Técnica Alternativa Para A Remoção De Stent Duplo J Em Doentes Pediátricos: Série De 3 Casos

Introduction: Double-J (DJ) ureteral stents are widely used in urological practice for the management of ureteral obstructions. As traditional techniques for ureteral stent removal, such as cystoscopy, may have limitations and associated risks, the development of more cost-effective alternative methods is relevant. In this study, we describe a novel technique for the removal of ureteral stents in three pediatric patients with the diagnosis of ureteropelvic junction (UPJ) stenosis. Case presentation: The surgical technique involves using a Nelaton urethral catheter with a polypropylene 3.0 wire attached. After bladder catheterization, the wire is fixed with two loops, and the bladder catheter is gently rotated and removed, enabling the extraction of the stent connected to the wire loop. Discussion: The described technique was successfully employed in all cases. The surgical procedure was quick, easy to perform, and required minimal sedation. Although other cost-effective methods have been described, there is a lack of larger studies comparing these techniques. Conclusions: Among the different modalities described, the decision regarding the best DJ removal procedure is still controversial and should be individualized, and further comparison between techniques is warranted.  Introdução: Os stents ureterais Duplo-J (DJ) são amplamente utilizados na prática urológica para o tratamento de obstruções ureterais. Como as técnicas tradicionais de remoção de stents ureterais, como a cistoscopia, podem ter limitações e riscos associados, o desenvolvimento de métodos alternativos mais económicos é relevante. Neste estudo, descrevemos uma nova técnica para a remoção de stents ureterais em três doentes pediátricos com diagnóstico de estenose da junção ureteropélvica (JUP). Apresentação dos casos: A técnica cirúrgica envolve o uso de um cateter uretral de Nelaton com um fio de polipropileno 3.0 anexado. Após a cateterização da bexiga, o fio é fixado com dois laços, e o cateter vesical é suavemente rodado e removido, permitindo a extração do stent conectado ao laço do fio. Discussão: A técnica descrita foi utilizada com sucesso em todos os casos. O procedimento cirúrgico foi rápido, fácil de realizar e exigiu sedação mínima. Embora outros métodos económicos tenham sido descritos, há uma falta de estudos mais amplos comparando essas técnicas. Conclusões: Entre as diferentes modalidades descritas, a decisão sobre o melhor procedimento de remoção de DJ ainda é controversa e deve ser individualizada, sendo necessária uma comparação adicional entre as técnicas

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used