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Importance Low-molecular-weight heparin is recommended over warfarin for the treatment of acute venous thromboembolism (VTE) in patients with active cancer largely based on results of a single, large trial. Objective To study the efficacy and safety of tinzaparin vs warfarin for treatment of acute, symptomatic VTE in patients with active cancer. Design, Settings, and Participants A randomized, open-label study with blinded central adjudication of study outcomes enrolled patients in 164 centers in Asia, Africa, Europe, and North, Central, and South America between August 2010 and November 2013. Adult patients with active cancer (defined as histologic diagnosis of cancer and receiving anticancer therapy or diagnosed with, or received such therapy, within the previous 6 months) and objectively documented proximal deep vein thrombosis (DVT) or pulmonary embolism, with a life expectancy greater than 6 months and without contraindications for anticoagulation, were followed up for 180 days and for 30 days after the last study medication dose for collection of safety data. Interventions Tinzaparin (175 IU/kg) once daily for 6 months vs conventional therapy with tinzaparin (175 IU/kg) once daily for 5 to 10 days followed by warfarin at a dose adjusted to maintain the international normalized ratio within the therapeutic range (2.0-3.0) for 6 months. Main Outcomes and Measures Primary efficacy outcome was a composite of centrally adjudicated recurrent DVT, fatal or nonfatal pulmonary embolism, and incidental VTE. Safety outcomes included major bleeding, clinically relevant nonmajor bleeding, and overall mortality. Results Nine hundred patients were randomized and included in intention-to-treat efficacy and safety analyses. Recurrent VTE occurred in 31 of 449 patients treated with tinzaparin and 45 of 451 patients treated with warfarin (6-month cumulative incidence, 7.2% for tinzaparin vs 10.5% for warfarin; hazard ratio [HR], 0.65 [95% CI, 0.41-1.03]; P = .07). There were no differences in major bleeding (12 patients for tinzaparin vs 11 patients for warfarin; HR, 0.89 [95% CI, 0.40-1.99]; P = .77) or overall mortality (150 patients for tinzaparin vs 138 patients for warfarin; HR, 1.08 [95% CI, 0.85-1.36]; P = .54). A significant reduction in clinically relevant nonmajor bleeding was observed with tinzaparin (49 of 449 patients for tinzaparin vs 69 of 451 patients for warfarin; HR, 0.58 [95% CI, 0.40-0.84]; P = .004). Conclusions and Relevance Among patients with active cancer and acute symptomatic VTE, the use of full-dose tinzaparin (175 IU/kg) daily compared with warfarin for 6 months did not significantly reduce the composite measure of recurrent VTE and was not associated with reductions in overall mortality or major bleeding, but was associated with a lower rate of clinically relevant nonmajor bleeding. Further studies are needed to assess whether the efficacy outcomes would be different in patients at higher risk of recurrent VTE. Trial Registration clinicaltrials.gov Identifier:NCT01130025

To assess treatment options for calculi in horseshoe kidneys and the impact of extracorporeal shockwave lithotripsy (ESWL) on the management of renal stones.From June 1971 to January 1998, 52 patients with horseshoe kidneys and calculi received treatment at our Urologic Stone Unit. There were 40 men (77%) and 12 women (23%). Average patient age was 41 years (range: 10-70 years). Clinical onset, treatment received and outcome were evaluated retrospectively. A successful outcome was defined as a patient without residual calculi or with fragments0.4 cm in size.Clinical onset was mainly low back pain in 37 patients (71%). Eighty-nine stones were treated, i.e. an average of 1.7 treatments per patient. Before the ESWL era (May 1987), we performed two heminephrectomies, 16 pyelolithotomies, 12 pyelolithotomies combined with ureteropyeloplasty and one percutaneous nephrolithotomy. Since the advent of ESWL, seven pyelolithotomies and three pyelolithotomies combined with ureteropyloplasty have been done. ESWL was used to treat 48 calculi. In three cases the patient was placed in the prone position due to difficulties in stone focusing. In 37 cases (77%) patients were either rendered stone-free or had residual fragments0.4 cm in size. Urinary diversion for obstruction was carried out in two cases (4%).At present ESWL is the first-choice treatment for calculi in horseshoe kidneys. It involves no significant focusing difficulties and is associated with a low incidence of obstructive complications. Open surgery is indicated in cases of stone-related pyeloureteral stenosis and in the presence of calculi2-2.5 cm in size.

Se presenta el caso de un varón de 45 años que llevaba olvidado durante 2 años un catéter ureteral doble J izquierdo. El catéter presentaba ambos extremos calcificados no pudiéndose extraer mediante cistoscopia y pinzas. Se realizaron sesiones de litotricia extracorpórea en ambos extremos consiguiéndose la fragmentación de la litiasis y posteriormente pudo ser extraído en dos trozos mediante cistoscopia y ureteroscopia. A 45 year old man with a 2 year forgotten left double-pigtail ureteric stent was referred to our hospital. Because of distal calcifications, the stent could not be removed by means of a cystoscopy. So, extracorporeal wave lithotripsies were performed and then the stent were easily removed in two fragments by cystoscopy and ureteroscopy.