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BackgroundSystemic lupus erythematosus (SLE) often affects women in their childbearing years, and pregnancy may affect SLE disease activity during pregnancy and post-partum (1,2). Limited data assessing the likelihood and characteristics of SLE activity in an extended time period post-partum which may be relevant as patients may wish further pregnancies exist.ObjectivesTo assess predicting factors that might influence SLE disease activity in women in an extended follow-up period of 2 years after giving birth and clinical assessment every three months.MethodsThe study was design as an international retrospective, data-driven case collection study, enrolling 119 women with a first birth and with a strictly monitored follow-up period of 2 years.ResultsTable 1 shows pregnancy outcomes of all pregnancies. When considering disease manifestations, joint involvement was present in 80% of patients, acute cutaneous in 64%, haematological in 54%and renal in 41%; 75% of patients were positive for anti-dsDNA, 49% for anti-ENA and 37% for anti-Ro/SSA positive. The mean SLE disease activity index 2000(SLEDAI-2k) at diagnosis was 13.5±6.8 and at first birth was 2.8±4.4.Table 1.Pregnancy outcomes of all pregnancies and relative breastfeeding dataPregnancy CharacteristicsAll (214)%OutcomesLive births16979Miscarriages3717.3Stillbirths83.7Maternal and Foetal ComplicationsPrematurity3918.2Pre-eclampsia2310.7HELLP syndrome41.9Placental Infarction125.6Breastfeeding (all pregnancies)Any breastfeeding (n, %)10964.5*Exclusive breastfeeding (n, %)8751.5*Breastfeeding (after first birth)Any breastfeeding (n, %)8773.1**Any breastfeeding duration (months) (m±sd)10.29±10.04Exclusive breastfeeding*** (n, %)6252.1**Exclusive breastfeeding*** duration (months) (m±sd)6.07±6*Percentages are calculated considering viable babies (total= 169)**Percentages are calculated considering first birth (total= 119)***Exclusive breastfeeding was defined as feeding infants only breast milkAt follow-up, 51.3% of patients had at least one flare after a mean time after birth of 9±6.3 months(mean flare per patient 0.94±1.1). The most frequent flare manifestations were joint involvement(48%), followed by renal(33%), cutaneous(28%) and haematologic(20%).Patients with remission of disease(SLEDAI-2K=0; no clinical or laboratory manifestations of SLE) at conception had significantly lower rates of flares than those not in remission (18/49–37% vs. 43/70–61%;p=0.008) (Figure 1).Figure 1.Flare proportion: Survival Curve based on remission status at conception of the patients included in the study.Patients who experienced a flare during pregnancy (17 patients), when compared to those who did not, had higher rates of flares during follow-up (76% vs. 47%, respectively, p=0.019), lower time for first flare (4.4±2.3 months vs. 10.3±6.5, respectively, pRemission of disease and flares during pregnancy remained significantly associated with the development of flares during follow-up after multivariate analysis.ConclusionRemission at conception can influence SLE disease positively, even at long-term. Planned pregnancy counseling is fundamental when managing SLE patients.References[1]Tincani A, Nalli C, Khizroeva J, Bitsadze V, Lojacono A, Andreoli L, et al. Autoimmune diseases and pregnancy. Best Pract Res Clin Endocrinol Metab 2019;33.[2]Clowse MEB, Magder LS, Witter F, Petri M. The impact of increased lupus activity on obstetric outcomes. Arthritis Rheum 2005;52:514–521.Disclosure of InterestsNone declared

Chemerin is an adipokine produced by the white adipose tissue and other tissues, which plays various roles in the pathogenesis of inflammatory and metabolic diseases in multiple organs. The present review aims at gathering scientific evidence reported in the last ten years, concerning the relationship of chemerin with alterations of glycaemic control, such as insulin resistance, type 2 diabetes and gestational diabetes in humans. Although the vast majority of the studies have shown a positive correlation between the chemerin level and a bad glycaemic control, a general consensus has not been reached. The reported results come from case-control and observational longitudinal studies, thereby limiting their interpretation. In fact, it cannot be stated whether insulin resistance and diabetes lead to an increase in chemerin levels or, on the contrary, if high levels of chemerin contribute to an impaired glycaemic control. Elevated levels of circulating chemerin are also associated with gestational diabetes mellitus. Chemerin gene polymorphisms could be proposed as mediators of glucose-related diseases. Nevertheless, to date very little is known about their implication in glucose metabolism. With regard to the mechanisms of action, chemerin impairs insulin cascade signaling by acting on several proteins of this cascade and by inducing inflammation.

La estimulación eléctrica en urología ha tenido un desarrollo muy importante desde los años 70, los sistemas implantables de estimulación del aparato urinario se utilizan para el vaciamiento vesical en vejigas neurógenas (Neuroestimulación) o la modulación de la transmisión eléctrica del ciclo miccional por disfunción vesicoesfinteriana crónica (Neuromodulación). Ambas técnicas tienen en común el estímulo directo de la raíz sacra responsable del arco reflejo miccional, en el primer caso mediante estímulo externo sobre una antena implantada; y en el segundo por estímulo permanente a través de un marcapasos implantado. En éste artículo realizamos una revisión de las indicaciones, técnica y resultados de ambas terapias, con especial atención a la experiencia española.

In the event of a loss of integrity of the main coolant line, a large mass and energy release from the primary circuit to the containment is to be expected. The temporal evolution of such depressurization is mainly governed by the critical flow, whose correct prediction requires, in first place, a correct description of the different friction terms. Within this work, selected friction models of the CESAR module of the Accident Source Term Evaluation Code (ASTEC) V2.1 integral code are validated against data from the Moby Dick test facility. Simulations are launched using two different numerical schemes: on the one hand, the classical five equation (drift flux) approach, with one momentum conservation equation for an average fluid plus one algebraic equation on the drift between the gas and the liquid; on the other hand, the recently implemented six equation approach, where two differential equations are used to obtain the phase velocities. The main findings are listed hereafter: The use of five equations provides an adequate description of the pressure loss as long as the mass fluxes remain below 1.24 kg/cm2 s and the gas mass fractions below 5.93 × 10 − 4. Beyond those conditions, the hypotheses of the drift flux model are exceeded and the use of an additional momentum equation is required. The use of an additional momentum equation leads to a better agreement with the experimental data for a wider range of mass fluxes and gas mass fractions. However, the qualitative prediction for high gas mass fractions still shows some deviations due to the decrease of the regular friction term at the end of the test section.

Background:Psoriatic Arthritis (PsA) displays increased traditional cardiovascular (CV) risk factors, such as insulin resistance (IR), metabolic syndrome or obesity. Thus, it is an urgent need to treat and manage these cardiometabolic comorbidities associated. Some evidence points out that methotrexate could improve CV risk due to its anti-inflammatory properties, however the effect of PDE4 inhibitor treatment on CV risk have not been elucidated yet.Objectives:1) To evaluate the effect of conventional therapy and PDE4 inhibitor in PsA patients with high prevalence of cardiometabolic comorbidities. 2) To identify a molecular patient profile susceptible of being benefit from each therapy regarding disease activity and CV risk.Methods:Thirty biological-naïve patients with PsA were treated with the PDE4 inhibitor (Apremilast), Methotrexate or combined therapy (Apremilast and Methotrexate) following the clinical routine practice for 6 months. A cohort of 30 age and sex-matched healthy donors (HDs) was included. Plasma and peripheral blood mononuclear cells (PBMCs) were isolated from peripheral blood of patients and HDs. Different parameters related to the cardiometabolic risk were analyzed, including: atherogenic index, ratio apolipoprotein B (apo B)/apolipoprotein A (apo A), insulin resistance (IR), metabolic syndrome, obesity, arterial hypertension, and the SCORE. Clinical and analytical parameters were collected: lipid profile (total cholesterol, HDL-cholesterol, LDL-cholesterol, triglycerides, apo A and apo B), glucose and insulin, body surface area (BSA) affected by psoriasis, number of tender and swollen joints, DAPSA, C-reactive protein and erythrocyte sedimentation rate. A panel of 92 proteins involved in cardiovascular disease (cardiovascular panel II, Olink) and an adipocytokine profile was measured in plasma and PBMCs. Hard cluster analysis was carried out in order to identify two distinctive molecular phenotypes depending on the treatment response related to the reduction of CV risk.Results:Among the 92 CV-related proteins, the higher levels of two molecules, CD163 and FABP4 observed in PsA patients compared to HDs, were strongly associated with elevated rates of CV risk factors such as apolipoprotein B/A and atherogenic risks, metabolic syndrome, obesity, IR, arterial hypertension and smoking. Thus, we could identify two clinical profiles of patients according to the plasma levels of these molecules: cluster 1 defined by 20 patients with low levels of CD163 and FABP4 and low prevalence of CV comorbidities and cluster 2 defined by 10 patients with high levels of CD163 and FABP4 and high prevalence of CVD comorbidities. Regarding cluster 2, those patients that were treated with Apremilast or combined therapy had a significant reduction of CD163 and FABP4 associated with a drop in total cholesterol, apo B, IR state and body mass index. In addition, both PDE4 inhibitor and combined treatment reduced activity disease. However, Methotrexate in monotherapy did not show a beneficial effect in PsA patients displaying higher levels of CD163, FABP4, total cholesterol and no changes in disease activity after treatment. In regard to cluster 1, the three therapy strategies reduced disease activity after 6 months. Even with low rates of comorbidities, those patients treated with Apremilast had reduced levels of total cholesterol and apolipoprotein B and body mass index after 6 months of therapy. However, no changes were observed in the treatment with Methotrexate or Methotrexate combined with Apremilast.Conclusion:1- CD163 and FABP4 could be considered as potential biomarkers of treatment efficacy regarding cardiometabolic comorbidities. 2- Apremilast might target metabolic alterations in PsA modulating lipid profile, insulin resistance and body mass index, decreasing the levels of surrogate CV-related molecules. 3- Apremilast treatment should be considered in PsA patients with higher rates of cardiometabolic comorbidities.Funded by ISCIII (PI17/01316 and RIER RD16/0012/0015) co-funded with FEDER.Disclosure of Interests:None declared.

Objectives:To analyze the effect of differents anti-rheumatic treatments on the carotid intima-medial thickness (cIMT) in patients with Rheumatoid Arthritis (RA).Methods:Controlled cross-sectional observational study of a cohort of patients with RA. 146 patients with RA (ACR/EULAR2010).cIMT was measured by semi-automatic carotid ultrasound.Other variables: atheroma plaques, bilateral plaques, DAS28-VSG, lipid metabolism, apoB, apoA1, apoB/apoA1, uric acid, homocysteine. Biological or conventional synthetic disease-modifying antirheumatic drug therapy (bDMARDs/csDMARDs), glucocorticoids. Descriptive, bivariate, Spearman’s test and multivariate model were constructed to identify factors associated with cIMT.Results:The baseline characteristics are shown in Table 1.Significant positive correlation was found between cIMT and apoB (r=0.22; p=0.014), apoB/apoA1 (r=0.18; p=0.044), cholesterol(r=0.23; p=0.006),triglycerides(r=0,21, p=0.013),uric acid(r=0.26; p=0.009),age(r=0.65, p>0.001),RF(r=0.16, p=0.05) homocysteine (r=0.5, pr=0.19, p=0.023),CRP(r=0.18, p=0.032) and negative correlation with anti-TNFα treatment time(r=-0.20, p=0.02).Patients receiving bDMARDs alone or combined with csDMARDs had less cIMT than those taking only csDMARDs[median (IQR): 0.54 (0.50-0.63), 0.57(0.53-0.65) and 0.65(0.53-0.75); p=0.046].The factors associated with cIMT were age(ß= 0.007, pp=0.027) and methotrexate treatment ever(ß= -0.07, p=0,08).Table 1.Baseline characteristicsVariablesRA n=146Epidemiological characteristics and comorbiditiesAge (years), mean (SD)55.9 (13.1)Female sex; n (%)112 (76.7)Smoker, n (%)30 (21.6)Arterial hypertension, n (%)45 (30.8)Diabetes mellitus, n (%)5 (3.4)Previous Cardiovascular disease, n (%)10 (14.6)Hyperlipidemia, n (%)46 (31.5)BMI (kg/m2), median (IQR)26.8 (23.4-29.7)Clinical-laboratory characteristicsDisease duration, years, median (IQR)6.77 (2.2-14.2)Erosions, n (%)53 (36.6)RF positive, n (%)119 (81.55)ACPA positive, n (%)123 (84.2)CRP (mg/dl), median (IQR)4.8 (1.6-11.5)ESR (mm/h), median (IQR)12 (6-24)DAS28 at protocol, median (IQR)2.8 (2.1-3.7)HAQ, mean (SD)0.78 (0.6)ApoB (mg/dl), mean (SD)86.8 (21.8)ApoA1 (mg/dl), mean (SD)149.8 (32.7)Cholesterol (mg/dl), mean (SD)198.7 (37.3)cLDL (mg/dl), mean (SD)119.3 (30.3)cHDL (mg/dl), median (IQR)56 (47-70)Triglycerides (mg/dl), median (RIQ)92 (73-121)Homocisteyne (mg/dl), median (RIQ)2.08 (1.7-2.8)cIMT mean (mm), median (IQR)0.6 (0.53-0.7)Atherosclerotic plaques, n (%)51 (34.9)Bilateral plaques, n (%)22 (15.1)Anti-rheumatic treatmentSynthetic DMARDs ever, n (%)146 (100)Methotrexate ever, n (%)132 (90.4)Time with methotrexate (years), median (IQR)4.4 (1.04-9.5)Leflunomide ever, n (%)83 (56.8)Sulfasalazine ever, n (%)13 (8.9)Hydroxychloroquine ever, n (%)99 (67.8)Biological DMARDs ever, n (%)76 (52.05)Anti TNFα ever, n (%)47 (32.2)Time with antiTNF-α (years), mean (SD)1.18 (2.8)Jak inhibitor ever, n (%)10 (6.8)Anti-IL-6 ever, n (%)28 (19.2)Rituximab ever, n (%)15 (10.3)Glucocorticoids at protocol, n (%)82 (56.5)Glucocorticoids dose at protocol (mg), median (IQR)5 (0-5)Abbreviations: RF: rheumatoid factor; ACPA: anti-citrullinated peptide antibodies, cIMT: carotid intima media thickness; ApoB: apolipoprotein B, ApoA1: apolipoprotein A1, LDL: low-density lipoprotein; HDL: high-density lipoprotein; DAS28: 28-joint Disease Activity Score; HAQ: Health Assessment Questionnaire; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; IL-6: interleukin 6; Anti TNF, anti–tumor necrosis factorConclusion:biological disease-modifying antirheumatic drug therapy, in particular Anti TNFα, could protect against the development of atherosclerosis in RADisclosure of Interests:None declared

Background:Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with an increased prevalence of cardiovascular (CV) events. Traditional CV risk factors do not account for the increased CV disease mortality in PsA. Inflammation seems to have a key role in the development of this comorbidity, however the specific molecular mechanisms involved are not defined yet.Objectives:To evaluate clinical CV risk factors and surrogate markers and their relationship with inflammation, disease activity and metabolic comorbidities in PsA patientsMethods:This is a cross-sectional study including 100 PsA patients without CV disease recruited in the routine clinical practice at the Rheumatology Department, Reina Sofia Hospital of Cordoba and 100 age-matched healthy donors (HDs). Different parameters related to the cardiometabolic risk were analyzed. Clinical and analytical parameters were collected: lipid profile (cholesterol, HDL, LDL, TG, ApoA and ApoB), glucose and insulin, body surface area (BSA) affected by psoriasis, number of tender and swollen joints, DAPSA, VAS, CRP and ESR. To measure the persistence of inflammation, CRP levels were recorded retrospectively once, twice, or three times during the 5 years prior to study and at the moment of the study. Increased levels of CRP in at least 50% of the determinations was considered as persistent inflammation. Plasma and peripheral blood mononuclear cells (PBMCs) were isolated from peripheral blood of patients and HDs. A panel of 92 proteins involved in CV disease and an adipocytokine profile was measured in plasma and PBMCs. In addition, activation of 18 intracellular pathways involved in cell activation was also measured in PBMCs. In vitro experiments in adipocytes treated with serum from PsA patients were also carried out.Results:Traditional CV risk factors including atherogenic risk, insulin resistance (IR), metabolic syndrome, smoking, obesity, arterial hypertension, apolipoprotein B/A risk, type 2 diabetes mellitus and the levels of SCORE were significantly increased in PsA patients. The presence of IR was associated with disease activity markers (DAPSA, ESR and CRP). In fact, the HOMA-IR index was related to the CRP persistence. PsA patients with obesity had significantly increased the number of tender and swollen joints, the levels of DAPSA and CRP. Twenty-eight proteins involved in CV disease and six adipocytokines were significantly elevated in the plasma of PsA patients. Several of these cardiovascular molecules were associated with higher levels of DAPSA (CTSD, GAL3, CD163, FABP4, IL6 and IL1RT2), acute phase reactants (GAL3, TNFα, Adiponectin, TNFR1 and IL6), affected body surface area (IL2RA, GAL3, CCL15, TRAP, CSTB, CD163, OPG and CNTN1) and onychopaty (TRAP, VWF, MCP-1, GAL3, LTBR, TFPI, CHI3L1, CTSZ and JAM-A). In addition, the mRNA expression of most of those 28 CV molecules were significantly increased in PBMCs from PsA patients. At intracellular level, the activation of 11 kinases (ERK1/2, AKT, S6 Ribosomal, mTOR, HSP27, Bad, p70 S6 kinase, PRAS40, p53 and caspase-3) involved in insulin signaling, inflammation, cell survival and apoptosis were altered in PBMCs. Finally, serum from PsA patients was able to modify the expression of these molecules in adipocytes.Conclusion:1) Disease activity and inflammatory burden are closely associated with the presence of metabolic alterations, specifically obesity and IR in patients with PsA. 2) The development of IR is extremely related to the persistence of CRP levels in the previous 5 years. 3) Inflammation is closely associated to the adipose tissue dysfunction in PsA and 4) FABP4, CD163 and GAL3 are surrogate CV markers commonly associated with clinical features of PsA, suggesting the role of these molecules linking CVD and PsA pathogenesis.Funded by ISCIII (PI17/01316 and RIER RD16/0012/0015) co-funded with FEDER.Disclosure of Interests:None declared.

Background:It has been shown that the cardiovascular risk (CV) in spondyloarthritis (SpA) patients is higher than that of the general population. Furthermore, an association has recently been described between structural damage at the axial level and an increase in estimated CV risk 1.Objectives:To evaluate the association between the estimated cardiovascular risk (CV) and the presence of subclinical atherosclerosis with the MASEI index (Madrid Sonographic Enthesis Index) in patients with axial spondyloarthritis (Ax-SpA) as an expression of peripheral enthesitis.Methods:Cross-sectional study performed in 103 patients with ax-SpA from the Córdoba AxSpA Task force, Registry and Outcomes (CASTRO), in which patients undergoing treatment with biological therapy and with a previous history of CV event were excluded. Clinical data, disease activity data and factors related to CV risk were collected, as well as the presence of persistently elevated CRP levels in the five years prior to the study visit. The SCORE index was calculated, as well as the thickness of the carotid intima media (CIMT) and the MASEI index, both measured by ultrasound. The association between MASEI-SCORE and MASEI-atheroma plaques was evaluated using generalized linear models (GLM), adjusted for time of evolution of the disease, disease activity and smoking.Results:Of the patients included, 35 were men (34.0%), with a mean age of 45.2 (±12.1) years and time of evolution of the disease of 18.5 (±13.0) years. The mean MASEI score was 13.6 (±9.1), and the mean SCORE score was 8.1 (±8.9). The GLM regressions showed that the MASEI was independently associated with the SCORE (coefficient β 0.22; 95% CI 0.02-0.43) adjusted for the duration of the disease, smoking, and the presence of persistent CRP (Table 1A). The MASEI index was also significantly associated with the CIMT, although these differences disappeared when the model was adjusted for other factors (Table 1B).Table 1.A. Association between MASEI and SCORE adjusting for disease duration, smoking status and CRP.Crude modelAdjusted for disease durationAdjusted for disease duration and smokingAdjusted for disease duration, smoking and CRPβ coefficient (95%CI)p-valueβ coefficient (95%CI)p-valueβ coefficient (95%CI)p-valueβ coefficient (95%CI)p-valueMASEI0.37 (0.20-0.55)0.25 (0.08-0.42)0.0060.25 (0.09-0.42)0.0040.22 (0.02-0.43)0.039Conclusion:In patients with ax-SpA, peripheral enthetic damage measured by the MASEI index is associated with an increase in estimated CV risk independently of the time of evolution, smoking and levels of CRP.References:[1]Ladehesa-Pineda ML, Arias-de la Rosa I, López-Medina C, et al. Assesment of the relationship between estimated cardiovascular risk and structural damage in patients with axial spondyloarthritis. Ther Adv Musculoskelet Dis 2020;12:1-15Table 1.B. Association between MASEI and intima media thickness (IMT) adjusting for disease duration, smoking status and CRP.Crude modelAdjusted for disease durationAdjusted for disease duration and smokingAdjusted for disease duration, smoking and CRPβ coefficient (95%CI)p-valueβ coefficient (95%CI)p-valueβ coefficient (95%CI)p-valueβ coefficient (95%CI)p-valueMASEI0.01 (0.00-0.01)0.0410.003 (-0.01-0.004)0.1780.002 (-0.001-0.004)0.1490.002 (-0.001-0.005)0.226Disclosure of Interests:None declared.

Background The objectives of Rheumatoid Arthritis (RA) treatment comprise achieving persistent Clinical Remission (CR) or sustained low clinical activity. Nowadays management follows a “treat to target” strategy based on adjustment of treatment in accordance with protocolos. In patients with persistent disease activity after treatment with at least two of the classic disease-modifying antirheumatic drugs the use of biological therapy is recommended. Once sustained CR is achieved, the most efficient strategy is optimisation, by tapering the dose of the biological therapy or by increasing administration intervals. Searching for the lowest effective dose for each patient could minimise the risk of adverse effects and improve the cost-effectiveness of RA treatment. Objectives To proof that the performance of an optimisation strategy in patients with RA and sustained CR under biological treatment maintains the proportion of patients with DAS28 ≤2,6 after 4 years, to assess the maintenance of the effectivenes of the optimisation at 4 years in terms of clinical manifestations, and to analyse the time until relapse. Methods An open observational prospective study that included 70 patients with RA (CREATE registry) in CR at least for 6 months, under treatment with tapered dose of biological therapy (TNFi, abatacept or tocilizumab). Treatment effectiveness was assessed with the main variable DAS28 ≤2,6. Statistical analysis included a descriptive study of variables and a confidence interval of 95% (95% CI) was estimated. For bivariate analysis, we used Student t-test for independent samples, repeated measures analysis of variance and mixed analysis of variance, and as a post-hoc contrast, Sidak adjustment. The log-rank test was used to compare the time until relapse according to the biological therapy. Results The mean age of the patients was 56,9 (13,7) years, 78,6% were women, 68,8% were rheumatoid factor (RF) positive and 66,7% ACPA positive; the mean DAS28 at the beginning of the optimisation was 2,24 (0,73). After 4 years, 27,7% (95%CI:16,82%–38,58%) of patients maintained CR with the optimised dose, with a DAS28 2,15 (0,81). Through the first year, the percentage of relapses was 15,71%, in the second year, 7,35% and 4,61% relapsed during the third year. The median time of optimisation until relapse was 13,833,18 months (95% CI:7,6–20,06). No significative differences were found at comparing the survival curves of the optimised patients until relapse for 4 years according to the biological therapy (TNFi vs no TNFi) (log-rank test:0,865, p:0,352) (graphic). Conclusions After 4 years, all of the patients maintained DAS28 levels of low disease activity, including those who had suffered a previous relapse and had turned back to the previous dose of biologic treatment. In view of this outcomes, optimisation strategy in clinical practice is posible and effective in patients with persistently controlled RA. Disclosure of Interest None declared

Resumen Estudio de los papilomas invertidos uroteliales en nuestra area. Material y metodos Realizamos un estudio de los papilomas invertidos uroteliales diagnosticados en nuestro centro entre enero de 1994 y diciembre de 2007. Se realizo un estudio retrospectivo y prospectivo con analisis estadistico descriptivo: antecedentes urologicos, motivo de consulta, metodo diagnostico, focalidad tumoral, metodo de seguimiento, pronostico y recurrencia. Se realizo un estudio estadistico con el software SPSS version 13. Resultados En el periodo de estudio se han diagnosticado 14 papilomas invertidos, con una mediana de 59 anos. El motivo de consulta fue hematuria en 7 enfermos (50%), seguido de dolor lumbar en 2 enfermos (14,28%) y de sindrome irritativo en 1 enfermo (7,14%), fue diagnosticado en 4 enfermos (28,5%) de manera incidental. Durante el periodo de seguimiento solo se produjo una recidiva/recurrencia en un tumor de bajo grado. Conclusiones El pronostico, la recurrencia y el potencial de malignizacion de este tumor no estan claros, existiendo controversias en la literatura medica mundial, hecho por el cual aunque desde nuestro punto de vista su naturaleza es benigna, aconsejamos un seguimiento como si se tratase de un tumor urotelial de bajo grado.

Estudio de los papilomas invertidos uroteliales en nuestra área. Material y métodos: Realizamos un estudio de los papilomas invertidos uroteliales diagnosticados en nuestro centro entre enero de 1994 y diciembre de 2007. Se realizó un estudio retrospectivo y prospectivo con análisis estadístico descriptivo: antecedentes urológicos, motivo de consulta, método diagnóstico, focalidad tumoral, método de seguimiento, pronóstico y recurrencia. Se realizó un estudio estadístico con el software SPSS versión 13. Resultados: En el período de estudio se han diagnosticado 14 papilomas invertidos, con una mediana de 59 años. El motivo de consulta fue hematuria en 7 enfermos (50%), seguido de dolor lumbar en 2 enfermos (14,28%) y de síndrome irritativo en 1 enfermo (7,14%), fue diagnosticado en 4 enfermos (28,5%) de manera incidental. Durante el período de seguimiento sólo se produjo una recidiva/recurrencia en un tumor de bajo grado. Conclusiones: El pronóstico, la recurrencia y el potencial de malignización de este tumor no están claros, existiendo controversias en la literatura médica mundial, hecho por el cual aunque desde nuestro punto de vista su naturaleza es benigna, aconsejamos un seguimiento como si se tratase de un tumor urotelial de bajo grado. A study of inverted urothelial papilloma in our area. Methods: A study was conducted of inverted urothelial papillomas diagnosed at our center from January 1994 to December 2007. This was a retrospective and prospective study with a descriptive statistical analysis: urological history, reason for consultation, diagnostic methods, tumor focality, follow-up method, prognosis, and recurrence. SPSS software version 13 was used for statistical analysis. Results: Fourteen inverted papillomas were diagnosed in the study period in patients with a median age of 59 years. The presenting complaint was hematuria in 7 patients (50%), followed by low back pain in 2 patients (14.28%), and irritative syndrome in 1 patient (7.14%). The tumor was incidentally diagnosed in 4 patients (28.5%). A single relapse/recurrence occurred in a low-grade tumor during the follow-up period. Conclusions: Prognosis, recurrence, and malignant potential of this tumor are unclear, and controversy exists in the literature on this subject. Thus, although we think this is a benign tumor, we advise follow-up as if it were a low-grade urothelial tumor.

Resumen Tumor Miofibroblastico De Vejiga El tumor miofibroblasticos es un tumor mesenquimal benigno de caracter excepcional, siendo su localizacion mas habitual es el pulmon; mientras que su aparicion en la vejiga, es excepcional, no existiendo mas de 100 casos publicados, de este tipo de tumor en la vejiga. Este tipo de tumor queclinica y radiologicamente, se comporta como un tumor maligno. El diagnostico patologico es complejo, debido a su similitud con los sarcomas, siendo necesario recurrir a la inmunohistoquimica para un diagnostico de certeza.El tratamiento mediante reseccion amplia suele ser suficiente no existiendo en la actualidad ningun caso de metastasis a distancia, ni de malignizacion. Presentamos un nuevo caso de este tumor, realizando una amplia revision bibliografica.

El tumor de células renales supone el 1% de los tumores del adulto, mientras que el carcinoma transicional tiene una incidencia del 7%. La aparición simultánea de un carcinoma de células renales, y un tumor transicional de pelvis en el mismo riñón, suponen un hecho excepcional no existiendo más de 30 casos publicados en el mundo, presentando una incidencia aproximada del 0,14% de la patología tumoral renal. Presentamos un nuevo caso de esta inusual asociación que supone el 4 caso referenciado en la literatura en español.

Se presenta un nuevo caso de carcinoma renal sarcomatoide, en un varón de 67 años con recidiva locorregional a los 4 meses de la cirugía, con dos episodios de hemorragia retroperironeal tras la segunda intervención. El objetivo de este trabajo es aportar un nuevo caso y hacer una revisión de la bibliografía.

BACKGROUND Early diagnosis of extra-pulmonary tuberculosis (EPTB) is important for successful treatment. METHODS All cases of EPTB diagnosed at Ramon y Cajal Hospital, Madrid, Spain, from 1997 to 2008 were analysed and compared with pulmonary tuberculosis (PTB) patients to identify differential parameters that could serve to predict the presence of EPTB at initial presentation. Different microbiological techniques were analysed, including amplification of 16S-rRNA in urine. RESULTS During the study period, 814 cases of TB were diagnosed at our centre; 330 (40.5%) were EPTB. Concomitant PTB was detected in 45% of EPTB cases. The main clinical forms of EPTB were lymphadenitis (86, 26%), miliary TB (60, 18%), and multifocal TB (43, 13%). Variables independently associated with EPTB were human immunodeficiency virus (HIV) infection (OR 3.6, 95%CI 2.4-5.4), older age (>60 years) (OR 3.7, 95%CI 2.5-5.6) and mortality (OR 2.9, 95%CI 1.3-6.3). 16S-rRNA in urine was performed in 82 EPTB patients (25%), among whom a positive result was obtained in 70%; in the PTB group, a positive result was found in 5 of 28 patients (18%) (P

Resumen Objetivo Presentar un caso de recidiva de carcinoma epidermoide de pene a los 21 anos de la cirugia. Metodo Se trata de un paciente de 85 anos con antecedentes de penectomia parcial por carcinoma epidermoide, que presenta lesion excrecente a nivel de glande de 1 mes de evolucion. Se biopsia siendo el resultado carcinoma epidermoide por lo que se realiza penectomia total con uretrostomia cutanea. Resultado El estudio histopatologico de la pieza confirmo un carcinoma epidermoide bien diferenciado.

During pregnancy, the prolonged stress and worry felt by mothers can alter the development and function of the right brain hemisphere. For this reason, importance is given to prenatal stimulation programs for pregnant women.To determine the perinatal results in the moment of childbirth in mothers who had participated in prenatal stimulation programs.An experimental study was conducted in five health districts in the town of Cienfuegos (Cuba) with a view to identifying the perinatal results at the moment of childbirth in women that had participated in prenatal stimulation programs.The study consisted of an intentional sampling of all of the subjects (n = 200 women who were 20-28 weeks pregnant). The variables studied were the following: duration of labor, baby's birth weight, Apgar score at birth, type of childbirth, and opinion of the subjects about the prenatal stimulation program.Of the population sample, 36% of the subjects gave birth in less than six hours; 67.5% had babies weighing 2,500-3,000 grams; and 96.5% had babies whose Apgar scores were between 8 and 9. Finally, 68.5% of the subjects had natural childbirths and 96% were satisfied with the prenatal stimulation program.The results obtained showed that these new prenatal stimulation programs were well received by the subjects in this study.

A study of inverted urothelial papilloma in our area.A study was conducted of inverted urothelial papillomas diagnosed at our center from January 1994 to December 2007. This was a retrospective and prospective study with a descriptive statistical analysis: urological history, reason for consultation, diagnostic methods, tumor focality, follow-up method, prognosis, and recurrence. SPSS software version 13 was used for statistical analysis.Fourteen inverted papillomas were diagnosed in the study period in patients with a median age of 59 years. The presenting complaint was hematuria in 7 patients (50%), followed by low back pain in 2 patients (14.28%), and irritative syndrome in 1 patient (7.14%). The tumor was incidentally diagnosed in 4 patients (28.5%). A single relapse/recurrence occurred in a low-grade tumor during the follow-up period.Prognosis, recurrence, and malignant potential of this tumor are unclear, and controversy exists in the literature on this subject. Thus, although we think this is a benign tumor, we advise follow-up as if it were a low-grade urothelial tumor.

About 2% of adults have an urachal cyst. The diagnosis is usually made due to its clinical complications. We report an inusual case of acute urinary retention due to an urachal cyst, with hipogastric pain and anuria as initial syntoms.

The TVT system is the most common surgical technique of female stress urinary incontinence, because of the simplicity. good clinical results and rare complications.From april, 1999 to march. 2004, it has been done in our department 100 TVT systems with the revision of the result over the six following months. The average follow-up rate was 10.36 months (R: 1-54 months) and looses mean the 11% of the cases. All the patients presented stress incontinence and their average age was 56.6 years old (30-80). The 12% of the cases have been previously operated of urinary incontinence. 21 patients presented previous surgery of pelvic floor. In the 17% of the cases, TVT systems was associated to another surgical technique: 15% of them was operated of cystocele, 1% of them had surgical correction of rectocele, 1% of them had a strong surgery of pelvic floor, that included TVT system, correction of pelvic floor and hysterectomy.We obtained 65% of successful cases, defined as objective confirmation of absence of looses from the observer and the subjective reference of the patient: 17% of clear improvement (clear decrease of looses from the patient and subjective improvement) and 7% of failure of the technique. The total percentage of appearance of novo post-surgery urgency is 9%. There were complications in the 12% of the cases: there were three cases of bladder perforation, two of them intra-operative and one of them deferred and associated to an infection of surgical wound; another three cases of residue in the immediate post-operative that were resolved with bladder catheterization: one case of acute urinary retention that was treated with bladder catheterization with suprapubic cistostomy: one case of chemical peritonitis corrected with a conservative treatment; two cases of vaginal extrusion of sling, which were resolved with the section of the outer sling; one patient presented a hipogastric hematoma resolved with conservative measures: and one patient presented pelvic discomfort with spontaneous resolution.We consider the TVT system as an effective surgical technique in the treatment of the female stress urinary incontinence. It is a simple technique with a short stay in the hospital and rare complications.

El quiste de uraco esta presente aproximadamente en el 2% de los adultos, siendo su diagnostico difícil y secundario a las manifestaciones de su complicaciones. Presentamos un caso inusual de retención aguda de orina en un quiste de uraco, que debutó como dolor hipogástrico y anuria.

The renal cell tumour supposes 1% of the adult's tumors, while the transitional carcinoma has an incidence of 7%. The simultaneous appearance of a carcinoma of renal cells, and a transitional tumour of pelvis in the same kidney, they suppose an exceptional fact not existing but of 30 cases published in the world, presenting an approximate incidence of 0.14% of the pathology renal tumoral. We present a new case of this unusual association that supposes the 4 case indexed in the literature in Spanish.

Resumen Introduccion: El sistema TVT (Tension-free Vaginal Tape) es la tecnica quirurgica de eleccion en los ultimos anos de la incontinencia urinaria de esfuerzo femenina (IUE), dada la facilidad de la tecnica, buenos resultados clinicos y escasas complicaciones Material y metodos Desde Abril de 1999 a Marzo 2004 se han implantado en nuestro servicio 100 sistemas TVT con revision de los resultados a los 6 meses, y un seguimiento medio de 10,36 meses (R: 1-54 meses), con una perdida de seguimiento en el 11% de los casos. Todas las mujeres estudiadas presentaban incontinencia de esfuerzo, siendo la edad media de 56,5 anos (30-80). Un 12% habian sido intervenidas previamente de IUE. Presentan cirugia previa del suelo pelvico 21 pacientes. En un 17% de los casos se realizo TVT asociado a otra tecnica quirurgica: 15% cistorrafia anterior, 1% correccion de rectocele, 1% cirugia compleja del suelo pelvico que incluye TVT, correccion de cistocele e histerectomia Resultados Obtenemos un 65% de exitos (comprobacion objetiva de la ausencia de escape por parte del medico y referencia subjetiva de la paciente), un 17% de mejoria (disminucion clara de escapes por parte de la paciente y mejoria subjetiva) y un 7% de fracaso de la tecnica. El porcentaje global de aparicion de urgencia de novo posquirurgica es del 9%. Existieron un 12% de complicaciones; 3 casos (3%) de perforacion vesical, 2 de ellos intraoperatorios y 1 diferida junto con infeccion de la herida quirurgica; 3 episodios (3%) de residuos altos en el postoperatorio inmediato, resueltos con autosondajes, y un caso de RAO (1%) dado de alta con cistostomia suprapubica; un caso (1%) de peritonitis quimica tras retirada de talla vesical resuelta con tratamiento conservador; dos casos (2%) de extrusion vaginal de la bandeleta, con seccion de la porcion de malla exteriorizada en ambos casos; un (1%) paciente presenta hematoma hipogastrico que se resuelve con medidas conservadoras; un 1 % de los pacientes (1 caso) presento molestias pelvicas subcronicas con resolucion espontanea Conclusiones Consideramos el sistema TVT una tecnica quirurgica eficaz en el tratamiento de la incontinencia urinaria femenina de esfuerzo. Es una tecnica sencilla, con baja estancia hospitalaria y escasas complicaciones

The primary bladder amiloidosis is an uncommon pathology, not existing in the world more than 150 published cases, being even more exceptional the secondary bladder amiloidosis being described around 25 cases. The secondary bladder amiloidosis associates in most from the patients to arthritis reumatoide of long evolution. The diagnoses clinical it is difficult, being necessary the differential diagnosis with the bladder tumour. The pathological study and inmunohistochemics, confirm the diagnosis. We present the case of a patient that I debut with frank hematuria, hemodynamic uncertainty and renal inadequacy that it required combined treatment, doctor and surgical for the resolution of their square.

The myofibroblastic tumor, is a mesenchymal benign tumor of exceptional character, being its localization but habitual it is the lung; while its appearance in the bladder, is exceptional, not existing but of 100 published cases, of this tumor type in the bladder. This tumor type that clinic and radiologics, behave as a wicked tumor. The pathological diagnosis is complex, due to its similarity with the sarcomas, being necessary to appeal to the inmunohistochemics for a I diagnose of certainty. The treatment by means of wide resection is usually enough not existing any case of metastasis at the present time at distance, neither of malignization. We present a new case of this neoplasm, carrying out a wide bibliographical revision.

The activity of linezolid was studied against 55 Mycobacterium tuberculosis (42 susceptible, 3 isoniazid resistant and 10 isoniazid and rifampicin resistant), one Mycobacterium bovis and two multidrug-resistant M. bovis isolates using the standard 7H10 agar proportion and the ESP Culture System II methods. Both methods displayed similar MIC 90 values (minimum inhibitory concentrations for 90% of the organisms) of 0.5 mg/L; however, the former method yielded slightly lower MIC 50 values (MICs for 50% of the organisms) (0.25 mg/L) compared with the latter method (0.5 mg/L). No differences were observed between susceptible and resistant isolates, including multidrug-resistant M. bovis isolates, with a MIC range of 0.12–0.5 mg/L. The potential role of linezolid in tuberculosis patients requires further in vivo evaluation.

The incidence of retroperitoneal primitive tumour varies from the 0.3 to 3%. The sarcomas suppose the group but it frequents of retroperitoneal tumour, being the Schwannoma an unusual tumour with an incidence from 1% to 50% of the retroperitoneal primary tumours. The schwannoma also denominated neurinoma or neurolenoma, it is a derived tumour of the cells of Schwann of the outlying nerves. It is characterized by their clinical and radiological inespecify, being the diagnose pathological, with intense positive inmunohistoquimics to the protein S-100. The election treatment is the surgical remove, with wide margins; not being described cases of malignización neither of metastasis at distance, but if the recurrence existence at probably secondary local level to incomplete resection.

The Virus of the Human Papiloma (HPV), classically he/she has been related with infections of sexual transmission and processes wicked oncologists of the feminine genital apparatus and with less frequency of the masculine one. The new technical diagnostics, based on molecular biology (by means of polymerase chain reaction), they help to a better epidemic approach, an improvement in the I diagnose viral, and a correct therapeutic focus. The object of this work is to revise the current state of the HPV from the points of view etiopathogenics, epidemic, clinical, diagnosis, therapeutic and preservative.

HEMATURIA AND SHARP RENAL FAILURE AS DEBUT OF SECONDARY BLADDER AMILOIDOSIS. PRESENTATION OF A NEW CASE AND REVISION OF THE LITERATURE The primary bladder amiloidosis is an uncommon pathology, not existing in the world more than 150 published cases, being even more exceptional the secondary bladder amiloidosis being described around 25 cases. The secondary bladder amiloidosis associates in most from the patients to arthritis reumatoide of long evolution. He diagnoses clinical it is difficult, being necessary the differential diagnosis with the bladder tumour. The pathological study and inmunohistoquimics, confirm the diagnosis. We present the case of a patient that I debut with frank hematuria, hemodynamic uncertainty and renal inadequacy that it required combined treatment, doctor and surgical for the resolution of their square.

Electric stimulation in Urology has undergone considerable development since the 1970s. The implantation methods for urinary system stimulation are used for bladder emptying in neurogenic bladders (Neurostimulation) or the modulation of the electrical transmission of the voiding cycle caused by chronic detrusor-sphincter dysfunction (Neuromodulation). Both techniques have in common the direct stimulation of the sacral roots, responsible for the urinary reflex arc. The first of them works via external stimulation over an implanted antenna, and the second via permanent stimulation through an implanted pacemaker. We review in this article the indications, technique and results of both therapies, specially focused on the Spanish experience.

Sacral root neuromodulation is an effective technique for the treatment of Chronic Micturition Dysfunction (CMD) refractory to conventional therapy. New indications such as chronic pelvic pain and interstitial cystitis are currently making their way within the urologic setting. Several groups of gastric surgeons are now choosing this technique for the management of rectal diseases (constipation, sphincter dysfunction). This paper contributes our experience in the treatment of patients with CMD and the comparative results at one year from implant in all patients.From December 1998 through July 2003, 18 neuromodulation definite implants were performed. The main indication was CMD in 62.5% patients. Follow up of patients was done at one month and three months, and every six months thereafter. Follow up is conducted through a micturition diary and QoL questionnaire. Electrode implant in the first 16 patients was achieved by open surgery. The next 2 patients had the electrode placed by a percutaneous technique using the "Tined Lead" kit.Results at one year after implant were compared in all patients. The total number of neuromodulation implants placed was 18, 14 (77.7%) of which were women and 4 (22.3%) men. Mean age was 52.56 years. Implant indication was CMD in 72.2% patients, mixed incontinence (urinary and faecal) in 22.1%, and interstitial cystic disease in 5.5%. Symptoms improvement at one year from implant, as determined by a micturition diary and QoL questionnaire was 76.4%. Clinical improvement was greater in patients with urgency symptoms than in patients with predominance of voiding symptoms.

Resumen El Virus del Papiloma Humano (VPH), clasicamente se ha relacionado con infecciones de transmision sexual y procesos oncologicos malignos del aparato genital femenino y con menos frecuencia del masculino. Las nuevas tecnicas diagnosticas, basadas en biologia molecular (mediante reaccion en cadena de la polimerasa), ayudan a una mejor aproximacion epidemiologica, una mejora en el diagnostico viral, y un correcto enfoque terapeutico. El objeto de este trabajo es revisar el estado actual del VPH desde los puntos de vista etiopatogenico, epidemiologico, clinico, diagnostico, terapeutico y profilactico.

Resumen Objetivo La neuromodulacion de raices sacras es una tecnica eficaz para el tratamiento de la Disfuncion Miccional Cronica (DMC), refractaria a tratamientos convencionales. En la actualidad estan surgiendo nuevas indicaciones en el ambito urologico, como el dolor pelvico cronico y la cistitis intersticial. Diversos grupos de cirujanos digestivos estan optando por esta tecnica para el tratamiento de patologia rectal (estrenimiento, disfuncion esfinteriana). Este trabajo aporta nuestra experiencia en el tratamiento de pacientes con DMC y los resultados comparativos al ano del implante de todos los pacientes. Material Y Metodos Desde diciembre de 1998 a julio del 2003 hemos realizados 18 implantes definitivos de neuromodulacion. La indicacion principal fue la DMC, en un 62,5% de los pacientes. El seguimiento de los pacientes lo realizamos al mes, tres meses, y posteriormente cada seis meses. Este se realiza mediante diario miccional y cuestionario de calidad de vida. El implante del electrodo en los 16 primeros pacientes se ha realizado mediante cirugia abierta, mientras que los 2 siguientes se ha colocado el electrodo mediante tecnica percutanea, utilizando el kit “Tined Lead”. Resultados Comparamos resultados al ano del implante en todos los pacientes. Se han realizado 18 implantes de neuromodulacion de los cuales 14 (77,7%) han sido en mujeres y 4 (22,3%) en varones. La edad media es de 52,56 anos. La indicacion del implante en un 72,2% de los pacientes fue por DMC, un 22,1% por incontinencia mixta (urinaria y fecal), y un 5,5% fue por cistopatia intersticial. La mejoria de los sintomas al ano del implante, medidos por el calendario miccional y el cuestionario de calidad de vida fue de 76,4%. La mejoria clinica fue mayor en los pacientes con sintomas de urgencia, que los pacientes con predominio de la sintomatologia de vaciado.

Acquired cystic renal disease (A.C.R.D.) is a risk factor for the development of renal carcinoma in the patient's own kidney after renal transplant (R.T.), development of a primitive tumor in the renal graft is infrequent, but the presence of metastasis of an epithelial tumor is very rare. This is the second case reported in the literature of metastasis of an epithelial tumor in the renal graft and the first case described of renal cell carcinoma metastasis (R.C.C.) in the renal graft. This paper describes the case of a patient with a normally functioning renal transplant and A.C.R.D. who develops RCC in his own kidney, with metastasis in the renal graft.

The authors explain the third and last phase in the surgical process, the post-operative phase. The authors propose a standardized model of nursing care for children and adolescents. The third and last phase in the surgical process commences at the moment the child arrives in the recovery room and lasts until he/she is released from the hospital. This phase includes the treatment applied in the recovery room and later in a hospital ward or in the child's home. The authors use the Gordon Functional Health Patterns. Special emphasis is given to the perception-management health pattern, the nutritional-metabolic pattern, the elimination pattern, the exercise-activity pattern, and the cognitive-perception pattern. Of special importance is the vigilance during the first post-operative hours, as well as the child's parenteral nutrition or total parenteral nutrition, TPN, and the evaluation of pain according to the age of the child. The authors select the NANDA (North American Nursing Diagnosis Association) Nursing Diagnoses which appear most frequently in this post-operative phase.

Primary testicular lymphoma is an uncommon testicular tumour that accounts for no more than 9% of all testicular tumours in those series with higher incidence; testicular lymphoma as haematopoietic tumours are also rare accounting for just 1% of all lymphomas; but due to their highly malignant histopathology they may become highly aggressive tumours. Patient age at presentation is over 60 years old which makes it the most frequent tumour for this age group. There is no standard protocol to treat this malignancy due to lack of extensive series. We contribute one case and make a literature review discussing the current therapeutic trends for this disease.

We report a recidive of penis carcinoma after 21 years of surgery.This is the case of a male of 85 years old, with partial penectomy; by epidermoid carcinoma. In physics exploration, that it displays excrecente lesion at level of gland of 1 month of evolution. Biopsy being the result of epidermoid carcinoma reason why is made. Total penectomy, a with cutaneus uretrostomy.The histopathological study of the piece, confirm a epidermoid carcinoma well differentiated.

La enfermedad renal quística adquirida (E.R.Q.A), es un factor de riesgo para el desarrollo de carcinoma renal en los riñones propios, tras el trasplante renal (T.R.). El desarrollo de un tumor primitivo del injerto renal es infrecuente. De otro lado, la incidencia de tumor primitivo en el injerto renal es infrecuente, pero la presencia de metástasis en el de un tumor epitelial es excepcional, siendo este el segundo caso de literatura de metástasis de tumor epitelial en injerto renal; y el primer caso descrito de metástasis de carcinoma de células renales (C.C.R.), sobre injerto renal. El caso de un paciente con TR normofuncionante y ERQA que desarrolla CCR en riñón propio, con metástasis sobre el injerto renal.

We report a new case of sarcomatoid renal cell carcinoma, in a male of 67 years old, with locoregional recidive four months after first surgery, with two episodes of retroperitoneal hemorrhage after second surgery. The objective of this work is to contribute a new case and of doing one revision.

Testicular torsion in adult, is an uncommonly etiology, but we should make differencial diagnosis in every person over thirty years old, with acute scrotum. The wrong diagnosis raises the incidence orchiectomy in adults for vascular etiology. We report a male of 74 years old with acute scrotum and review of the literature.

To report the case of a solitary renal metastasis secondary to hepatocellular carcinoma.We report the case of a 51 year old patient who on abdominal ultrasonography was revealed a left renal tumour and a hepatic mass incidentally. A TAC showed the left renal tumor measuring 17 cm in size, possible involvement of left renal vein and a tumour mass in the right lobe of the liver. A TAC guided fine needle punction aspiration biopsy demonstrated a malignant hepatic lesion compatible with hepatocarcinoma, and malignant renal cells compatible with renal or adrenal carcinoma. Left radical nephrectomy and right hepatectomy was performed.Histopathologic study confirmed the diagnosis of moderately differentiated trabecular hepatocarcinoma with lymph node and left renal metastasis.

Resumen Torsion testicular en el paciente geriatrico. y revision de la literatura: a proposito de un caso La torsion testicular en el adulto, es una nosologia infrecuente aunque debe de entrar dentro del diagnostico diferencial de cualquier adulto de mas de treinta anos, con cuadro de escroto agudo. El retraso e incorrecto diagnostico, aumenta la frecuencia de orquiectomias por procesos vasculares en el adulto frente al nino. Presentamos el caso de varon de 74 anos con escroto agudo, y revision de la literatura.

Resumen “Metastasis Renal De Hepatocarcinoma” Objetivo Presentar el caso de una metastasis renal solitaria secundaria a hepatocarcinoma. Metodo Describimos el caso de un paciente de 51 anos que en ecografia abdominal se descubre incidentalmente una masa renal izquierda y una masa hepatica. En el TAC se objetivo la masa renal izquierda de 17 cm de diametro con posible afectacion de vena renal izquierda y una masa hepatica en lobulo derecho. La PAAF guiada por TAC de ambas masas demostro en higado celularidad maligna compatible con hepatocarcinoma, y en rinon celularidad maligna compatible con carcinoma renal o suprarrenal. Se indico tratamiento quirurgico con nefrectomia radical izquierda mas hepatectomia derecha. Resultado El analisis histopatologico de la pieza mostro hepatocarcinoma trabecular moderadamente diferenciado con metastasis ganglionar y renal izquierda.

Sudden infant crib syndrome in nursing newborns means the syndrome which affects those babies less than one year old whose death can not be explained even after the conclusion of an in depth investigation. This article explains the causes currently provided as possible factors which cause this syndrome, risk factors supported by epidemiological data and preventive measures including the monitoring of babies deemed to be at risk. The authors also specify what this monitoring consists of and they elaborate a proposed nurses' action plan for the newborn and his/her family for those cases in which monitoring is taking place. The authors also present a proposed nurses' action plan in the event of a newborn's death due to this syndrome.