Reduced podocin expression in minimal change disease and focal segmental glomerulosclerosis is related to the level of proteinuria

Background

Glomerular podocyte molecules are involved in the pathogenesis of congenital nephrotic syndrome. However, their role in primary nephrotic syndrome is not clear. This study investigated the expression of nephrin, podocin and synaptopodin in primary nephrotic syndrome.

Methods

Eighty-seven patients with primary nephrotic syndrome including minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MN) and membranoproliferative glomerulonephritis Type I (MPGN) were included in the study. Glomerular expression of nephrin, podocin and synaptopodin was studied in renal biopsies by immunofluorescence and immunohistochemistry. Correlation of expression with clinical and biochemical parameters was performed.

Results

The pattern of expression for all podocyte proteins in controls was uniform fine granular along the capillary walls towards the visceral epithelial cell aspect. Glomerular expression of nephrin was present in all renal biopsies and was similar to that in controls. Glomerular synaptopodin expression was seen in all MN and MPGN patients, while it was seen in 74 % (17/23) MCD and 93.5 % (29/31) FSGS. Reduced synaptopodin expression showed no correlation with clinical and biochemical factors. Podocin expression was present in 5/23 MCD (22 %), 3/31 FSGS (9.6 %), 13/17 MN (76.4 %) and 13/16 MPGN (81 %) patients. The reduced expression of podocin significantly correlated with the degree of proteinuria (p = 0.032). No correlation with age, gender and serum creatinine level was observed.

Conclusion

Reduction of glomerular podocin expression found in MCD and FSGS is related to the amount of proteinuria. Our findings suggest that alteration in podocyte phenotype may not be a primary event and may reflect the degree of podocyte injury in primary nephrotic syndrome.     

Membranoproliferative glomerulonephritis and circulating cryoglobulins

Background

Previous studies on membranoproliferative glomerulonephritis (MPGN) and cryoglobulinemic glomerulopathy (CG) were based upon case series that were performed before hepatitis C virus (HCV) infection was routinely investigated. Therefore, it remains unknown how far HCV contributes to MPGN or CG, and there have only been a few reports about HCV-negative idiopathic MPGN.

Patients and methods

Thirty-five patients with MPGN diagnosed by renal biopsy who underwent examination for HCV infection at our institute between 1990 and 2008 were recruited for this study. Patients with HCV infection at presentation were included, but patients with complications such as underlying lymphoproliferative disorders, autoimmune diseases like lupus nephritis, infection, and liver disease due to hepatitis B virus or alcohol abuse were excluded. A total of 35 patients were enrolled and they were divided into two groups according to the presence/absence of circulating cryoglobulins (cryo). The 23 patients who had cryo-negative and HCV-negative idiopathic MPGN were divided into subgroups with type 1 and type 3 disease.

Results

In the cryo-positive group (n = 9), 7 patients were positive for HCV infection, while 2 patients were negative. In the cryo-negative group (n = 26), 3 patients were positive for HCV infection, while 23 patients were negative (idiopathic MPGN). Compared with the cryo-negative group, the cryo-positive group had several characteristics such as more severe thrombocytopenia, higher serum immunoglobulin (Ig)G and IgM levels, lower levels of hemolytic complement (CH50) and complement component (C)4, predominant IgM staining, and type 1 histology. Patients with cryo-negative and HCV-negative ‘idiopathic’ MPGN showed predominant staining for IgG in both type 1 and type 3 cases, unlike the predominant staining for IgM in the cryo-positive group. Compared with type 3 cases, type 1 cases had a younger age, lower levels of CH50, C3 and C4, and less proteinuria. In the cryo-positive group, 4 patients (44.4 %) died, with death from B cell lymphoma and liver failure in 2 patients each, while 1 patient (8 %) developed end-stage renal failure requiring dialysis. In contrast, all patients in the cryo-negative group remained alive during follow-up, although 4 patients (2 type 1 cases and 2 type 3 cases) required dialysis.

Conclusion

Cryo-positive MPGN shows a close relationship with HCV infection and IgM, resulting in a poor prognosis. Cryo-negative and HCV-negative idiopathic MPGN has a close relationship with IgG staining, and type 1 cases feature characteristics such as a younger age, more severe hypocomplementemia, and less proteinuria than in type 3 cases.     

Evolution of immunoglobulin deposition in C3-dominant membranoproliferative glomerulopathy

Background

Complement 3 glomerulopathy (C3GN) is a newly proposed subcategory of glomerular disease with features including membranoproliferative glomerulonephritis (MPGN), C3-dominant immunofluorescent staining without appreciable immunoglobulin deposition, and electron-dense deposits. Aberrations of alternative complement pathway (AP) have been found in many C3GN patients.

Case-diagnosis/treatment

A 13-year-old boy presented with edema in association with an upper respiratory infection. Studies demonstrated nephrotic syndrome with hematuria and markedly low C3 and C4. Initial renal biopsy showed MPGN with strong C3 and immunoglobulin deposition. The patient partially responded to immunosuppression. Follow-up biopsies at 10 months and 3 years demonstrated MPGN with strong C3, with little to no immunoglobulin deposition. Based on this and elevated SC5b-9, treatment was changed to eculizumab with further decrease in proteinuria.

Conclusions

Serial biopsies illustrated marked variability in immunoglobulin deposition in MPGN with persistently strong C3 deposition. Whether this evolution was related to the course of disease or to therapeutic intervention, the pathologic progression documented in this series of biopsies challenges the newly proposed subcategories of MPGN.     

Clinical features and pathogenesis of membranoproliferative glomerulonephritis: a nationwide analysis of the Japan renal biopsy registry from 2007 to 2015

Background

The incidence and age distribution of membranoproliferative glomerulonephritis (MPGN) vary throughout the world by race and ethnicity. We sought to evaluate the clinical features, pathogenesis, and age distribution of MPGN among a large nationwide data from the Japan Renal Biopsy Registry (J-RBR).

Methods

A cross-sectional survey of 593 patients with MPGN (types I and III) registered in the J-RBR between 2007 and 2015 was conducted. Clinical parameters, and laboratory findings at diagnosis were compared between children (<?20 years), adults (20–64 years), and elderly patients (≥?65 years).

Results

The median age of the patients was 59.0 years and mean proteinuria was 3.7 g/day. The rate of nephrotic syndrome was significantly higher in adults (40.4%) and elderly patients (54.0%) than in children (14.9%), whereas the rate of chronic glomerulonephritis was significantly higher in children (66.2%) than in adults (34.4%) and elderly patients (31.2%). According to the CGA risk classification, high-risk (red zone) cases accounted for 3.4% of children, 52.5% of adults and 84.1% of elderly patients with MPGN. As for pathogenesis, primary MPGN was most frequent (56.0%). Lupus nephritis was the most common disease among adult patients with secondary MPGN, whereas infectious disease was more common in elderly patients. Multiple regression analysis revealed that high systolic blood pressure and high proteinuria were independent factors associated with decreased estimated glomerular filtration rate (eGFR) in adults and elderly patients with MPGN.

Conclusions

In Japan, adults and elderly patients with MPGN had a lower eGFR and severer proteinuria than children.

     

Positive C1q staining associated with poor renal outcome in membranoproliferative glomerulonephritis

Background

Pathogenesis and clinical prognosis of membranoproliferative glomerulonephritis (MPGN) has not yet been established.

Methods

We conducted a retrospective study of 41 patients with MPGN (type I and III) and examined the renal survival. In addition, factors contributing to survival time were analyzed.

Results

Fourteen patients (34 %) were classified into the renal death group. Patients with nephrotic syndrome and positive C1q staining of glomerular deposits showed a particularly poor prognosis. Significantly higher frequency of nephrotic syndrome and higher urinary protein excretion were observed in the renal death group (p = 0.0002, p = 0.0002) than in the renal survival group. The intensity of C1q staining was positively correlated with the severity of the proteinuria (p = 0.004). Factors that influenced the survival time were positive C1q staining of glomerular deposits (p = 0.003), presence of nephrotic syndrome (p = 0.004), serum albumin (p = 0.02), and proteinuria (p = 0.04).

Conclusions

C1q staining in glomerular deposits and nephrotic syndrome were important factors influencing the prognosis and outcome in MPGN patients. C1q deposition may play a key role in the pathogenesis of MPGN, as evidenced by numerous observations, such as induction of proteinuria.     

A Comparison of Clinical and Pathologic Assessments for the Prediction of Occult Nipple Involvement in Nipple-Sparing Mastectomies

Background

Nipple-sparing mastectomy (NSM) for both risk reduction and cancer is increasing. In the cancer setting, most studies suggest the use of both clinical and intraoperative biopsy criteria in patient selection. This study examines the use of both biopsy and clinical criteria in women undergoing total nipple-removing mastectomy.

Methods

The study consisted of 58 patients undergoing total mastectomy without nipple sparing. Biopsies of the subareola tissue (SA), proximal nipple (NC) contents and radial sections of the residual nipple (NR) were examined microscopically. Tumor size and distance from the nipple were also noted.

Results

Using clinical criteria alone, the false negative rate was 53.8 % and a false positive rate of 44.4 %. When adding subareola and nipple core biopsies to clinical criteria the false negative rate fell to 7.7 % but the false positive rate remained at 44.4 %. When using only SA and NC biopsies to predict occult nipple involvement, the false negative rate was 11.8 %. In 4 cases the NC was positive while the SA was negative for cancer and in 6 cases the SA was positive and NC negative. In 2 cases both the NC and SA biopsies were negative while the NR was positive.

Conclusions

This study supports a more limited role in the use of clinical criteria for evaluating patients for NSM. This maximizes the number of patients who are candidates for NSM with minimal risk of nipple involvement. It was also noted that intraoperative biopsies are not totally reliable in predicting occult nipple involvement.     

Surgical Versus Nonsurgical Treatment of Infected Pancreatic Necrosis: More Arguments to Change the Paradigm

Objectives

This study aimed to compare primary surgical versus nonsurgical treatment in a series of patients with infected pancreatic necrosis (IPN) and to investigate whether the success of nonsurgical approach is related to a less severe disease.

Methods

Thirty-nine consecutive patients with IPN have been included and further subdivided into two groups: primary surgical (n?=?21) versus nonsurgical (n?=?18). Outcome measures were the differences in mortality, morbidity, and pancreatic function. Comorbidity, organ failure, and other severity indexes were compared between the two groups.

Results

Mortality occurred in 16.7 % of cases in the nonsurgical group versus 42.9 % in the surgical group. In the primary nonsurgical group, seven were operated on due to failure of initial conservative treatment. In this latter group, mortality was 28.6 % and was performed significantly later than in the primary surgical group. The group of primary surgical treatment was associated with a significant higher rate of multiple organ failure (MOF) at IPN diagnosis, new onset or worsening of organ failure, and MOF and nosocomial infection after surgery.

Conclusions

Initial nonsurgical approach in IPN is associated with better results both in cases which respond to this treatment as well as in those who, failing this conservative approach, have to be operated on after a delayed period. Primary surgically treated patients had a more severe disease at the time of IPN.     

Our experience with rituximab therapy for adult-onset primary glomerulonephritis and review of literature

Background

B cell-targeted immunosuppression with rituximab as primary treatment or when conventional therapy is contraindicated or unsuccessful can induce remission in idiopathic membranous nephropathy (IMN). We explored the efficacy and safety of rituximab therapy in an adult population with IMN and other primary glomerulonephritides.

Method

This study is a single-centre retrospective case review of 24 adult patients who received rituximab (RTX) for IMN (n = 11), minimal change disease (MCD, n = 7), focal segmental glomerulosclerosis (FSGS, n = 4), and membranoproliferative glomerulonephritis (MPGN, n = 2). Outcomes included the proportion of patients with complete and partial remission, frequency of relapse, the amount of post-RTX immunosuppression, and toxicity.

Results

The median follow-up for all patients was 31.5 months (IQR: 15.0–44.0). Rituximab therapy induced remission in 19/24 (79.2 %) patients (IMN: 63.6 %, MCD: 100 %, FSGS: 75 %, and MPGN: 100 %). Disease recurrence in patients with ≥3 relapses pre-RTX therapy (MCD, n = 6 and FSGS, n = 1) decreased from 37.0 to 19.6 events per 1,000 patient-months. All patients with steroid maintenance, discontinued or achieved at least a 50 % dose reduction at 3.0 months (IQR: 1.5–8.0) post-treatment. One patient ceased CSA in addition to a 50 % steroid dose reduction 13 months post-RTX. Rituximab was well tolerated with a single serious infection (4.2 %) responsive to treatment.

Conclusions

Rituximab induced remission in IMN comparable with published reports but had an additional benefit in inducing remission in other common glomerulonephritides. Additional randomized studies are needed to confirm its potential therapeutic benefit and optimal dosing for adult-onset primary glomerulonephritis.     

Prostatic biopsies in selected men aged 75 years and older guide key clinical management decisions

Purpose

Increasing life expectancy and PSA testing has increased the number of men over the age of seventy-five presenting for investigation of potential prostate malignancies. Prostatic biopsies provide diagnostic information; however, they are invasive and may not alter management decisions. Therefore, this study aimed to investigate whether prostate biopsies in this age group were justified.

Materials and methods

All men aged 75 years and older who underwent prostatic biopsies between January 2010 and November 2011 at Bedford Hospital were identified and the indication for the biopsies, histopathological results and subsequent management plan investigated.

Results

One hundred and thirty-eight (138) prostatic biopsies were undertaken and malignancies identified in 60/138 (43 %) cases. Prebiopsy PSA and examination findings had a poor positive predictive value of 54 %. Fifty-five out of sixty (92 %) cancers were classified as high or medium risk disease with 30/60 (50 %) patients commencing radiotherapy treatment with curative intent.

Conclusion

In selected patients aged 75 years or over, prostatic biopsies provide important diagnostic information which directly impacts on clinical decisions, supporting their use in this age group.     

Open reduction and internal-fixation versus radial head replacement in treatment of Mason type III radial head fractures

Purpose

The purpose of this study was to demonstrate whether open reduction and internal-fixation (ORIF) was superior to radial head replacement in treatment of Mason type III radial head fractures by comparing postoperative complication rate and satisfactory rate.

Methods

Clinical trials comparing ORIF with radial head replacement for Mason type III radial head fractures were reviewed published up to September 1, 2012. Methodological quality of each included trials was assessed using the Jadad scale. The analyses were performed with Cochrane RevMan software version 5.1.

Results

One prospective randomized controlled trial and one comparative study involving 67 patients with 67 cases were included in this systematic review and meta-analysis. Both the forest plots of complication rate and satisfactory rate indicated statistical differences between the two surgical techniques in treatment of Mason type III radial head fractures. The complication rate was 13.9 % in patients treated with radial head replacement and 58.1 % in patients treated with ORIF. The satisfactory rate was 91.7 % in patients treated with radial head replacement and 51.6 % in patients treated with ORIF.

Conclusions

Given the available evidence, radial head replacement appeared to reach better outcomes in patients with Mason type III radial head fractures followed 5 years or less.

Level of evidence

Therapeutic II.     

Do surgeon credentials affect the rate of incidental durotomy during spine surgery

Purpose

Incidental durotomy is a potential complication of spinal surgery which can cause a number of intra-operative and post-operative complications. The purpose of this study was to determine if the primary operator’s credentials impacted on the incidence of durotomy intra-operatively.

Methods

Prospectively collected data of operator credentials in relation to the incidence of durotomy were acquired from the International Eurospine Tango database. The significance of variability and risk factors between operators was measured using the Chi-squared test.

Results

Data from a total of 3,764 patients were captured from the Tango registry. Of these 162 (4.3 %) had a durotomy. Of the total number of patients, the primary operator was neurosurgical in 1,369 (36.4 %) cases; orthopaedic in 180 (4.8 %) cases; other (pre-certification) in 236 (6.3 %) cases; specialised spine surgeon in 1,741 (46.3 %) cases; 6 cases had missing operator data. cerebrospinal fluid (CSF) leak occurred in 57 (4.16 %) of neurosurgeon-operated cases; 5 (2.78 %) orthopaedic-operated cases; 19 (4.06 %) of other surgeon-operated cases; and 81 (4.65 %) in specialised spine surgeon-operated cases. Using Chi-squared test, the significance of the variation in incidence of CSF leak between primary operator groups was not statistically significant (P = 0.1405).

Conclusion

From the data captured and analysed, the rate of durotomy ranged from 2.78 to 4.65 % between operator groups with a mean rate of 4.3 %. The primary operator credentials do not appear to significantly impact the rate of durotomy in spine surgery.     

Effects of strontium on the quality of bone apatite crystals: a paired biopsy study in postmenopausal osteoporotic women

Summary

In paired biopsies of osteoporotic women treated with either strontium ranelate or a placebo for 36 months, characteristics of bone apatite crystals were not influenced by the presence of strontium. The mean rate of substitutions of calcium by strontium ions was 4.5 %.

Introduction

The potential effect of strontium (Sr) on bone apatite crystals was investigated in paired biopsies of osteoporotic women treated with either strontium ranelate (SrRan) or a placebo for 36 months.

Methods

In ten paired biopsies, crystallinity, apparent length and width/thickness of crystals, interplanar distances, and lattice parameters of unit cells were assessed by X-ray diffraction and selected area electron diffraction.

Results

All these parameters, reflecting crystal and unit cell characteristics, were not influenced by the presence of Sr and were similar in SrRan and placebo groups after 36 months of treatment. The mean rate of substitutions of calcium by Sr ions was 4.5 %.

Conclusion

Overall, the quality of bone apatite crystals was maintained after 36 months of treatment with SrRan.     

Differential regulation of MMP-2 in the gastrohepatic ligament of the gastroesophageal junction

Introduction

Ligamentous attachments maintain the normal anatomic position of the gastroesophageal (GE) junction. Failure of these elastic ligaments through an alteration in collagen synthesis, deposition, and metabolism may be a primary etiology of hiatal hernia formation. Differential expression of zinc-dependent matrix metalloproteinases (MMPs) is largely responsible for collagen remodeling. The purpose of this study was to survey baseline levels of MMPs in supporting ligaments of the GE junction from patients without hiatal hernia.

Methods

Following an institutional review board-approved protocol, plasma and tissue biopsies of the gastrohepatic ligament (GHL), gastrophrenic ligament (GPL), and phrenoesophageal ligament (PEL) were obtained in six patients without a hiatal hernia during laparoscopic anterior esophageal myotomy for achalasia. Total protein extracts from tissue biopsies were analyzed for elastases MMP-2, -9, and -12 and collagenases MMP-1, -3, -7, -8, and -13 using a multiplex profiling kit (R&D Systems, Minneapolis, MN). Data are reported as mean ± standard deviation. Statistical significance (p < 0.05) was determined using Tukey’s test and analysis of variance.

Results

In control patients without hiatal hernias, increased levels of MMP-2 (p < 0.02) were detected in the GHL compared with the GPL and PEL, respectively. Tissue levels of MMP-1, -12, and -13 were not detectable.

Conclusions

Gelatinase-A (MMP-2) is present in the GHL and plasma of control patients. The GHL may provide the primary GE junction supporting ligament to compare tissue from patients with type I (sliding) and type III (paraesophageal) hiatal hernias to examine the role of altered collagen metabolism in hiatal hernia formation.     

Infection rates of external ventricular drains are reduced by the use of silver-impregnated catheters

Background

External ventricular drainage (EVD) placement for temporary cerebrospinal fluid (CSF) diversion is a frequent therapeutic procedure. Several types of EVD catheters are currently available, some of which have an antibacterial effect. This study compares the rates of CSF infections in patients with different types of EVD catheters.

Methods

This is a retrospective study of 403 patients with a total of 529 implanted EVDs. We analyze the occurrence of EVD-associated infections, microbiological diagnosis, type of EVD catheter (plain polyurethane vs. silver-impregnated), duration of CSF diversion, primary disease, and outcome.

Results

There were a total of 29 patients with EVD infections in the whole study group (7.1 %). A pathogen was detected in all cases. Coagulase-negative staphylococci were detected most frequently (20 out of 29 cases, 70 %). The rate of infections by catheter type was 7.6 % (11 of 145) and 13.8 % (4 out of 29) for two different types of non-coated polyurethane catheters. Silver-impregnated polyurethane catheters became infected in 6.1 % (14 out of 228). The differences between non-coated and silver-coated catheters were statistically significant.

Conclusions

This study provides comparative data on EVD infections with regard to the type of catheter. Silver-impregnated catheters showed significantly lower infection rates when compared to non-impregnated catheters. The results are critically discussed and compared with the published literature.     

The threat of misdiagnosis of primary osteosarcoma over the age of 60: a series of seven cases and review of the literature

Background

Osteosarcoma is the most common, non-haematopoietic, primary malignant bone tumour with an incidence of 0.3–0.5 per 100,000. There is some discrepancy in literature concerning the peaks of incidence of osteosarcoma. Some describe only one peak which arises in adolescence, whilst others report a bimodal age distribution with a second peak over the age of 60. In this retrospective study, we evaluated osteosarcoma patients over age 60 treated at our department and reviewed previous studies from the literature.

Patients and methods

Sixty-four patients (40 male, 24 female) with a mean age of 29 years (from 7 to 82) were treated for primary osteosarcomas. At the time of diagnosis, seven patients (two male and five female) were over 60 years of age with a mean follow-up of 46 months after definite diagnosis.

Results

Three out of seven osteosarcomas were primarily radiologically or histologically misdiagnosed, but only one was mistreated with intramedullary nailing at a trauma centre. At last follow-up, two patients had died from the disease, three were alive with disease, and two had no evidence of osteosarcoma.

Conclusions

We did not find an increased incidence of primary osteosarcoma in the elderly; yet, older patients had a higher rate of misdiagnosis due to untypical radiological findings in combination with longer times from the onset of first symptoms to definite diagnosis. In cases of pathological fracture, it is essential to assess whether it is caused by mechanical stress or a primary or secondary tumour before leading into mistreatment, especially in older patients.     

Clinical outcomes of Kyocera Modular Limb Salvage system after resection of bone sarcoma of the distal part of the femur: the Japanese Musculoskeletal Oncology Group study

Purpose

The Japanese Musculoskeletal Oncology Group have developed an original prosthesis called the Kyocera Modular Limb Salvage system (KMLS system). This prosthesis has a semi-rotating hinge joint and is particularly designed for people with an Asian body type. The metallic parts of the prosthesis are made entirely of titanium alloy. The purpose of this study is to evaluate the clinical outcomes of treatment using this system following tumour resection of primary bone sarcoma of the distal femur.

Methods

Between 2002 and 2010, 82 patients with primary bone sarcomas of the distal femur were treated. Seventeen patients underwent stem cementation, while 65 patients were treated with cementless prostheses. The mean follow-up period after surgery was 61 months.

Results

Complications were observed in 28 of the 82 patients. Forty-one complications occurred in these 28 patients. Thirteen prostheses (16 %) required revision surgery due to complications, including five cases of stem breakage, three deep infections, three cases of aseptic loosening, one case of displacement of the shaft cap and one case of breakage of the tibial tray. The five-year overall prosthetic survival rate was 80.0 %. Four of the 82 patients underwent subsequent amputation due to local recurrence. The five-year limb salvage rate was 94.5 %. The mean function score according to the scoring system of the Musculoskeletal Tumour Society was 21.8 points (72.5 %).

Conclusions

Although further follow-up is required to determine the performance, this prosthesis is considered to be satisfactory for reconstruction of the distal femur after resection of bone sarcoma.     

Effect of MRI on the Management of Ductal Carcinoma In Situ of the Breast

Introduction

The accuracy of breast magnetic resonance imaging (MRI) for detection of ductal carcinoma in situ (DCIS) has prompted recommendations for its routine preoperative use, but its clinical benefit is debated. We reviewed our experience with MRI in DCIS patients to assess the utility of MRI for surgical planning.

Methods

DCIS patients (2008–2010) were identified through a prospectively maintained database and grouped into MRI and no-MRI groups. The rates of additional biopsies, altered surgical management, and reoperation were compared. Additionally, DCIS size ascertained by mammography, MRI, and final pathology was compared.

Results:

Of 352 DCIS patients, 217 received MRI and 135 did not. The type of initial operation and number of reoperations were similar between the two groups, but successful breast conservation was more frequent in the no-MRI group (p = 0.06). The additional biopsy rate was 38 % in the MRI group versus 7 % in the no-MRI group; ≥2 additional biopsies were performed in 18 % of the MRI group and 2 % of the no-MRI group (p < 0.0001). These yielded a cancer diagnosis in 26 % of MRI and 33 % of no-MRI patients (p = 0.73). MRI was not superior to mammogram in detecting size of DCIS lesions preoperatively; 52 % of mammograms were accurate (within 1 cm) compared with 41 % of MRIs.

Conclusions

DCIS patients who undergo preoperative breast MRI are far more likely to undergo additional biopsies. Unless these can be demonstrated to lead to improved long-term outcomes, the utility of routine preoperative MRI in DCIS patients remains questionable.     

Obturator hernia: the relationship between anatomical classification and the Howship–Romberg sign

Background

The obturator hernia sac may follow the anterior or posterior branch of the obturator nerve, and thus, it can be classified anatomically. The relationship between the symptoms and the anatomical classification of obturator hernia has not yet been clearly described in the literature.

Methods

Multidetector-row computed tomography (MDCT) examinations of 35 consecutive cases of new-onset obturator hernia admitted from March 2005 to April 2012 were reviewed retrospectively. Obturator hernia was classified anatomically using MDCT. Patient characteristics and clinical presentations were compared among the anatomical classifications.

Results

Fifteen cases were classified as type I (anterior branch type) and 20 cases as type II (posterior branch type). There were no significant differences regarding time from onset of symptoms to diagnosis, presence of small bowel obstruction, and need for bowel resection. The Howship–Romberg sign was seen in 6 cases (30 %) of type II and 10 cases (67 %) of type I (p = 0.044).

Conclusions

The Howship–Romberg sign was present significantly more often with the anterior than the posterior branch type of obturator hernia.     

Incremental value of transition zone and midline apical biopsy at baseline TRUS-guided biopsy for prostate cancer detection

Purpose

To determine the diagnostic yield of transition zone (TZB) and midline apical biopsies (MAB) in baseline transrectal ultrasound (TRUS)-guided biopsies and to establish whether TZB and MAB for the diagnosis of prostate cancer (PCa) add clinical relevant information.

Methods

We performed baseline 9-core TRUS-guided biopsy in 412 consecutive subjects using sextant biopsies of the PZ (PZB), with an additional TZB on either side and a MAB at the prostatic apex. We determined the incremental diagnostic value of additional TZB an MAB to sextant PZB.

Results

Within a cohort of 412 patients with a median PSA of 7.5 ng/ml, 178 (43.2 %) patients were diagnosed with PCa upon baseline TRUS-guided biopsies. In 102 cases, at least one TZB was positive for PCa, with 6/412 (1.4 %) cases displaying PCa in the TZB only. MAB alone was positive for PCa in 4/412 (1.0 %) cases. One case (1/412; 0.2 %) had only a TZB and a MAB positive for PCa without positive PZB. Thus, 11/412 (2.7 %) of cases would not have been diagnosed with PCa at baseline TRUS-guided biopsy had only sextant PZ biopsy been performed. TZB detected a high-grade Gleason component (Gleason 4 and/or 5) not present in the PZB in 2.4 % of PCa cases.

Conclusions

There is limited value for TZB and MAB in the context of sextant PZB at baseline TRUS-guided biopsies for PCa.     

Surgical treatment of esophageal perforations: the importance of a primary repair

Purpose

The aim of the current study was to evaluate the outcome after primary repair in comparison to other surgical treatments and the advantage of reinforcing the sutures with an absorbable polyglactin 910 prosthesis.

Methods

All esophageal perforations surgically managed in this institution from January 1985 through April 2009 (n = 40) were retrospectively analyzed. Patients that underwent surgery with primary sutures (group A, n = 24) were compared with patients that received other surgical procedures (group B, n = 16). The time to initiate treatment (within or after the first 24 h) and if the suture was reinforced with a polyglactin 910 mesh were also analyzed in group A patients.

Results

The outcome was more favorable in group A than group B in terms of time in the intensive care unit (p = 0.005), and rate of reoperation (p = 0.005). There was no difference in the outcome after the primary suture with or without mesh reinforcement, although the rate of fistulization was lower in patients with a mesh (17 vs. 50 %, p = 0.19).

Conclusions

Primary repair has a better outcome than other surgical treatment, even when performed more than 24 h after symptom onset, but not later than 48 h. Reinforcing the sutures with an absorbable polyglactin 910 mesh therefore seems to improve the outcome.