Tratamiento endoscópico de cálculos ureterales: experiencia en una serie de 102 casos / Endoscopic treatment of ureteral stones: experience in a series of 102 cases

INTRODUCCIÓN: La ureterolitectomía endoscópica (URS) es una técnica validada para el manejo de cálculos ureterales, ya que tiene alto poder resolutivo y es poco invasiva. El desarrollo de instrumentos flexibles ha facilitado el manejo endoscópico de los cálculos en uréter medio y proximal. El objetivo de este trabajo es describir la experiencia de nuestro centro en URS. Material y metodos: Análisis retrospectivo de las URS realizadas en nuestro centro entre Diciembre 2009 y Mayo 2012. Se consignaron las características del cálculo, el método de fragmentación, la efectividad del procedimiento y las complicaciones. Se utilizaron los ureteroscopios semirrígido Wolf (6,0-9,5 Fr) y flexible Karl Storz Flex X2. Resultados: Se revisaron 102 ureteroscopías, 85 con ureteroscopio semirrígido y 17 con flexible. Los cálculos tuvieron un promedio de 5,7 mm y 642 UH. El 89,4 por ciento de los cálculos resueltos mediante URS semirrígida se localizaban en uréter distal y 52,9 por ciento de los resueltos con URS flexible en uréter proximal. Se realizó litotripsia con láser Holmium en un 25,9 por ciento y 70,6 por ciento de los casos con URS semirrígida y flexible, respectivamente. Se utilizó litotripsia pneumática en un 4,7 por ciento de los casos de URS semirrígida. En URS semirrígida y flexible, la tasa de stone-free + fragmentos < 2 mm fue de 89,4 por ciento y 88,2 por ciento, respectivamente. Sólo hubo una complicación en nuestra serie (infección urinaria febril en 1 caso con URS flexible). La mediana de hospitalización fue de 1 día (rango 1-5 días). Conclusion: Nuestros resultados reafirman a la URS como una técnica eficaz, segura y poco invasiva para el tratamiento de los cálculos ureterales.

INTRODUCTION: The endoscopic ureterolithotomy (URS) is a validated technique for the management of ureteral calculi, which is highly resolutive and minimally invasive. The development of flexible instruments has facilitated the endoscopic management of stones in the mid and proximal segments of the ureter. The aim of this paper is to describe the experience of our center in endoscopic ureterolithotomy. Material and methods: Retrospective analysis of URS performed at our center between December 2009 and May 2012. We recorded the characteristics of the stones, the fragmentation method, the effectiveness of the procedure and complications. The Wolf semi-rigid (6.0 to 9.5 Fr) and the flexible Karl Storz Flex X2 ureteroscopes were used. RESULTS: We reviewed 102 URS, 85 with semi-rigid and 17 with flexible ureteroscope. The calculi were 5.7 mm and 642 HU in average. 89.4 percent of the stones treated with a semi-rigid URS were localized in the distal ureter and 52.9 percent of the calculi treated with a flexible URS were in the proximal ureter. Holmium laser lithotripsy was performed in 25.9 percent and 70.6 percent of the cases of semi-rigid and flexible URS, respectively. Pneumatic lithotripsy was used in 4.7 percent of the semi-rigid URS. In semi-rigid and flexible URS, the rate of stone-free + fragments < 2 mm was 89.4 percent and 88.2 percent, respectively. There was only one complication in our series (febrile urinary tract infection in 1 case of flexible URS). The median length of stay was 1 day (range 1-5 days). CONCLUSION: Our results confirm that URS is an effective, safe and minimally invasive treatment for ureteral calculi.

The registry of the German Network for Systemic Scleroderma: frequency of disease subsets and patterns of organ involvement.

OBJECTIVE: Systemic sclerosis (SSc) is a rare, heterogeneous disease, which affects different organs and therefore requires interdisciplinary diagnostic and therapeutic management. To improve the detection and follow-up of patients presenting with different disease manifestations, an interdisciplinary registry was founded with contributions from different subspecialties involved in the care of patients with SSc. METHODS: A questionnaire was developed to collect a core set of clinical data to determine the current disease status. Patients were grouped into five descriptive disease subsets, i.e. lcSSc, dcSSc, SSc sine scleroderma, overlap-syndrome and UCTD with scleroderma features. RESULTS: Of the 1483 patients, 45.5% of patients had lcSSc and 32.7% dcSSc. Overlap syndrome was diagnosed in 10.9% of patients, while 8.8% had an undifferentiated form. SSc sine scleroderma was present in 1.5% of patients. Organ involvement was markedly different between subsets; pulmonary fibrosis for instance was significantly more frequent in dcSSc (56.1%) than in overlap syndrome (30.6%) or lcSSc (20.8%). Pulmonary hypertension was more common in dcSSc (18.5%) compared with lcSSc (14.9%), overlap syndrome (8.2%) and undifferentiated disease (4.1%). Musculoskeletal involvement was typical for overlap syndromes (67.6%). A family history of rheumatic disease was reported in 17.2% of patients and was associated with early disease onset (P < 0.005). CONCLUSION: In this nationwide register, a descriptive classification of patients with disease manifestations characteristic of SSc in five groups allows to include a broader spectrum of patients with features of SSc.

Determination of the oxidation state for iron oxide minerals by energy-filtering TEM.

The oxidation state of iron oxide nanoparticles was determined using the two principally different technical realisations of energy filtering TEM, in one case using the JEOL 3010 equipped with a LaB6 cathode and a post-column GIF and in the second, the newly designed LIBRA 200FE equipped with an corrected in-column 90 degrees energy filter and a field emission gun (Schottky emitter). The samples studied were oxide-coated iron nanoparticles, and iron oxide inclusions in feldspars in granites. Five possible candidates exist for the iron-oxide phases: FeO, alpha-Fe2O3 (hematite), gamma-Fe2O3 (maghemite), Fe3O4 (magnetite) or alpha-FeO(OH) (goethite). Fingerprinting the O K-edge ELNES allows to distinguish between oxide phases with the same stochiometry and enables to make a first selection of possible candidates. The additional determination of the chemical composition allows unique identification of the phase present. For the oxide coated iron nanoparticles the most probable iron oxide phase of the shell is maghemite, which was additionally confirmed by HRTEM studies. The second studied system were iron oxide needles in alkali feldspar, where we obtained hematite as the most probable phase. There we additionally demonstrated the drastic changes of the ELNES of the O K-edge for the alkali feldspar and iron oxide needle by spatially resolved EELS.

A reticular variant of elastolytic giant cell granuloma.

An 80-year-old man presented with a distinctive reticular form of elastolytic giant cell granuloma (EGCG). This represents a rare subset of EGCG, thus belonging to a larger group of granulomatous skin diseases with poorly understood pathogenesis. The patient exhibited numerous erythematous to brownish, sharply demarcated patches of reticulate appearance with partial central atrophy and nonelevated margins, which involved the trunk and especially chest, shoulders, upper back and arms. Skin biopsy revealed a granulomatous infiltrate with multinucleate histiocytes containing remnants of elastic fibres in conjunction with a significant loss of elastic fibres throughout the dermis. There is little published information on treatment, which remains unsatisfactory.

Lymphogranuloma venereum - a rare cause of genital ulcers in central Europe.

Lymphogranuloma inguinale, caused by Chlamydia trachomatis serovar L1-L3 is rare in patients from western countries but needs yet to be considered in the differential diagnosis of genital ulcers. We report a case of a young male patient without any eventful travel history who presented with a genital ulcer at the sulcus coronarius and painfully enlarged lymph nodes in the right inguinal area. The typical clinical picture and serum IgM and IgG antibody titers of 1:16 and 1:512, respectively, against C. trachomatis were suggestive of infection with C. trachomatis serovar L1-L3. The diagnosis was confirmed by isolation of the organisms from the ulcer ground and subsequent sequence analysis of the omp1 gene which led to identification of C. trachomatis genotype L2 with 99% homology to a reference strain of C. trachomatis serovar L2. The lesion healed rapidly under treatment with doxycycline for 3 weeks, and the lymph nodes did not ulcerate. Thus, clinical suspicion was confirmed by genotyping of the isolated strain allowing timely diagnosis and treatment of lymphogranuloma inguinale.

Cutaneous leukaemic infiltrations in a patient with previously undiagnosed myelodysplastic syndrome.

We report the rare case of a patient with leukaemia cutis first presenting only on the hand and fingers and then subsequently spreading over the trunk and face. The lesions heralded the transformation of a previously undiagnosed myelodysplastic syndrome type RAEB (refractory anaemia with blast excess) into frank myeloid leukaemia. The haematological disease was first detected by the dermatohistopathologist. This case underlines the need to look meticulously for skin changes and perform early skin biopsies in haematological patients, as the skin can reveal the first clinical signs of an otherwise not evident bone marrow disorder. Leukaemia cutis as the initial clinical presentation of a transforming myelodysplastic syndrome type RAEB into acute myeloid leukaemia has been reported only very rarely.

[Allergic contact dermatitis to common ivy (Hedera helix L.)]. / Allergische Kontaktdermatitis auf Efeu (Hedera helix L.).

Common ivy (Hedera helix L.) is a ubiquitous plant in Europe whose major allergen falcarinol has moderate allergic potential. It is not related to poison ivy (Toxicodendron spp.). There are no cross reactions between the allergens of common ivy (falcarinol) and poison ivy (urushiol). Contact with common ivy or falcarinol may lead to sensitization and then a delayed hypersensitivity reaction. There are only few cases described in the literature. We report on a male hobby gardener with appropriate clinical history and positive patch test. The pathogenic mechanism is a type IV reaction following a sensitization exposure. Gardeners and landscape architects with frequent exposure to common ivy and thus a high risk of sensitization should wear appropriate protective clothing.

Myocardial fibrosis in transforming growth factor-beta(1) (TGF-beta(1)) transgenic mice is associated with inhibition of interstitial collagenase.

BACKGROUND: TGF-beta(1) mediates effects on fibroblast proliferation and collagen synthesis in the myocardium. The extracellular matrix remodeling depends on the fibrillar collagen degrading matrix metalloproteinases (MMPs) and their inhibitors (TIMPs). The in vivo effects of TGF-beta(1) on the MMP/TIMP system in TGF-beta(1) overexpressing transgenic mice were studied. METHODS: Male Alb/TGF-beta(1)(cys(223,225)ser) transgenic mice (TG) and nontransgenic controls (C; 8 weeks) were examined. Protein expression of collagen type I, -III, interstitial collagenase (Int Coll), MMP-2, -9, TIMP-1, -2, -4 and TGF-beta(1) as well as enzyme activity (MMP-2, -9) were measured (Western blots, zymographic assays). mRNA expression of the interstitial collagenase and MMP-9 was studied with the Light-Cycler based real-time PCR. RESULTS: Overexpression of TGF-beta(1) resulted in a 10-fold increase in plasma and a seven-fold increase in myocardial TGF-beta(1) concentrations. Relative heart weights increased (mg g(-1): 7.8 +/- 0.4 vs. 4.8 +/- 0.6, n = 6; P < 0.01) in TG compared to C. Collagen type I and III increased in TG (1.9-fold and 1.7-fold) compared to controls. Interstitial collagenase protein activity (- 91%) and mRNA expression (-75%) in TG were reduced (P < 0.05-P < 0.001). Gelatinase (MMP-2, MMP-9) expression and activity were not significantly alterated. MMP-inhibitors were increased 2.5-fold (TIMP-1, -4) and 6-fold (TIMP-2) in TG. CONCLUSIONS: TGF-beta(1) produces myocardial fibrosis in vivo. This effect is not only produced by a stimulation of matrix protein formation: a complex regulation of MMP and TIMP interaction, namely decrease of expression and activity of interstitial collagenase and an enhanced inhibition by increased levels of TIMPs, are involved. These mechanisms are optional targets for therapeutic interventions in myocardial diseases.

Vascular endothelial growth factor causally contributes to the angiogenic response upon ultraviolet B irradiation in vivo.

BACKGROUND: Ultraviolet (UV)-B irradiation has been shown to be an inducer of vascular endothelial growth factor (VEGF) in primary keratinocytes and epidermal cell lines in vitro. OBJECTIVES: To determine the expression pattern and the causal role of VEGF in the UVB-mediated angiogenic response in vivo in human skin and in a mouse model. METHODS: Skin biopsies or epidermal lysates thereof were studied for VEGF expression following UVB irradiation at a dose of 50 or 60 mJ cm-2, respectively, using immunostaining and a VEGF-specific highly sensitive sandwich enzyme-linked immunosorbent assay. The VEGF-dependent increase in vessels upon repetitive UVB irradiation was studied in skh-1 hairless mice using immunostaining for factor VIII-related antigen (FVIII RAG) in the presence and absence of intraperitoneally injected neutralizing VEGF antibodies. RESULTS: VEGF was found to be induced in the epidermis following UVB irradiation of human and mouse skin. Repetitive UVB irradiation of skh-1 hairless mice resulted in an increase in FVIII RAG positive vessels in the skin. UVB-induced angiogenic response could be partly abrogated by neutralizing antibodies against VEGF, while isotype-matched IgG control antibodies did not reveal any suppressive effect. CONCLUSIONS: Our results support previous in vitro data and show the in vivo relevance of VEGF as a paracrine inducer of cutaneous vessels after UVB irradiation.