synchronization of treatment with respiratory movement. In gating we capture the tumor and other organs at risk at a specific moment in the breathing cycle, while in tracking we trace the tumor and the organs at risk throughout the breathing cycle. It is therefore essential to obtain good images and to correlate them with each phase of the breathing cycle. The tumors with which these strategies have been most employed are those of the lung, breast and lymphomas, and less frequently with some abdominal tumors such as pancreas, liver and prostate.

[Image-guided brachytherapy]. / Braquiterapia guiada por imagen.

Brachytherapy consists in the administration of radiation in intimate contact with the tumour, with a low exposure of neighbouring healthy tissues. Its use began in the early XX century and it has developed since then: different radioisotopes, systems of remote treatment, computer programs making individual dose calculation possible. In recent years there have been changes affecting two aspects of brachytherapy. In the first place, the incorporation of imaging techniques such as echography, computerised tomography (CT) and magnetic resonance (MR), indispensable for diagnosis and tumoural staging. Their use when the implant is being done helps in guiding and carrying out the operation with greater precision. In the second place, the use of CT, MR and echography makes better coverage of the tumour possible, or reduces the dose to healthy organs. They are used in inverse planning systems, which carry out dose calculation on the basis of the doses to be administered to the tumour and healthy organs. In these planning programs it is possible to make calculations more rapidly, taking account of the placement of the source at each moment in time. This technique, called real-time planning, is starting to show advantages in the treatment of prostate cancer. Incorporation of imaging techniques and improvements in calculation systems mean that brachytherapy is currently playing an important role in treating cancer of the prostate, cervix, breast, head and neck tumours, bronchial tubes or oesophagus.

[Current state of PET in head and neck tumours: impact on the planning of radiotherapy treatment]. / Estado actual del PET en los tumores de cabeza y cuello: impacto en la planificación del tratamiento radioterápico.

The use of positron emission tomography (PET) in head and neck tumours is increasingly widespread. To its clinical indications--especially in the staging of patients but also in evaluating response to treatment and in detecting or confirming relapses--is now added its possible therapeutic impact through its contribution to the planning of radiotherapy treatment. The integration of PET images in the radiotherapy process seems promising, although important doubts remain about it, which means that it is still under research. This article reviews the current state of PET in the area of head and neck tumours, as well as its impact on radiotherapy treatment planning.

[Interaction of radiotherapy and new agents with molecular targets]. / Interacción de la radioterapia con los nuevos agentes con dianas moleculares.

Radiochemotherapy represents one of the greatest achievements in cancer treatment in recent decades, although it involves significant toxicity for patients. Research developed recently in the molecular biology of cancer has enabled understanding of the genetic and molecular changes that determine malign cellular transformation, which has led to the identification of key molecules, converting them into molecular targets that have led to a revolution in radiobiological concepts of cellular response to radiations and radioresistance. The new agents against molecular targets possess greater specificity and less adverse effects, making them more attractive than chemotherapy for combination with radiotherapy. They can act by inhibiting intracellular transduction signals, modulating the cellular cycle, apoptosis or inhibiting angiogenesis. The effect of radiotherapy can be strengthened through inhibition of cellular repopulation, improvement of tumour oxygenation, redistribution of the cellular cycle, inhibition of invasion and metastasis, and increase of radiosensitivity. The available data support its efficacy and applicability in preclinical and clinical studies in different tumour models and open up a promising path in cancer treatment.

[Digestive haemorrhage in a patient with oropharyngeal cancer. A case study]. / Hemorragia digestiva en paciente con cáncer de orofaringe. A propósito de un caso.

Gastric metastases from solid tumours are very infrequent and in most cases appear simultaneously with other metastases. The most frequent primary tumors are lung and breast. Clinical data and symptoms are non-specific, and can range from abdominal discomfort to massive gastrointestinal bleeding. The diagnoses must be established by gastroscopy and biopsy. We present an unusual case of digestive haemorrhage secondary to gastric metastases from oropharyngeal carcinoma.

Empiema bacteriano espontáneo por campylobacter jejuni / Spontaneous bacterial empyema due to Campylobacter jejuni

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[Bacteremic urinary infection in men: comparative study with bacteremic pyelonephritis in women]. / Infección urinaria bacteriémica en el varón. Estudio comparativo frente a la pielonefritis bacteriémica femenina.

OBJECTIVE: To compare the clinic and microbiologic characteristics of the extrahospitalary bacteremic urinary infections (EBUI) between men and women assisted in a 200 bed community hospital. PATIENTS AND METHODS: A prospective study of the EBUI diagnosed in our hospital from January 1991 to April 1994 was carried out. Quantitative variables were evaluated with t Student analysis, chi 2 was used for the comparation of proportions. The logistic regression step-by-step model was used in order to find out which variables influenced that the microorganism causing EBUI was Escherichia coli. RESULTS: 107 episodes of EBUI were recorded, 39 men and 68 women, with the same microorganism in blood and urine. Significative diferences in age (70 +/- 17 years in men, 58 +/- 24 years in women); the presence of urinary tract alterations (49% men vs 12% women) and in the presence of indwelling urinary catheter (26% men vs 3% female) were found. E. coli was responsible in a major proportion (p = 0.03) of the EBUI in women that in men, but only age > 65 was selected as explaining variable with the logistic regression model. CONCLUSIONS: The EBUI appears in old men with urinary tract alterations and/or manipulations, clearly different from the EBUI in women. Age greater than 65 years is the only predisponent factor of EBUI in men by bacteria other than E. coli.