BACKGROUND Schwannomas are rare,often benign,tumors deriving from Schwann cells that have low incidence in the retroperitoneal region(0.5%to 5%).Their diagnosis is hardly confirmed at early stage due to lack of specif...BACKGROUND Schwannomas are rare,often benign,tumors deriving from Schwann cells that have low incidence in the retroperitoneal region(0.5%to 5%).Their diagnosis is hardly confirmed at early stage due to lack of specific features in signs,symptoms and imaging tests.Thus,it is necessary performing guided punch biopsy in order to identify it.Tumor removal is the treatment of choice due to its low sensitivity to radiation and chemotherapy.CASE SUMMARY Forty-seven years old female patient who was hospitalized for elective orthopedic procedure,without complications,evolved with severe pain in the lower limbs,thigh and gluteal region associated with neurogenic claudication.Persistent pain required magnetic resonance imaging(MRI)of the lumbar spine,which showed epidural collection with dural compression and massive heterogeneous perihepatic nodular lesion.The surgical team opted for draining the collection,as well as requested an MRI of the abdomen and pelvis,whose analysis showed expansive lesion in the retroperitoneum,in close contact with the inferior vena cava and with the right renal vein.A guided puncture was performed for diagnostic clarification,which showed immunohistochemical profile compatible with schwannoma.The selected treatment comprised retroperitoneum tumor resection in association with laparoscopic cholecystectomy.The patient was discharged and remained stable after 4-mo follow-up;she remains under followup to check the need of cancer investigations.CONCLUSION Schwannoma features requires surgical treatment based on laparoscopic resection,which often presents low relapse rates and optimistic prognosis.展开更多
BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is the primary therapeutic procedure for the treatment of diseases affecting the biliary tree and pancreatic duct.Although the therapeutic success rate of...BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is the primary therapeutic procedure for the treatment of diseases affecting the biliary tree and pancreatic duct.Although the therapeutic success rate of ERCP is high,the procedure can cause complications,such as acute pancreatitis[post-ERCP pancreatitis(PEP)],bleeding and perforation.AIM To assess the efficacy of non-steroidal anti-inflammatory drugs(NSAIDs)in preventing PEP during follow-up.METHODS Databases such as MEDLINE,EMBASE and Cochrane Central Library were searched.Only randomized controlled trials(RCTs)comparing the efficacy of NSAIDs and placebo for the prevention of PEP were included.Outcomes evaluated included the incidence of PEP,severity of pancreatitis,route of administration,types,dose,and timing of administration of NSAIDs.RESULTS Twenty-six RCTs were considered eligible with a total of 8143 patients analyzed.Overall,4020 patients used NSAIDs before ERCP and 4123 did not use NSAIDs(control group).Ultimately,298 cases of post-ERCP acute pancreatitis were diagnosed in the NSAID group and 484 cases in the placebo group.The risk of PEP was lower in the NSAID group risk difference(RD):-0.04;95%confidence interval(CI):-0.07 to-0.03;number needed to treat(NNT),25;P<0.05.NSAID use effectively prevented mild pancreatitis compared to placebo use(2.5%vs 4.1%;95%CI:-0.05 to-0.01;NNT,33;P<0.05),but information on moderate PEP and severe PEP could not be fully elucidated.Only rectal administration reduced the incidence of PEP with RD:-0.06;95%CI:-0.08 to-0.04;NNT,17;P<0.05).Furthermore,only the use of diclofenac or indomethacin was effective in preventing PEP,at a dose of 100 mg,which must be administered before performing ERCP.CONCLUSION Rectal administration of diclofenac and indomethacin significantly reduced the risk of developing mild PEP.Additional RCTs are needed to compare the efficacy between NSAID routes of administration in preventing PEP.展开更多
Atrial fibrillation(AF)is the most common arrhythmia in the elderly and its incidence increases with aging.[1]Electrical cardioversion is used as a strategy for rhythm control in patients with supraventricular arrhyth...Atrial fibrillation(AF)is the most common arrhythmia in the elderly and its incidence increases with aging.[1]Electrical cardioversion is used as a strategy for rhythm control in patients with supraventricular arrhythmias.In octagenarians,there are challenges associated with the indication for electrical cardioversion,such as the use of appropriate sedation and anticoagulant agents.Most decisions in clinical practice for these patients derive from observational data and personal experience,since octagenarians represent a minority of patients included in randomized clinical trials.Little evidence is available regarding the clinical context of electrical cardioversion in this vulnerable population.Therefore,we aimed to describe the clinical profile of octagenarians undergoing electrical cardioversion in a cardiology reference center from 2014 to 2018.展开更多
BACKGROUND Radiosurgery for multiple brain metastases has been more reported recently without using whole-brain radiotherapy.Nevertheless,the sparsity of the data still claims more information about toxicity and survi...BACKGROUND Radiosurgery for multiple brain metastases has been more reported recently without using whole-brain radiotherapy.Nevertheless,the sparsity of the data still claims more information about toxicity and survival and their association with both dosimetric and geometric aspects of this treatment.AIM To assess the toxicity and survival outcome of radiosurgery in patients with multiple(four or more lesions)brain metastases.METHODS In a single institution,data were collected retrospectively from patients who underwent radiosurgery to treat brain metastases from diverse primary sites.Patients with 4-21 brain metastases were treated with a single fraction with a dose of 18 Gy or 20 Gy.The clinical variables collected were relevant to toxicity,survival,treatment response,planning,and dosimetric variables.The Spearman’s rank correlation coefficients,Mann-Whitney test,Kruskal-Wallis test,and Log-RESULTS From August 2017 to February 2020,55 patients were evaluated.Headache was the most common complaint(38.2%).The median overall survival(OS)for patients with karnofsky performance status(KPS)>70 was 8.9 mo,and this was 3.6 mo for those with KPS≤70(P=0.047).Patients with treated lesions had a median progression-free survival of 7.6 mo.There were no differences in OS(19.7 vs 9.5 mo)or progression-free survival(10.6 vs 6.3 mo)based on prior irradiation.There was no correlation found between reported toxicities and planning,dosimetric,and geometric variables,implying that no additional significant toxicity risks appear to be added to the treatment of multiple(four or more)lesions.CONCLUSION No associations were found between the evaluated toxicities and the planning dosimetric parameters,and no differences in survival rates were detected based on previous treatment status.展开更多
BACKGROUND Venous thromboembolism,which includes deep venous thrombosis and pulmonary embolism,is a well-known causal disorder with high morbidity and mortality rates.Inherited or acquired conditions affecting compone...BACKGROUND Venous thromboembolism,which includes deep venous thrombosis and pulmonary embolism,is a well-known causal disorder with high morbidity and mortality rates.Inherited or acquired conditions affecting components of coagulation and fibrinolysis systems have been linked to venous thromboembolism pathogenesis as they may lead to a pro-inflammatory state in human bodies.Toxoplasmosis is a zoonosis that potentially leads to acute systemic cachectic-inflammatory effects in experimental animal models but is not yet proven in humans.It is known that venous thrombosis can occur during acute inflammatory/infectious diseases,although it is not well established with regard to toxoplasmosis alone.CASE SUMMARY A 70-year-old Caucasian man and his 32-year-old son developed general malaise,chills,fever,and myalgia,having established a diagnosis of toxoplasmosis.Twenty days later,they presented dry cough leading to further investigations that revealed an incidental deep venous thrombosis plus pulmonary embolism in them both.Thrombophilia screening showed both patients had a factor V Leiden mutation heterozygosis.Father and son completely recovered without any sequalae after anticoagulant treatment.They have not presented symptom recurrence of either medical disorder during 1 year of follow-up.CONCLUSION Toxoplasmosis may enhance the risk of venous thromboembolism in patients showing factor V Leiden mutation heterozygosis.展开更多
BACKGROUND Challenging lesions,difficult to diagnose through non-invasive methods,constitute an important emotional burden for each patient regarding a still uncertain diagnosis(malignant x benign).In addition,from a ...BACKGROUND Challenging lesions,difficult to diagnose through non-invasive methods,constitute an important emotional burden for each patient regarding a still uncertain diagnosis(malignant x benign).In addition,from a therapeutic and prognostic point of view,delay in a definitive diagnosis can lead to worse outcomes.One of the main innovative trends currently is the use of molecular and functional methods to diagnosis.Numerous liver-specific contrast agents havebeen developed and studied in recent years to improve the performance of liver magnetic resonance imaging(MRI).More recently,one of the contrast agents introduced in clinical practice is gadoxetic acid(gadoxetate disodium).AIM To demonstrate the value of the hepatobiliary phases using gadoxetic acid in MRI for the characterization of focal liver lesions(FLL)in clinical practice.METHODS Overall,302 Lesions were studied in 136 patients who underwent MRI exams using gadoxetic acid for the assessment of FLL.Two radiologists independently reviewed the MRI exams using four stages,and categorized them on a 6-point scale,from 0(lesion not detected)to 5(definitely malignant).The stages were:stage 1-images without contrast,stage 2-addition of dynamic phases after contrast(analogous to usual extracellular contrasts),stage 3-addition of hepatobiliary phase after 10 min(HBP 10’),stage 4-hepatobiliary phase after 20 min(HBP 20’)in addition to stage 2.RESULTS The interobserver agreement was high(weighted Kappa coefficient:0.81-1)at all stages in the characterization of benign and malignant FLL.The diagnostic weighted accuracy(Az)was 0.80 in stage 1 and was increased to 0.90 in stage 2.Addition of the hepatobiliary phase increased Az to 0.98 in stage 3,which was also 0.98 in stage 4.CONCLUSION The hepatobiliary sequences improve diagnostic accuracy.With growing potential in the era of precision medicine,the improvement and dissemination of the method among medical specialties can bring benefits in the management of patients with FLL that are difficult to diagnose.展开更多
Background and objective The advances in the lung cancer screening methods and therapeutics,together with awareness towards deleterious habits,such as smoking,is increasing the overall survival with better quality of ...Background and objective The advances in the lung cancer screening methods and therapeutics,together with awareness towards deleterious habits,such as smoking,is increasing the overall survival with better quality of life for the patients.However,lung cancer is still one of the most common and fatal neoplasm with a high incidence and consequently burden to public health worldwide.Thus,based on guidelines and recent phasesⅡandⅢclinical trials studies,this manuscript summarizes the current treatment sequencing strategies in lung cancer.Methods A comprehensive search of related articles was performed focused on phasesⅡandⅢclinical trials studies.Results The lung cancer management should take into consideration the tumor characteristics,histology,molecular pathology and be discussed in a multidisciplinary team.Lung cancer treatment options comprises surgery whenever possible,radiotherapy associate with/or chemotherapy and immunotherapy as monotherapy,or combined with chemotherapy and best palliative care.Conclusions The screening predictability in more patients,smoking reduction,early diagnosis,better disease understanding and individualized,more effective and tolerable therapeutics are related to an increasing in overall survival and quality of life.In the near future improvement of personalized therapy in precision medicine is expected,enhancing new predictive biomarkers,optimal doses and optimal treatment sequencing as well as anti-cancer vaccines development.展开更多
In this paper we present a model to estimate the density of aedes mosquitoes in a community affected by dengue.The method consists in fitting a continuous function to the incidence of dengue infections,from which the ...In this paper we present a model to estimate the density of aedes mosquitoes in a community affected by dengue.The method consists in fitting a continuous function to the incidence of dengue infections,from which the density of infected mosquitoes is derived straightforwardly.Further derivations allow the calculation of the latent and susceptible mosquitoes'densities,the sum of the three equals the total mosquitoes'density.The method is illustrated with the case of the risk of urban yellow fever resurgence in dengue infested areas but the same procedures apply for other aedes-transmitted infections like Zika and chikungunya viruses.展开更多
Pre-contoured anatomical locking plates were designed to address the clinical need of fixing small epiphyseal segments with a larger number of screws.Those plates match the contour and shape of a variety of bones allo...Pre-contoured anatomical locking plates were designed to address the clinical need of fixing small epiphyseal segments with a larger number of screws.Those plates match the contour and shape of a variety of bones allowing for optimal buttress properties.The aim of this manuscript is to highlight the benefits of applying proximal humerus locking plates in the fixation of lower extremity bones.Although designed for the proximal humerus,the low-profile plate shape and anatomic contour also provides versatile use in certain areas of the lower extremity.This technical narrative highlights the versatile and reliable use of this plate for other anatomical areas than the one to which it has been originally conceived.展开更多
文摘BACKGROUND Schwannomas are rare,often benign,tumors deriving from Schwann cells that have low incidence in the retroperitoneal region(0.5%to 5%).Their diagnosis is hardly confirmed at early stage due to lack of specific features in signs,symptoms and imaging tests.Thus,it is necessary performing guided punch biopsy in order to identify it.Tumor removal is the treatment of choice due to its low sensitivity to radiation and chemotherapy.CASE SUMMARY Forty-seven years old female patient who was hospitalized for elective orthopedic procedure,without complications,evolved with severe pain in the lower limbs,thigh and gluteal region associated with neurogenic claudication.Persistent pain required magnetic resonance imaging(MRI)of the lumbar spine,which showed epidural collection with dural compression and massive heterogeneous perihepatic nodular lesion.The surgical team opted for draining the collection,as well as requested an MRI of the abdomen and pelvis,whose analysis showed expansive lesion in the retroperitoneum,in close contact with the inferior vena cava and with the right renal vein.A guided puncture was performed for diagnostic clarification,which showed immunohistochemical profile compatible with schwannoma.The selected treatment comprised retroperitoneum tumor resection in association with laparoscopic cholecystectomy.The patient was discharged and remained stable after 4-mo follow-up;she remains under followup to check the need of cancer investigations.CONCLUSION Schwannoma features requires surgical treatment based on laparoscopic resection,which often presents low relapse rates and optimistic prognosis.
文摘BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is the primary therapeutic procedure for the treatment of diseases affecting the biliary tree and pancreatic duct.Although the therapeutic success rate of ERCP is high,the procedure can cause complications,such as acute pancreatitis[post-ERCP pancreatitis(PEP)],bleeding and perforation.AIM To assess the efficacy of non-steroidal anti-inflammatory drugs(NSAIDs)in preventing PEP during follow-up.METHODS Databases such as MEDLINE,EMBASE and Cochrane Central Library were searched.Only randomized controlled trials(RCTs)comparing the efficacy of NSAIDs and placebo for the prevention of PEP were included.Outcomes evaluated included the incidence of PEP,severity of pancreatitis,route of administration,types,dose,and timing of administration of NSAIDs.RESULTS Twenty-six RCTs were considered eligible with a total of 8143 patients analyzed.Overall,4020 patients used NSAIDs before ERCP and 4123 did not use NSAIDs(control group).Ultimately,298 cases of post-ERCP acute pancreatitis were diagnosed in the NSAID group and 484 cases in the placebo group.The risk of PEP was lower in the NSAID group risk difference(RD):-0.04;95%confidence interval(CI):-0.07 to-0.03;number needed to treat(NNT),25;P<0.05.NSAID use effectively prevented mild pancreatitis compared to placebo use(2.5%vs 4.1%;95%CI:-0.05 to-0.01;NNT,33;P<0.05),but information on moderate PEP and severe PEP could not be fully elucidated.Only rectal administration reduced the incidence of PEP with RD:-0.06;95%CI:-0.08 to-0.04;NNT,17;P<0.05).Furthermore,only the use of diclofenac or indomethacin was effective in preventing PEP,at a dose of 100 mg,which must be administered before performing ERCP.CONCLUSION Rectal administration of diclofenac and indomethacin significantly reduced the risk of developing mild PEP.Additional RCTs are needed to compare the efficacy between NSAID routes of administration in preventing PEP.
文摘Atrial fibrillation(AF)is the most common arrhythmia in the elderly and its incidence increases with aging.[1]Electrical cardioversion is used as a strategy for rhythm control in patients with supraventricular arrhythmias.In octagenarians,there are challenges associated with the indication for electrical cardioversion,such as the use of appropriate sedation and anticoagulant agents.Most decisions in clinical practice for these patients derive from observational data and personal experience,since octagenarians represent a minority of patients included in randomized clinical trials.Little evidence is available regarding the clinical context of electrical cardioversion in this vulnerable population.Therefore,we aimed to describe the clinical profile of octagenarians undergoing electrical cardioversion in a cardiology reference center from 2014 to 2018.
文摘BACKGROUND Radiosurgery for multiple brain metastases has been more reported recently without using whole-brain radiotherapy.Nevertheless,the sparsity of the data still claims more information about toxicity and survival and their association with both dosimetric and geometric aspects of this treatment.AIM To assess the toxicity and survival outcome of radiosurgery in patients with multiple(four or more lesions)brain metastases.METHODS In a single institution,data were collected retrospectively from patients who underwent radiosurgery to treat brain metastases from diverse primary sites.Patients with 4-21 brain metastases were treated with a single fraction with a dose of 18 Gy or 20 Gy.The clinical variables collected were relevant to toxicity,survival,treatment response,planning,and dosimetric variables.The Spearman’s rank correlation coefficients,Mann-Whitney test,Kruskal-Wallis test,and Log-RESULTS From August 2017 to February 2020,55 patients were evaluated.Headache was the most common complaint(38.2%).The median overall survival(OS)for patients with karnofsky performance status(KPS)>70 was 8.9 mo,and this was 3.6 mo for those with KPS≤70(P=0.047).Patients with treated lesions had a median progression-free survival of 7.6 mo.There were no differences in OS(19.7 vs 9.5 mo)or progression-free survival(10.6 vs 6.3 mo)based on prior irradiation.There was no correlation found between reported toxicities and planning,dosimetric,and geometric variables,implying that no additional significant toxicity risks appear to be added to the treatment of multiple(four or more)lesions.CONCLUSION No associations were found between the evaluated toxicities and the planning dosimetric parameters,and no differences in survival rates were detected based on previous treatment status.
文摘BACKGROUND Venous thromboembolism,which includes deep venous thrombosis and pulmonary embolism,is a well-known causal disorder with high morbidity and mortality rates.Inherited or acquired conditions affecting components of coagulation and fibrinolysis systems have been linked to venous thromboembolism pathogenesis as they may lead to a pro-inflammatory state in human bodies.Toxoplasmosis is a zoonosis that potentially leads to acute systemic cachectic-inflammatory effects in experimental animal models but is not yet proven in humans.It is known that venous thrombosis can occur during acute inflammatory/infectious diseases,although it is not well established with regard to toxoplasmosis alone.CASE SUMMARY A 70-year-old Caucasian man and his 32-year-old son developed general malaise,chills,fever,and myalgia,having established a diagnosis of toxoplasmosis.Twenty days later,they presented dry cough leading to further investigations that revealed an incidental deep venous thrombosis plus pulmonary embolism in them both.Thrombophilia screening showed both patients had a factor V Leiden mutation heterozygosis.Father and son completely recovered without any sequalae after anticoagulant treatment.They have not presented symptom recurrence of either medical disorder during 1 year of follow-up.CONCLUSION Toxoplasmosis may enhance the risk of venous thromboembolism in patients showing factor V Leiden mutation heterozygosis.
文摘BACKGROUND Challenging lesions,difficult to diagnose through non-invasive methods,constitute an important emotional burden for each patient regarding a still uncertain diagnosis(malignant x benign).In addition,from a therapeutic and prognostic point of view,delay in a definitive diagnosis can lead to worse outcomes.One of the main innovative trends currently is the use of molecular and functional methods to diagnosis.Numerous liver-specific contrast agents havebeen developed and studied in recent years to improve the performance of liver magnetic resonance imaging(MRI).More recently,one of the contrast agents introduced in clinical practice is gadoxetic acid(gadoxetate disodium).AIM To demonstrate the value of the hepatobiliary phases using gadoxetic acid in MRI for the characterization of focal liver lesions(FLL)in clinical practice.METHODS Overall,302 Lesions were studied in 136 patients who underwent MRI exams using gadoxetic acid for the assessment of FLL.Two radiologists independently reviewed the MRI exams using four stages,and categorized them on a 6-point scale,from 0(lesion not detected)to 5(definitely malignant).The stages were:stage 1-images without contrast,stage 2-addition of dynamic phases after contrast(analogous to usual extracellular contrasts),stage 3-addition of hepatobiliary phase after 10 min(HBP 10’),stage 4-hepatobiliary phase after 20 min(HBP 20’)in addition to stage 2.RESULTS The interobserver agreement was high(weighted Kappa coefficient:0.81-1)at all stages in the characterization of benign and malignant FLL.The diagnostic weighted accuracy(Az)was 0.80 in stage 1 and was increased to 0.90 in stage 2.Addition of the hepatobiliary phase increased Az to 0.98 in stage 3,which was also 0.98 in stage 4.CONCLUSION The hepatobiliary sequences improve diagnostic accuracy.With growing potential in the era of precision medicine,the improvement and dissemination of the method among medical specialties can bring benefits in the management of patients with FLL that are difficult to diagnose.
文摘Background and objective The advances in the lung cancer screening methods and therapeutics,together with awareness towards deleterious habits,such as smoking,is increasing the overall survival with better quality of life for the patients.However,lung cancer is still one of the most common and fatal neoplasm with a high incidence and consequently burden to public health worldwide.Thus,based on guidelines and recent phasesⅡandⅢclinical trials studies,this manuscript summarizes the current treatment sequencing strategies in lung cancer.Methods A comprehensive search of related articles was performed focused on phasesⅡandⅢclinical trials studies.Results The lung cancer management should take into consideration the tumor characteristics,histology,molecular pathology and be discussed in a multidisciplinary team.Lung cancer treatment options comprises surgery whenever possible,radiotherapy associate with/or chemotherapy and immunotherapy as monotherapy,or combined with chemotherapy and best palliative care.Conclusions The screening predictability in more patients,smoking reduction,early diagnosis,better disease understanding and individualized,more effective and tolerable therapeutics are related to an increasing in overall survival and quality of life.In the near future improvement of personalized therapy in precision medicine is expected,enhancing new predictive biomarkers,optimal doses and optimal treatment sequencing as well as anti-cancer vaccines development.
文摘In this paper we present a model to estimate the density of aedes mosquitoes in a community affected by dengue.The method consists in fitting a continuous function to the incidence of dengue infections,from which the density of infected mosquitoes is derived straightforwardly.Further derivations allow the calculation of the latent and susceptible mosquitoes'densities,the sum of the three equals the total mosquitoes'density.The method is illustrated with the case of the risk of urban yellow fever resurgence in dengue infested areas but the same procedures apply for other aedes-transmitted infections like Zika and chikungunya viruses.
文摘Pre-contoured anatomical locking plates were designed to address the clinical need of fixing small epiphyseal segments with a larger number of screws.Those plates match the contour and shape of a variety of bones allowing for optimal buttress properties.The aim of this manuscript is to highlight the benefits of applying proximal humerus locking plates in the fixation of lower extremity bones.Although designed for the proximal humerus,the low-profile plate shape and anatomic contour also provides versatile use in certain areas of the lower extremity.This technical narrative highlights the versatile and reliable use of this plate for other anatomical areas than the one to which it has been originally conceived.
