Aborto séptico por Clostridium perfringens complicado con shock séptico / Septic abortion due to Clostridium perfringens complicated with septic shock

ANTECEDENTES: La sepsis por Clostridios es una entidad poco frecuente que conlleva una mortalidad del 8090% a pesar del tratamiento antibiótico y quirúrgico. A pesar de que la mayoría de los casos de septicemia secundaria a Clostridios se originan en el aparato genital femenino tras un aborto séptico, solo un pequeño porcentaje de abortos sépticos (1%) se siguen de septicemia. CASO CLÍNICO: Gestante de 15 semanas que acude a urgencias por rotura prematura de membranas pretérmino. Ante el deseo de la paciente se mantiene actitud conservadora con antibioterapia iv, produciéndose a las pocas horas el aborto de forma espontánea junto con aparición de signos de infección. Rápidamente la paciente evoluciona a sepsis grave, y ante la sospecha de aborto séptico se efectúa histerectomía. Tras la intervención ingresa en situación de shock séptico con insuficiencia renal, hepática y respiratoria. Durante el ingreso se confirma Clostridium perfringens como agente responsable del proceso séptico. Finalmente la paciente es dada de alta definitiva tras seis meses, una vez resueltas las alteraciones derivadas del proceso séptico.

BACKGROUND: Clostridial sepsis is a rare condition which carries a mortality of 80-90% despite antibiotic and surgical treatment. Although most cases of septicemia due to Clostridium are originated in female genital tract after septic abortion, only a small percentage of septic abortions (1%) are followed by septicemia. CLINICAL CASE: Our case is about a 15 weeks pregnant woman attended the emergency room for preterm premature rupture of membranes. Due to the desire of the patient we proceed conservative treatment with antibiotics iv, in the following few hours the abortion develops spontaneously along with signs of infection. Rapidly the patient progresses into a severe sepsis, due to suspected septic abortion, the patient is intervened urgently by hysterectomy. After the intervention she enters into septic shock state with respiratory, kidney and liver failure. During the admission Clostridium perfringens is confirmed as a causative agent for septic process. Finally the patient is discharge after six months once resolved all complications arising from septic process.

Utilization of advanced-age donors in renal transplantation.

The shortage of organ availability in recent years has made it necessary to use grafts from advanced-aged donors to maintain the rate of renal transplantation in our country. The objective of this study was to evaluate the graft function and patient survival using kidneys from deceased donors of over 65 year of age. From 2005 until 2010, we compared the outcomes of patients who received grafts from donors over 65 years old vs less than 65 years. We observed no significant difference in sex, time on dialysis, or cold ischemia time between the groups. As expected the recipient age was significantly different. For the analysis of survival, we used the Tablecloth-Haenzel test and the Kaplan-Meier survival estimator. Actuarial survivals at 3 years after transplantation showed 84.8% among patients transplanted with kidneys from donors over 65 years old versus 97.5% in the control group. The graft survival was 78.8% among expanded criteria versus 86.85% in the control group. When we analyzed graft survival using an "exitus-censured" analysis, we obtained graft survivals of 89.1% in the expanded criteria kidney group versus 88.6% among the controls. We concluded that the use of kidney from donors over 65 years of age allows us to increase the rate of renal transplantation to about 15 to 20 per million population, with good graft and patient survivals provided that the protocol for expanded criteria organs ensured proper macroscopic and microscopic evaluation of the organ for transplantation.

Long-term follow-up of a randomized prospective trial comparing a standard 81 mg dose of intravesical bacille Calmette-Guérin with a reduced dose of 27 mg in superficial bladder cancer.

OBJECTIVES: To determine the efficacy of a three-fold reduced dose (RD, 27 mg) of intravesical bacille Calmette-Guérin (BCG) against the standard dose (81 mg) in patients with superficial bladder cancer, assessing recurrence, progression and differences in toxicity. PATIENTS AND METHODS: Five hundred patients with superficial bladder cancer (Ta, T1, Tis) were enrolled and randomly assigned to be treated after transurethral resection of all visible lesions with intravesical BCG Connaught strain (weekly x six and thereafter fortnightly x six) either with the standard or RD instillation. RESULTS: All but one of the 500 patients were evaluable for efficacy and toxicity (252 in the standard arm and 247 in the RD arm). The median follow-up was 69 months (maximum 104); 71 (28%) patients in the standard arm and 76 (31%) in the RD arm developed recurrences; the median time to recurrence has not yet been attained, but at 5 years the mean (sd) percentage of recurrence-free patients was 70.5 (3.12) and 70.4 (3.1) for the standard and RD arms, respectively. In patients presenting with multifocal tumours, the standard dose was more effective against recurrences than the RD (P=0.0151). In those with G3 and high-risk tumours overall, the superiority of the standard dose was marginal (P=0.060 and P=0.082). Twenty-nine (11.5%) tumours in the standard arm and 33 (13.3%) in the RD arm progressed to invasive disease; the median time to progression has not yet been attained, but the percentage of progression-free patients at 5 years was 88.8 (2.23) and 86.9 (2.31) for the standard and RD arms, respectively. The standard dose was more effective than the RD against progression only in patients with multifocal disease (P=0.048). Twelve (4.8%) cystectomies were performed in the standard and 15 (6.1%) in the RD arm. Currently, 106 (21.2%) patients have died, but only 38 (7.6%) from bladder cancer, i.e. 20 (7.9%) in the standard and 18 (7.5%) in RD arm. Overall the disease-specific death rate was lower for those patients who completed the scheduled treatment. The cause-specific survival at 5 years did not differ between the arms (P=0.76) but there was a trend toward better cause-specific survival for patients with multifocal tumours in the standard arm. Toxicity differed between the arms, significantly more patients having no toxicity in the RD arm, and fewer having delayed instillations or withdrawing. However, severe systemic toxicity occurred even in patients treated with the RD, in a similar proportion to those receiving the standard dose. CONCLUSION: Overall, the RD gave similar results for recurrence and progression but with significantly less toxicity. However, patients with multifocal tumours fared better with the standard dose and there was a trend towards better recurrence rates in patients with high-risk tumours. We recommend continuing to use the standard dose for high-risk tumours, while we consider the reduced dose safe and effective for intermediate-risk lesions and for maintenance schedules.

[Treatment of metastatic prostatic cancer with monthly injections of leuprolide acetate depot]. / Tratamiento del cáncer prostático metastásico con inyección mensual de leuprolide acetato depot.

Seventy-two patients were admitted in a multicentre trial with the purpose of assessing the clinical efficacy and safety of the hormonal control and tolerance of leuprolide acetate in a once-a-month depot injection formulation for the treatment of disseminated prostate cancer. During a 1-year follow-up, there were ten withdrawals for different reasons. At baseline and at 6 months of treatment the following parameters were evaluated: clinical examination, routine blood analysis, PAP, PSA, LH and testosterone, as well as bone scan. LH and testosterone determinations were repeated at 2, 4, 8, 12, 16, 20 and 24 weeks. Testosterone reached castration levels within the second week and was maintained until the end of the study. In agreement with the NPCP criteria, 65 patients were assessed as: complete response 3%, partial response 40%, disease stabilization 36%, and progression 21%. In summary, a once-a-month injection of leuprolide acetate offers a safe and effective alternative to surgical castration.

In vitro lithotripsy with the Alexandrite laser.

The Alexandrite laser system has proven to be an effective and safe method of ureteral lithotripsy. Some authors have recently reported the risk of interspersion of fiber splinters into tissue during lithotripsy, when short pulses and high power densities are employed. In vitro lithotripsy on renal calculi artificially placed in human ureters was realized under the parameters of a manufactured model (Alexantriptor, HMT). We have observed neither interspersion of fragments nor ureteral damage. These in vitro experiments and our clinical experience confirm that Alexandrite laser lithotripsy is reliable and safe.

Lithotripsy with the alexandrite laser: our initial 100 clinical cases.

The alexandrite laser system has proven to be an effective and safe method of treating ureteral stones. When the electromagnetic energy of a laser light pulse is selectively absorbed by the stone, a plasma forms at the surface. This plasma, which is composed of ions and electrons, continues to absorb laser energy, reaching very high pressure and generating a shock wave that fragments the stone. The degree of stone fragmentation is directly related to the composition and crystal lattice structure of the calculus. 112 calculi have been treated, and laser lithotripsy was successful in 87.5%. 6% of the stones were inadvertently flushed back into the kidney. No patient required an open ureterolithotomy. Guidance of the laser fiber onto the stone was performed by rigid ureteroscopy. There were no troublesome complications, and in a 3-month follow-up, no sequelae were reported.

[Genital brucellosis]. / Brucelosis genital.

Since this is a systemic disease, it is not uncommon to find brucella organisms in urine during acute infection however, it frequently presents with orchi-epididymitis (2-20%) and, rarely, with granulomas in the urinary tract. We report on two cases of acute epididymitis. The pathogenesis, diagnosis and treatment of this disease entity are briefly viewed highlighting the urological problem.

[Scrotal and perineal pain following coitus interruptus]. / Dolor escroto-perineal tras coitus interruptus.

A case of perineal-scrotal and hypogastric pain following coitus interruptus in a young male patient is described. The physiopathological mechanisms involved in this condition in normal subjects or those with neuropathic disorders are discussed.

PIP: A 27-year old male was treated in a hospital emergency room in Vizcaya, Spain, for perineal-scrotal and hypogastric pain following coitus interruptus. There were no other systemic alterations and the genital examination was normal. The patient was treated with analgesics and the physiopathologic mechanism was explained to him. THe complex mechanism of nervous and muscular coordination leading to ejaculation is sometimes disturbed by anomalous external stimuli, e.g., during masturbation or coitus interruptus, producing a constant pain in the entire genital and hypogastric area, even after ejaculation. Some authors suggest the possibility of an underlying psychopathology. It is possible that a delayed ejaculation factor also exists in these patients. Similar pains described in diabetes with neuropathy or in lesions of the sympathetic system are attributed to functional incompetence of the internal sphincter. It is recommended that men who frequently encounter this problem seek psychotherapy. Possible medical treatments include administration of analgesics and antispasmodic or muscle relaxants and tranquilizers.

[Usefulness of CAT in retroperitoneal fibrosis]. / Valor del TAC en la fibrosis retroperitoneal.

We report on six patients with with retroperitoneal fibrosis (RPF) who were evaluated preoperatively by CT. Patient scans disclosed a retroperitoneal fibrous layer localized between L4-S2, S3 in four of the six cases (65%). Similarly, varying degrees of uni-or bilateral utero-hydronephrosis were observed in five patients, and venous involvement with collateral abdominal circulation was observed in two. The surgical findings coincided with those of the CT scans, and disclosed that in the two patients with no evidence of a fibrous layer on the scan, this was due to the its being localized to an area in one or both sides of the pelvic cavity. The diagnosis was histologically confirmed as idiopathic retroperitoneal fibrosis in all six cases. We consider CT to be the preoperative method of choice in the diagnosis of RPF because it not only provides information on the status of the urinary system, the involvement of other retroperitoneal structures and the extent of the fibrous layer, it also provides orientation as to the possible etiology of the retroperitoneal fibrosis.

[Local antibiotic therapy in the treatment of chronic bacterial prostatitis]. / Antibioterapia local en el tratamiento de las prostatitis bacterianas crónicas.

In view of the great incidence of bacterial prostatitis and the small number of antibiotics which reach significant levels in the prostate gland, we have used Baert's local antibiotherapy on 24 patients suffering from chronic, bacterial prostatitis and in whom, previous treatment with trimethoprim-sulphamethoxazol had failed. 95.9% of sterilizations of prostate liquid growths were obtained six months after the treatment.