Increasing urinary calcium excretion after ceftriaxone and cephalothin therapy in adults: possible association with urolithiasis

In children, stone formation after ceftriaxone (CTRX) therapy by increasing calcium excretion was showed in the literature. In this study, we investigated the effect of CTRX, cephalothin (CP) and ampicillin (AS) therapy on urinary calcium excretion in adults. 180 participants included in the study who divided into six equal groups. The groups were; (1) CTRX therapy in stone free patients, (2) CTRX therapy in patients who have urinary stone; (3) CP therapy in stone free patients, (4) CP therapy in patients with urinary stone, (5) AS therapy in stone free patients, (6) AS therapy in patients with urinary stone. The patients received 2 g/day intravenous CTRX, CP and AS for 5 days in all groups respectively. There were no significant differences in demographic characteristics and blood biochemistry between the groups. Before and 5 days after the antibiotic therapies, the participants were evaluated by 24-h urinary calcium to creatinine ratio. Results were compared between the groups statistically by ANOVA and Tukey test. After drug therapies in group 2 and 4, the excretion of calcium to creatinine ratio in 24-h urine was more than the other groups. We found that both groups of two drugs therapy with or without stones (groups 1, 2, 3, 4), have significantly increased calcium to creatinine ratio in 24-h urine (p < 0.05). We did not find statistically difference in groups 5 and 6, after AS therapy. As a result of the study, we suggest that the patients who have taken antibiotic therapy with CTRX or CP, have an increased risk for the urolithiasis. In addition, we think that these drugs should be used carefully especially in patients with urolithiasis.     

Influence of catheter orientation on lesion formation in bovine myocardium by using an open-irrigated laser ablation catheter

Lesion sizes and quality are crucial for successful catheter ablation procedures. We sought to test the influence of catheter orientation towards the endocardial surface on lesion formation in bovine myocardium by using an open-irrigated laser ablation catheter. Continuous wave 1064-nm laser catheter applications at 15 W (4.5 W/mm²)/30 s, (135 J/mm²), irrigation flow 30 mL/min, were aimed at the left ventricular endocardial surface of bovine myocardium. The catheter was kept in vertical, in slanting (67.5°, 45°, 22.5°), and in flat positions; in flat position, also 60 s of radiation times were applied (n?=?10, each). Lesions were evaluated morphometrically. Maximum depth of lesion was achieved with the catheter in a vertical orientation. Catheter inclination of <22.5 showed a highly significant decrease of lesion depth from 5.6?±?1.1 to 3.7?±?0.5 mm (p?=?0.0001). In a flat catheter position, laser radiation of 30 s achieved the smallest lesions. However, after 60 s of radiation, the flat lesions were similar in depth (p?=?087) and were larger in width (p?=?0.0004) and in volumes (p?=?0.0025) as compared to the lesions achieved with the catheter in vertical position after 30 s of radiation. Steam-pop with intramural cavitation or tissue vaporization with crater formation did not occur. Longer radiation times can achieve larger lesions regardless of catheter orientation. Catheter orientation is not a major determinant for laser ablation lesion size and quality, and a steerable support may not be needed when using the open-irrigated electrode-laser mapping and ablation (ELMA) catheter RytmoLas.     

Radiation-associated cutaneous atypical vascular lesions and angiosarcoma: clinicopathologic analysis of 42 cases

Cutaneous angiosarcoma is a rare but well-recognized complication after radiation therapy. Atypical post-radiation vascular lesions (AVLs) with a benign course have been described recently, but few cases with limited follow-up have been studied so far. A total of 42 cases diagnosed as either radiation-associated cutaneous vascular lesions or angiosarcoma were retrieved from departmental and consultation files from 1995 to 2003. Hematoxylin and eosin-stained sections and clinical as well as follow-up data were evaluated. All patients were female with a median age of 59 years (range, 36-90 years). Presentation ranged from small erythematous/violaceous papules or nodules to large plaques with discoloration located on the chest wall (35), abdomen (2), shoulder, groin, flank, axilla, and lower leg (1 each). Reasons for radiation included breast carcinoma (35 cases) and a variety of other lesions (mainly malignant disease). Size range was 0.1 to 20 cm. Angiosarcomas presented as larger lesions (median, 7.5 cm) compared with AVLs (median, 0.5 cm). The time interval from radiation was significantly shorter for the development of AVL (median, 3.5 years) compared with cutaneous angiosarcoma (median, 6 years). Histologic evaluation revealed 26 lesions meeting criteria for angiosarcoma, ranging from morphologically low-grade to high-grade; 16 cases were classified as AVLs. These were fairly well-circumscribed lesions confined within superficial to mid dermis and composed of complex anastomosing and focally dilated vascular spaces. Some showed prominent hyperchromatic endothelial cells, while others were characterized by areas with a dissecting growth pattern within dermal collagen. Endothelial multilayering was absent. Clinical follow-up, available for 36 patients (range, 2-84 months; median, 17 months), revealed 4 patients who died of disease, 4 patients had systemic metastasis, and 12 patients with local recurrence. All patients with systemic relapse had an initial diagnosis of angiosarcoma. One patient with an AVL had a recurrence at the same site, 3 patients developed additional new lesions, and 1 patient developed multiple small papules on the chest wall, which progressed from an AVL to angiosarcoma. This study outlines the morphologic spectrum of radiation-associated cutaneous AVLs. No adverse outcome has been observed so far in this more benign subset of cases, but longer-term follow-up is necessary.     

HAROW: the first comprehensive prospective observational study comparing treatment options in localized prostate cancer

Purpose

To collect data on primary treatment decision and follow-up in patients with diagnosed, histologically confirmed localized (T1a–T2c/N0/M0) prostate cancer (PCa) for up to 5 years in a prospective observational non-interventional study.

Methods

Patients were non-randomly allocated to one of the five treatment strategies: hormone therapy, active surveillance, radiation, operation, or watchful waiting.

Results

A total of 3169 patients were included by 259 participating sites; 2957 patients had at least one follow-up visit. 54.8 % of tumors at baseline were staged as T1c, 38 % as T2a–T2c, and 7.1 % as T1a or T1b (missing: 0.2 %). 38.9, 32.6 and 26.6 % of patients were classified as low risk, intermediate risk, and high risk according to d’Amico, respectively (missing: 1.8 %). 56.6 % of patients underwent prostatectomy as primary therapy, 16.4 % received radiation, 6.9 % HT, 15.8 and 4.3 % decided for AS or WW. Mean follow-up was 28.4 months. Progression rates were between 8.6 % (RT) and 33.1 % (AS).

Conclusion

Whereas RP remains the main treatment option of localized PCa, active surveillance appears to become an accepted and selectively employed treatment option. Careful selection of patients is documented by the highest proportion of patients with low risk (82.5 %), PSA density <0.2 ng/ml/ml (77.5 %), T1 staging (83.6 %), Gleason score ≤6 (92.5 %), ≤2 positive biopsies (79.4 %), and lowest mean PSA (5.8 ng/ml) in the AS group. The relatively high progression rate in the AS group has to be considered in the context of treatment changes; 71/155 patients had a documented change of treatment and 62 of them with a follow-up period of >3 months.

     

The diminishing role of surgery in the treatment of gastric lymphoma

OBJECTIVE: This article reviews the pathogenesis, diagnosis, and treatment of patients with primary gastric lymphoma, with special attention to the changing role of surgery. SUMMARY BACKGROUND DATA: Primary gastric lymphomas are non-Hodgkin lymphomas that originate in the stomach and are divided into low-grade (or indolent) and high-grade (or aggressive) types. Low-grade lesions nearly always arise from mucosa-associated lymphoid tissue (MALT) secondary to chronic Helicobacter pylori (H. pylori) infection and disseminate slowly. High-grade lesions may arise from a low grade-MALT component or arise de novo and can spread to lymph nodes, adjacent organs and tissues, or distant sites. METHODS: A review of the relevant English-language articles was performed on the basis of a MEDLINE search from January 1984 to August 2003. RESULTS: About 40% of gastric lymphomas are low-grade, and nearly all these low-grade lesions are classified as MALT lymphomas. For low-grade MALT lymphomas confined to the gastric wall and without certain negative prognostic factors, H. pylori eradication is highly successful in causing lymphoma regression. More advanced low-grade lymphomas or those that do not regress with antibiotic therapy can be treated with combinations of H. pylori eradication, radiation therapy, and chemotherapy. Nearly 60% of gastric lymphomas are high-grade lesions with or without a low-grade MALT component. These lymphomas can be treated with chemotherapy and radiation therapy according to the extent of disease. Surgery for gastric lymphoma is now often reserved for patients with localized, residual disease after nonsurgical therapy or for rare patients with complications. CONCLUSION: The treatment of gastric lymphoma continues to evolve, and surgical resection is now uncommonly a part of the initial management strategy.     

Pregnancy in women with Alport syndrome

Background

Little is known about pregnancy in women with Alport syndrome (AS), as only four cases have been reported in the literature. We herein describe the course of pregnancy in two sisters with overt forms of AS.

Cases

Both women were diagnosed as having autosomal recessive AS. Before pregnancy, their renal function and their blood pressure were normal, and proteinuria values were below 2 g/24 h. Both patients faced a progressive and remarkable increase in proteinuria during pregnancy, with subsequent hypoproteinemia. The clinical condition worsened, particularly in the first case, who was managed with some success with a combination of diuretics. She delivered at 32 weeks of pregnancy. The second patient was less challenging and she delivered at 36 weeks. Proteinuria returned to pre-pregnancy levels in both cases, after delivery.

Conclusion

Management of pregnant women with overt AS is challenging and worsening of renal disease has to be expected. The use of diuretic therapy may be of benefit.     

Cyclosporine A treatment in patients with Alport syndrome: a single-center experience

Limited and discordant data are available on cyclosporine A (CsA) treatment for proteinuria in Alport syndrome (AS). To address this lack of consistent data, we have studied 15 AS patients (14 males; mean age 15.3?±?6.0 years) treated with CsA. Patient selection criteria included a urinary protein/creatinine ratio ≥1 mg/mg and a creatinine clearance >40 ml/min/1.73 m². CsA treatment was started at an initial dose of 5 mg/kg/day and subsequently adjusted to reach target C2 levels of 500 ng/ml. Renal function, proteinuria, and blood pressure were monitored. Blood pressure was treated to avoid the administration of angiotensin converting enzyme or angiotensin receptor blockers for the first 2 years of therapy. The average follow-up was 3.5 years. Five patients had chronic renal failure at the beginning of treatment, of whom three and one reached end-stage renal failure within 1 and 3 years, respectively. In the remaining 11 patients, the glomerular filtration rate declined by 11?±?6% within 6 months, but remained stable thereafter. Proteinuria decreased by 63?±?21% from baseline, but returned nearly to baseline after 2.5 years of follow-up. Based on these results, we suggest that CsA is effective in reducing proteinuria in patients with Alport syndrome but that this effect is temporary. Our data do not support the use of CsA therapy for proteinuric patients with AS, particularly if they have chronic renal failure.     

A comparative assessment of active surveillance for localized prostate cancer in the community versus tertiary care referral center

Objectives

To date, evidence on active surveillance (AS) is restricted to protocol-based studies. Conversely, practice patterns outside of such protocols are unknown. The aim of this study was to capture the current AS treatment patterns for localized prostate cancer in patients managed by office-based urologists compared to patients treated at a tertiary care center.

Methods and materials

Two prospective cohorts were investigated: 361 AS arm patients of the German Hormonal treatment, Active surveillance, Radiation therapy, OP, Watchful waiting (HAROW) study, an observational health service study and 387 protocol-based AS patients treated at the Department of Urology of the Kantonsspital Aarau, Switzerland were included. Observational non-protocol HAROW versus on-protocol Kantonsspital Aarau (KSA) was compared, and active-treatment-free survival represented the primary outcome.

Results

Study population of the observational HAROW versus tertiary care protocol-based KSA cohorts differed statistically significantly regarding age (p < 0.001) and proportion of patients meeting the Chism criteria (p < 0.001). In stratified analyses, AFTS at 1 and 2 years was, respectively, 87.7 % (95 % CI 84.0–91.7) and 75.0 % (95 % CI 69.7–80.8) in HAROW patients compared to 90.8 % (95 % CI 87.8–93.9) and 75.3 % (95 % CI 70.7–80.1) for patients in the KSA cohort (p = 0.97).

Conclusion

We demonstrate significant differences in terms of AS inclusion, surveillance and discontinuation criteria between patients managed by office-based urologists compared to their tertiary care counterparts. Interestingly, the risk of deferred active therapy was equally moderate for both groups in the short-term follow-up.     

Off-label photodynamic therapy for recalcitrant facial flat warts using topical 5-aminolevulinic acid

The facial flat wart (verruca plana) is one of the most common reasons for dermatology and primary care visits. Although there are many therapeutic modalities, no single therapy has been proven to be completely curative. Case reports and uncontrolled studies suggested that photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA) can effectively treat recalcitrant facial flat warts. A total of 12 patients with recalcitrant facial flat warts were enrolled in the study. ALA gel (10 %) was applied topically to lesions and incubated for 3 h. The lesions were irradiated by an LED light of 630?±?10 nm at dose levels of 60–100 mW/cm. Clinical assessment was conducted before and after every treatment for up to 24 weeks. Among the ten patients completing three sessions of ALA-PDT, five had complete lesions clearance, and the other five patients were significantly improved. At the 24-week follow-up, the average effective rate was 88.8 %, with no recurrences. No significant side effects were reported. A low-dose topical ALA-PDT regimen using 10 % ALA, 3 h incubation, and a red light source for three treatment sessions are suggested as the optimal scheme for the treatment of recalcitrant flat warts on the face in Chinese patients. Superior efficacy is found in elevated or active period lesions with mild side effects.     

Practice in rehabilitation after cartilage therapy: an expert survey

Background

Current cartilage therapy modalities like microfracture, ACT/MACT, AMIC or osteochondral transplantation are important tools to treat symptomatic (osteo)chondral lesions of the knee joint. However, until now there exists no high-level evidence based accepted rehabilitation plan for the postoperative treatment.

Hypothesis/purpose

This survey describes the predominantly used rehabilitation plan as implemented by expert musculoskeletal surgeons for operatively treated (osteo)chondral lesions.

Study design

Survey and systematic review.

Methods

An electronic questionnaire covering general and specific items concerning aftercare following cartilage therapy in the knee joint was designed and disposed to analyze rehabilitation programs among a population of expert musculoskeletal surgeons of the AGA (Society of arthroscopy and joint surgery). All instructors (304 in 01/2011) were included into the survey. A total of 246 (80.9 %) instructors answered the questionnaire.

Results

The predominant used therapy to treat cartilage lesions is microfracture and for osteochondral lesions the osteochondral transplantation. Physiotherapy starts directly after surgery and takes more than 6 weeks. Most surgeons do not immobilize patients after surgery and use partial weight-bearing for up to 5 weeks. The change from partial to full weight-bearing is done step-wise with a 20-kg/week increase. Free ROM is allowed by the majority of instructors (55 %) directly after surgery. A CPM-device is also used directly and up to 5 weeks. Swimming and biking are allowed after 6 weeks, running is allowed after 12 weeks and contact sports after 24 weeks. Most instructors do not use braces in the aftercare procedure, but nearly all (93 %) prescribe crutches. Typical drugs used during the aftercare are NSAID, Heparin and antibiotics. For most instructors (79 % respectively 75 %) knee stability and a straight leg axis are necessary for a successful cartilage therapy. If a concomitant therapy like ACL reconstruction or an osteotomy is performed, aftercare is mainly dependent on cartilage therapy (62 % respectively 59 % of instructors).

Conclusions

Today there exists no detailed rehabilitation program for treatment after a cartilage-related operation on the basis of an evidence-based level I study. The reason might be that many variables contribute to a specific aftercare procedure. Therefore, the survey of experienced surgeons may help to identify the most promising rehabilitation regime for today, at least until evidence-based level I studies are accomplished.     

Atypical vascular lesions after surgery and radiation of the breast: a clinicopathologic study of 32 cases analyzing histologic heterogeneity and association with angiosarcoma

We report the clinicopathologic study of 32 cases of atypical vascular lesions (AVLs) after surgery and radiation of the breast, which were referred to us in consultation over a 17-year period. The patients, all women, ranged in age from 41 to 95 years (mean 61 y). The lesions developed within the radiation field from 1 to 12 years (median 6.0 y) after therapy. They occurred as one (n=18) or more (n=10) flesh-colored papules or erythematous patches/plaques ranging in size from 1 to 60 mm (mean 8.0 mm, median 4.0 mm). Tumors could be divided into 2 histologic types: a lymphatic type (LT) (n=22) and a vascular type (VT) (n=10). LT AVLs consisted predominantly of thin-walled, variably anastomosing lymphatic vessels that were usually confined to the superficial dermis but occasionally extended into the deep dermis and even subcutis. The VT (n=10) typically consisted of small, irregularly dispersed, often blood-filled, pericyte-invested, capillary-sized vessels involving the superficial or deep dermis. VTs were often associated with extravasated erythrocytes, hemosiderin, and a surrounding minor LT component. In 4 cases, endothelial atypia, consisting of nuclear and nucleolar enlargement, was noted. Follow-up of 21 patients with LT AVLs (1 to 106 mo; mean 47 mo) disclosed recurrence/additional lesions in 6, all of whom had additional surgery. Of the 21 patients, 17 are alive without disease, 1 is alive with disease, 1 died of breast carcinoma, 1 died of unknown causes, and 1 showed progressive histologic changes in the AVLs over a period of 5 years resulting in a well-differentiated angiosarcoma. Follow-up in 8 patients with VT AVL (2 to 181 mo; mean 40 mo) disclosed that 6 were alive and well, but 2 of the 4 patients whose lesions displayed endothelial atypia had additional complications. One patient underwent a mastectomy that revealed extensive residual AVL and the second developed a high-grade angiosarcoma after 14 months. We conclude that AVLs encompass a wider spectrum of changes than previously appreciated, ranging from superficial lymphatic proliferations to more complex lymphatic and capillary vascular lesions. There seems to be an association of AVL with angiosarcoma that differs depending on the histologic features, with the VT AVLs having the higher risk. In the 2 patients who developed angiosarcoma, morphologic evidence suggested AVLs to be a precursor rather than simply a risk factor. Future outcome and management studies should take into account these differences.     

Utility of anterior vaginal wall length measurement in vaginal reconstructive surgery

Introduction and hypothesis

The pelvic organ prolapse quantification system (POP-Q) is the most commonly used method to quantify the extent of pelvic organ prolapse. However, it does not include assessment of anterior vaginal wall length (AVL). The objectives of this study were to characterize AVL and distance to the sacrospinous ligament (SSL), and to examine associations between total vaginal length (TVL), AVL, body mass index (BMI) and age.

Methods

This was a retrospective chart review of 139 patients with cervix in situ presenting during an 8-month period for initial evaluation to the University of Rochester Medical Center Urogynecology practice. AVL, TVL and distance to the SSL were measured in addition to POP-Q measurements. Age, height, BMI, presenting complaint and prolapse stage were obtained from medical records. Simple linear regression was used to assess the relationship between TVL and AVL. Multivariate regression was used to test independent variables.

Results

The mean?±?SD TVL, AVL and distance to the SSL were 9.4?±?1.2 cm, 7.4?±?0.9 cm and 7.2?±?0.9 cm, respectively. All three measurements approached a normal distribution. TVL decreased slightly with age. No association was found between vaginal length and BMI or parity.

Conclusions

AVL is a useful measurement that may aid in surgical decision-making. Providers should consider using AVL when planning sacrospinous hysteropexy.

     

Quality of life and fecal incontinence after transanal endoscopic microsurgery for benign and malignant rectal lesions

Background

Transanal endoscopic microsurgery (TEM) is a minimally invasive treatment used to excise a variety of rectal lesions. Potential overstretching of the sphincter’s musculature due to dilation of the anal canal to allow placement of a 40-mm-wide scope combined with partial resection of the rectum and subsequent loss of rectal volume creates a concern regarding anorectal function postoperatively. Data regarding patient satisfaction with anorectal function and quality of life after TEM are scant. This report presents data on patient satisfaction gathered during a period of 10 years.

Methods

A prospectively maintained database of patients undergoing TEM from 1997 to 2007 was queried to identify patients to survey using the Fecal Incontinence Quality of Life Scale questionnaire, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) questionnaire version 3, and a questionnaire designed by the authors to assess satisfaction with quality of life. From a group of 86 patients, 57 (66 %) responded to the questionnaires. Patient satisfaction outcomes were determined by age, preoperative diagnosis, tumor level in the rectum, excision method, and radiation treatment.

Results

Most of the patients (94.7 %) preferred TEM to having a stoma. Age (p = 0.03) and nature of the lesion (p = 0.03) were the only factors that affected coping. Depression was affected only by the presence of malignancy (p = 0.001). Excision method was the only factor that significantly influenced overall lifestyle (p = 0.002). Neither tumor level (p = 0.8) nor radiation therapy (p = 0.9) affected patient satisfaction with lifestyle after TEM. The presence of malignancy (p = 0.004) and full-thickness excision (p = 0.02) were related to more problems with fecal incontinence.

Conclusion

Satisfaction with fecal continence generally is high after TEM. Tumor level, size of tumor, and radiation therapy do not affect the level of satisfaction after TEM. Younger age and benign nature of the lesion help patients to cope better with lifestyle changes and reduce depression. Patients with submucosal excision have a significantly higher level of satisfaction.     

Analysis of active surveillance uptake for low-risk localized prostate cancer in Canada: a Canadian multi-institutional study

Purpose

Although the uptake of active surveillance (AS) appears to be increasing in published series, the uptake in most geographic regions remains largely unknown. Our aim was to examine practice patterns around the use of AS in low-risk prostate cancer in Canada. In addition, we examined regional variations in AS uptake, predictors of AS uptake, and persistent use for 12 months.

Methods

This is a retrospective multicentre review of low-risk patients who underwent a prostate biopsy in 2010 in six centres in four provinces (BC, QC, MB and ON). AS was identified based on chart review and required a minimum of 6 months of follow-up after diagnosis without any active treatment.

Results

Of 986 patients, 781 patients (mean age 64 years) were incident cases and over three-quarters (77.3 %) chose AS at diagnosis. There were significant differences in uptake of AS by centre (range 65.0–98.0 %, p ≤ 0.05). Key multivariate predictors of pursuing AS included older age (OR 1.34, p = 0.044), centre (p = 0.021), lower number of cores (OR 1.09, p = 0.025), lower number of positive biopsy cores (OR 0.52, p < 0.001), and lower percent core involvement (OR 0.84, p < 0.001). In total, 516 (85.4 %) men remained on AS over 12 months. Maintenance with AS over 12 months differed by centre, ranging from 64.1 to 93.9 % (p = 0.001). Predictors of maintenance with AS over 12 months included older age, centre, and lower number of positive cores.

Conclusions

Active surveillance is widely practiced across Canada, but important regional differences were observed. Further analyses are required to understand the root causes of differences and to determine whether AS uptake is changing over time.

     

Contemporary strategy for aortic valve stenosis in octogenarians

The number of patients with aortic stenosis (AS) has been increasing over recent decades with the longer life expectancy of the general population. AS is life-threatening without surgery and since many elderly patients have a variety of comorbid conditions, 30–40 % of those with severe AS have been denied surgery. However, recent data on standard aortic valve replacement (AVR) for octogenarians have revealed excellent outcomes, with 2.4–6.8 % early mortality and similar survival rates of octogenarians who undergo AVR vs. the general population. The reported incidences of postoperative stroke, dialysis, and pacemaker implantation were 2.4, 2.6, and 4.6 %, respectively. Transcatheter aortic valve replacement (TAVR) is the alternative therapy for patients who are not able to undergo standard AVR and it is developing rapidly. The placement of aortic transcatheter valves (PARTNER) trial showed acceptable early outcomes. The mortality rates from any cause were 3.4 % in the TAVR group and 6.5 % in the AVR group at 30 days, 24.2 and 26.8 % at 1 year, and 33.9 and 35.0 % at 2 years, respectively. Stroke rate was higher in the TAVR group than in the AVR group (3.4 vs. 1.9 %). Vascular complications and paravalvular leakage are frequent procedure-related complications, which must be addressed because they are associated with increased mortality.     

Maturational changes in the interdependencies between cortical brain areas of neonates during sleep

This work aims at assessing the maturational changes in the interdependence between the activities of different cortical areas in neonates during active sleep (AS) and quiet sleep (QS). Eight electroencephalography (EEG) channels were recorded in 3 groups of neonates of increasing postmenstrual age. The average linear (AVL) and average nonlinear (AVN) interdependencies of each electrode region with the remaining ones were calculated using the coherence function and a recently developed index of nonlinear coupling between 2 signals in their state spaces, respectively. In theta band, AVL increased with neonate's age for central and temporal regions during QS. In beta band, AVL increased for most cortical regions during QS and a parallel decrease of AVL with neonate's age was found during AS. For all regions, beta AVL was greater in AS than in QS in preterm neonates but the reverse happened in older term neonates. Contrarily to AVL, AVN decreased with age during QS for most cortical regions. Surrogate data test showed that the interdependencies were nonlinear in preterm and younger term neonates but in older term both linear and nonlinear interdependencies coexisted. It is concluded that neonatal maturation is associated with changes in the magnitude and character of the EEG interdependencies during sleep.     

Cyclosporin A may cause injury to undifferentiated glomeruli persisting in patients with Alport syndrome

Background/Aims

Alport syndrome (AS) is a renal disorder caused by a genetic abnormality of type IV collagen α3 and α4, or α5 genes and shows a poor prognosis. Since the defect of type IV collagen synthesis disturbs the maturation process of the glomerular capillary loop, residual immature glomeruli persist after birth. The therapeutic efficacy of cyclosporin A (CyA) for AS patients seems to be controversial. We recently noted that renal specimens obtained from a child with AS who was treated with CyA and then developed CyA nephropathy included an increased number of undifferentiated embryonic-type glomeruli.

Methods

We analyzed renal histologic and immunohistologic findings in children with AS who did (n = 3) or did not (n = 2) develop CyA-induced nephropathy despite appropriately low serum CyA concentrations (<100 ng/mL) being maintained over a period of 2 years. To discriminate embryonic-type from mature glomeruli, staining for type IV collagen α1, laminin β1, and laminin β2 accompanied by light microscopic observation were employed. Staining patterns were used to semiquantitatively assess glomerular immaturity (glomerular immaturity index, or GII).

Results

In initial biopsy specimens, residual embryonic-type glomeruli were observed in each patient. Patients with early-onset CyA nephropathy had a high GII (median value 2.91 vs 1.23 ± 0.62 normal kidney tissues). In the follow-up biopsy after CyA treatment, surviving embryonic-type, collapsing embryonic-type, and sclerotic glomeruli that had failed to differentiate were observed. Taken together, the number of these glomeruli essentially equaled the total number of embryonic-type glomeruli in specimens obtained before CyA treatment.

Conclusions

Our findings indicate a need for caution in CyA therapy for patients with AS, even for a relatively short course of administration, because some patients may have an unexpected number of embryonic-type glomeruli that predispose to CyA nephropathy.     

Transperineal reanastomosis for the treatment for highly recurrent anastomotic strictures as a last option before urinary diversion

Purpose

To evaluate safety and efficacy of open transperineal reanastomosis (TPRA) for highly recurrent anastomotic strictures (AS) after radical prostatectomy. While the majority of AS can be managed successfully by endoscopic treatment, in highly recurrent AS, open reanastomosis represents a viable therapeutic option.

Methods

Retrospective analysis by standardized questionnaire, inquiring for recurrence, incontinence, sexual function, satisfaction and changes in quality of life (QoL) in 15 patients undergoing TPRA 08/2007–03/2010.

Results

Mean patient age was 65 years (51–75) and mean follow-up 20.5 months (5.8–37.0). Success rate was 93.3 % (14/15). The single recurrence was successfully treated by cold knife incision. Incontinence was found in 93.3 % (14/15) preoperatively and aggravated in 60 % (9/15) after surgery; no de novo incontinence occurred. Implantation of an artificial urinary sphincter (AUS) has been performed successfully in 10 patients, 2 refused implantation and 2 are scheduled for surgery. Erectile dysfunction was present in 86.7 % (13/15); 13.3 % (2/15) reported a severely declined rigidity. Compared to preoperative status, 33.3 % (5/15) complained about impaired erectile function after TPRA. A good or very good subjective overall health status and an improvement in QoL were noted in 86.7 % (13/15). Patient satisfaction with the outcome of TPRA was high or very high in 13; two were undecided.

Conclusions

After repeated endoscopic treatment, TPRA is a valuable therapeutic option in selected patients with an overall success rate of 93.3 % (14/15) for anastomotic patency, which can even be raised to 100 % by further transurethral surgery. Incontinence can be easily treated by implantation of an AUS.     

Multimodal treatment strategies for advanced hilar cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common primary malignancy of the liver arising from malignant transformation and growth of biliary ductal epithelium. Approximately 50–70 % of CCAs arise at the hilar plate of the biliary tree, which are termed hilar cholangiocarcinoma (HC). Various staging systems are currently employed to classify HCs and determine resectability. Depending on the pre-operative staging, the mainstays of treatment include surgery, chemotherapy, radiation therapy, and photodynamic therapy. Surgical resection offers the only chance for cure of HC and achieving an R0 resection has demonstrated improved overall survival. However, obtaining longitudinal and radial surgical margins that are free of tumor can be difficult and frequently requires extensive resections, particularly for advanced HCs. Pre-operative interventions may be necessary to prepare patients for major hepatic resections, including endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, and portal vein embolization. Multimodal therapy that combines chemotherapy with external beam radiation, stereotactic body radiation therapy, bile duct brachytherapy, and/or photodynamic therapy are all possible strategies for advanced HC prior to resection. Orthotopic liver transplantation is another therapeutic option that can achieve complete extirpation of locally advanced HC in judiciously selected patients following standardized neoadjuvant protocols.     

Identification of intervertebral disc regeneration with magnetic resonance imaging after a long-term follow-up in patients treated with percutaneous diode laser nucleoplasty: a retrospective clinical and radiological analysis of 14 patients

Purpose

The aim of this study was to demonstrate regeneration of intervertebral discs undergoing laser therapy with sagittal relaxation time (T2) mapping after a long-term follow-up.

Materials and methods

Fourteen patients (9 men, 5 women; age range 20–57 years; mean age 36.5 years) treated with percutaneous 908-nm wave-length diode laser nucleoplasty for lumbar disc prolapsus at our clinic between January 2006 and June 2009 were studied. For the application of laser nucleoplasty in the past, patients who did not have central canal stenosis and/or lateral stenosis, sequestered disc fragment, operation scars and bleeding disorders were selected. The intervertebral disc levels undergoing laser therapy were L3–L4 (n = 2) or L4–L5 (n = 12). Patients were called for follow-up visits after a maximum 6-years (n = 2) or a minimum 3 years (n = 3) with a mean of 4.4 years. The patients’ clinical status for leg pain was evaluated according to the visual analog scale (VAS) and subsequently, a lumbar magnetic resonance imaging was performed. Sagittal T2 mapping was performed for the intervertebral discs undergoing laser nucleoplasty. We analyzed the relationship between T2 in the regions of interest (ROIs), which is known to correlate with changes in the composition of intervertebral discs, and the degree of degeneration determined using the Pfirrmann grading system and VAS of patients.

Results

On the basis of the evaluation of the results of intervertebral discs in all patients, there was a significant increase in T2 in the anterior NP (ROI 2, +10.3 ms; p < 0.05). A significant increase was noted in T2 in the middle NP (ROI 3, +24.6 ms; p < 0.001). The most significant increase was recorded for the posterior NP (ROI 4, +28.6 ms; p < 0.001). No significant decrease was found in T2 in the anterior and posterior AF (ROI 1, ?1.5 ms; p = 0.925; ROI 5, ?0.1 ms; p = 0.683). According to the Pfirrmann grading system, disc degeneration grades before laser therapy were recorded as grade III (n = 6) and grade IV (n = 8) whereas disc degeneration grades after laser therapy were found to be grade I (n = 6) and II (n = 8). A significant decrease was noted in Pfirrmann grades of disc degeneration after laser therapy (p < 0.0005).

Conclusions

In this study, there was a prolongation of T2 indicating regeneration in the nucleus pulposus after laser therapy and these results were found to be consistent with VAS measurements after a long-term follow-up. This study, which demonstrates the quantitative efficacy of laser therapy, indicates that MRG can be more effectively used in the future.