Pathological sub-analysis of a multicenter randomized controlled trial of tonsillectomy combined with steroid pulse therapy versus steroid pulse monotherapy in patients with immunoglobulin A nephropathy

Background

The IgA nephropathy (IgAN) Study Group in Japan conducted a multicenter, randomized, controlled trial of tonsillectomy with steroid pulse therapy (TSP) versus steroid pulse monotherapy in patients with IgAN (UMIN Clinical Trial Registry Number; C000000384). The effects of therapies in relation to pathological severity were analyzed in this study.

Methods

The patients with IgAN, urinary protein 1.0–3.5 g/day, serum creatinine of 1.5 mg/dl or less were randomly assigned to receiving TSP (Group A) or steroid pulses alone (Group B). The primary endpoint was the disappearance of proteinuria and/or hematuria. Twenty-six biopsies in Group A and 33 in Group B were available. The histological grades (HG) according to the percentage of glomeruli with crescent or sclerosis and the Oxford classification were analyzed.

Results

The patients in Group A had a 4.32- to 12.1-fold greater benefit of disappearance of proteinuria and 3.61- to 8.17-fold greater benefit of clinical remission (disappearance of proteinuria and hematuria) than those in Group B in patients with HG2–3, acute lesions (cellular or fibrocellular crescent) affecting more than 5 % of glomeruli, chronic lesions (fibrous crescents or sclerosis) affecting more than 20 % and S1. In contrast, odds ratios for disappearance of proteinuria or clinical remission in Group A to Group B were not significant in patients with HG 1, acute lesion in 5 % or less of glomeruli, chronic lesion in 20 % or less and S0. The disappearance of hematuria showed no relation to pathological severity.

Conclusion

TSP might be better employed according to the pathological severity.

     

Impact of tonsillectomy combined with steroid pulse therapy on immunoglobulin A nephropathy depending on histological classification: a multicenter study

Background

In addition to corticosteroids and inhibition of the renin–angiotensin–aldosterone system, tonsillectomy with steroid pulse therapy (TSP) may have a beneficial impact on the clinical course of IgA nephropathy (IgAN). However, there is still much uncertainty regarding the indications for therapy, treatment protocol, and therapeutic options for IgAN.

Methods

In this multicenter retrospective cohort study, we enrolled 284 patients with biopsy-proven IgAN who received TSP or corticosteroid therapy or conservative therapy. The effects of TSP on clinical remission (CR) were evaluated after a median follow-up period of 4.1 years in relation to histological classifications.

Results

Among the 284 participants, 161 patients received TSP. During the observation time, 141 patients (49.6 %) achieved CR, with a median time to remission of 397 days. In multivariate Cox regression analyses, TSP had an impact on achieving CR in only the group with histological grade 3 defined as glomerulosclerosis, crescent formation or adhesion to Bowman’s capsule in 10–30 % of all biopsied glomeruli, or mild cellular infiltration in the interstitium (hazard ratio (HR) 4.29, 95 % confidence interval (95 %CI) 1.88–11.19, P < 0.001). TSP independently contributed to a higher incidence of CR, particularly in the patient group showing evident mesangial hypercellularity (HR 2.54, 95 %CI 1.38–5.08, P = 0.002).

Conclusions

TSP may have a beneficial effect on the clinical course in IgAN patients with mild to moderate glomerular and interstitial lesions, particularly with distinct mesangial cell proliferation.

     

Anti-inflammatory use may not negatively impact oncologic outcomes following intravesical BCG for high-grade non-muscle-invasive bladder cancer

Purpose

To evaluate whether anti-inflammatory agents affect outcomes in patients receiving intravesical BCG therapy for high-grade (HG) non-muscle-invasive bladder cancer (NMIBC).

Methods

We reviewed the records of 203 patients in a prospective database of HG NMIBC from 2006 to 2012 at a single institution. Patients who had muscle-invasive disease (n = 32), low-grade pathology (n = 4), underwent early cystectomy within 3 months (n = 25), had <3 months of follow-up (n = 11), or did not receive an induction course of intravesical BCG (n = 32) were excluded. Clinicopathologic data were tabulated including demographics, comorbidities, pathologic stage and grades, intravesical therapy, and concomitant use of aspirin, NSAIDs, COX inhibitors, and statins. Multivariate Cox regression analysis explored predictive factors for recurrence, progression (stage progression or progression to cystectomy), cancer-specific survival (CSS), and overall survival (OS).

Results

Ninety-nine patients with HG NMIBC who received at least one induction course of intravesical BCG were identified, with median follow-up of 31.4 months. There were 20 (20.2 %) deaths, including 6 (6.1 %) patients with bladder cancer-related mortality. 13 % patients experienced tumor progression and 27 % underwent cystectomy following failure of intravesical therapy. Anti-inflammatory use included statins (65 %), aspirin (63 %), or non-aspirin NSAIDs/COX inhibitors (26 %). Anti-inflammatory use was not significantly predictive of recurrence, progression, or mortality outcomes on Cox regression. CIS stage was associated with higher progression, while age, BMI, and Charlson score were independent predictors of overall mortality.

Conclusion

Despite speculation of inhibitory effects on BCG immunomodulation there was no evidence that anti-inflammatory agents impacted oncologic outcomes in patients receiving BCG for HG NMIBC.

     

Prognosis of Hepatocellular Carcinoma Patients Who Achieved Long-Term Recurrence-Free Survival After Curative Therapy: Impact of the ALBI Grade

Background/Aims

Some patients experience very late recurrence of HCC more than 5 years after initial therapy. We aimed to clarify the predictive factors for very late recurrence of HCC in such cases.

Methods

Among 807 HCC patients undergoing surgical resection or ablative therapy with curative intent, the patients who survived for 5 years without any recurrence were reviewed. The prognosis and possible predictive factors for late recurrence were analyzed retrospectively.

Results

A total of 184 patients survived for more than 5 years without recurrence. Among them, 61 patients experienced recurrence, at a median of 6 years after initial therapy. In univariate analysis, the pre-treatment aspartate aminotransferase, alanine aminotransferase, Child-Pugh class, and ALBI grade were not related to recurrence, but those at 5 years after treatment were significantly related to recurrence. By multivariate analysis, an ALBI grade of 2–3 at 5 years was an independent risk factor for recurrence (P?<?0.0001). Moreover, variation of the ALBI grade over the 5 years after the initial treatment was significantly related to recurrence-free survival.

Conclusions

The ALBI grade is an effective index of the variation in liver function after curative therapy and may be a useful prognostic factor for the long-term recurrence-free survival of HCC patients.

     

Comparison of methods of steroid administration combined with tonsillectomy for IgA nephropathy patients

Background

IgA nephropathy (IgAN) is a chronic glomerular disease that causes end-stage renal disease in 20–40 % of patients within 20 years. The efficacy of tonsillectomy combined with steroid pulse (SP) administration (TSP) for clinical remission of IgAN has been reported. Particularly in Japan, TSP has been performed widely. However, the optimum method for steroid administration in TSP has not been established.

Methods

We retrospectively compared clinical remission in IgAN patients treated with tonsillectomy combined with two different steroid administration methods: (1) three courses of SP therapy and oral prednisolone administered on alternate days (group 3A; n = 25); and (2) one course of SP therapy and oral prednisolone administered on consecutive days (group 1C; n = 22).

Results

There was no significant difference in the clinical remission rates between the two groups at 12 (48.0 vs. 40.9 %, P = 0.77) and 24 months after starting treatment (68.0 vs. 72.7 %, P = 0.76) and at the final observation (76.0 vs. 81.8 %, P = 0.73). The mean period from starting treatment to remission of hematuria in group 3A was significantly shorter than that in group 1C (5.7 ± 4.4 vs. 9.9 ± 5.9 months, P = 0.03). Dyslipidemic patients treated for the first time with statin after the SP therapy were more present in group 3A at 24 months (P = 0.02).

Conclusions

In IgAN patients, treatment of group 3A may be effective for inducing rapid remission of hematuria. Further studies are needed to establish an appropriate protocol for TSP.

     

Comparison between Oxford Cobbmeter and digital Cobbmeter for measurement of Cobb angle in adolescent idiopathic scoliosis

Purpose

The purpose of this study was to compare Cobb angle measurements performed using an Oxford Cobbmeter and digital Cobbmeter in a series of 20 adolescent idiopathic scoliosis (AIS) patients.

Methods

Four observers measured major Cobb angles on 20 standing postero-anterior radiographs of AIS patients with both Oxford Cobbmeter and digital Cobbmeter (iPhone Cobbmeter Application). The measurements were repeated a week after the original measurements.

Results

The mean Cobb angle in this study was 43.6° ± 23.62°. The mean measurement time for an observer to measure the 20 Cobb angles was 24.9 min for the smart phone compared with 25.6 min for the Oxford Cobbmeter. The 95 % confidence interval for differences between smart phone and Oxford Cobbmeter measurements on the same radiograph was ±3.68°. The intra-observer variability of the smart phone is equivalent to the Oxford Cobbmeter. The 95 % confidence intervals for inter-observer error were ±5° and ±5.8° for the smart phone and Oxford Cobbmeter, respectively.

Conclusions

We conclude that the smart phone with integrated Tiltmeter and Cobbmeter application is an equivalent Cobb measurement tool to the Oxford Cobbmeter. The advantages of smart phone are the accuracy of determining the most inclined vertebrae and accordingly more precise Cobb angle measurement. The new smart phones with these integrated applications may be really helpful to the spine surgeons, especially in hospitals where PACS or Oxford Cobbmeter is not available.

     

Laparoscopic inguinal hernioplasty after robot-assisted laparoscopic radical prostatectomy

Purpose

To evaluate the efficacy and safety of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair in patients who have undergone robot-assisted laparoscopic radical prostatectomy (RALP).

Methods

From July 2014 to December 2016, TAPP inguinal hernia repair was conducted in 40 consecutive patients who had previously undergone RALP. Their data were retrospectively analyzed as an uncontrolled case series.

Results

The mean operation time in patients who had previously undergone RALP was 99.5 ± 38.0 min. The intraoperative blood loss volume was small, and the duration of hospitalization was 2.0 ± 0.5 days. No intraoperative complications or major postoperative complications occurred. During the average 11.2-month follow-up period, no patients who had previously undergone prostatectomy developed recurrence.

Conclusions

Laparoscopic TAPP inguinal hernia repair after RALP was safe and effective. TAPP inguinal hernia repair may be a valuable alternative to open hernioplasty.

     

A comparison of the Dobbs method for correction of idiopathic and teratological congenital vertical talus

Introduction

Congenital vertical talus (CVT) is a rare deformity. Traditionally, CVT correction involved extensive soft tissue releases, and this was associated with high complication rates. The Dobbs method is less invasive and comprises serial manipulation and casting, followed by minimally invasive reduction and K-wire fixation of the talonavicular joint and percutaneous Achilles tenotomy.

Aim

The purpose of our study was to compare the outcomes of using the Dobbs method for CVT correction in idiopathic and teratological patients.

Methods

A retrospective analysis of all patients treated with the Dobbs method for CVT between the years 2007 and 2012 was carried out. Notes, electronic records and radiographs were reviewed for every patient. The Oxford ankle foot score was obtained at follow-up.

Results

There was a total of ten children with 18 affected feet. Five children (ten feet) had teratological CVT. Recurrence was noted in six feet (two from the idiopathic group and four from the teratological group). The median age was 5 months (range 2–8 months). The mean follow-up was 53 months (range 24–80 months). There was a significant difference between pre-operative to initial post-operative and pre-operative to latest follow-up measurements for all angles in the successfully treated CVT group (p < 0.000001). The mean Oxford ankle foot scores for each domain in all patients are 59.9 (physical), 88.8 (school and play) and 99.1 (emotional).

Conclusion

The Dobbs method is a less invasive technique of CVT correction. It is an effective initial method of treatment in both teratological and idiopathic patients. A higher recurrence rate was observed in the teratological group, although this was not statistically significant.

     

Adjuvant I-131 Lipiodol After Resection or Radiofrequency Ablation for Hepatocellular Carcinoma

Background and objectives

High rates of recurrence have been observed after curative treatment for hepatocellular carcinoma (HCC). The main aim of this study was to establish the influence of adjuvant transarterial radioembolization-based I-131 lipiodol on survival and recurrence.

Methods

Between 2004 and 2010, 38 patients were treated with adjuvant I-131 lipiodol therapy, at a dosage of 2220 MBq, within 4 months after surgery. This treated cohort was compared to a control cohort consisting of 42 consecutive patients operated prior to the time the I-131 lipiodol treatment became available.

Results

Recurrence-free survival in the control and in the I-131 lipiodol cohort was 12.6 and 18.7 months, respectively (HR = 1.871, p = 0.025). At 2 and 5 years, the cumulative incidence of a first recurrence or death was, respectively, 50 % and 61 % in the treated cohort versus 69 % and 74 % in the control cohort. Median overall survival was 55 and 29 months, respectively (p = 0.051). Among patients with a recurrence at 2 years, more patients had already experienced such recurrence at 1 year in the control cohort (70 % vs 33 %, p = 0.014).

Conclusions

Adjuvant I-131 lipiodol improves disease-free survival in patients with HCC.

     

Significance of tonsillectomy combined with steroid pulse therapy for IgA nephropathy with mild proteinuria

Background

Medical intervention for patients with IgA nephropathy and mild proteinuria (<1.0 g/day) is controversial, and the effectiveness of tonsillectomy plus steroid pulse therapy (TSP) for such patients remains obscure.

Methods

Among 323 patients in our multicenter cohort study, 79 who had mild proteinuria (0.4–1.0 g/day) at diagnosis were eligible to participate in this study. We compared the clinicopathological findings at diagnosis, a decline in renal function defined as a 50 or 100 % increase in serum creatinine (sCr) and clinical remission (CR) defined as the disappearance of hematuria and proteinuria (<0.3 g/day) among groups given TSP (n = 46), steroid therapy (ST) (n = 9), and non-ST (n = 24). Factors contributing to CR were also evaluated using multivariate analysis.

Results

Background factors at diagnosis including age, ratio (%) of patients with hypertension, sCr, proteinuria, and histological severity did not significantly differ among the groups. Only two patients each in the TSP (4.3 %) and non-ST (8.3 %) groups achieved a 50 % increase in sCr during a mean follow–up period of 4.7 years. At the final observation, 71.7, 44.4, and 41.7 % of patients in the TSP, ST, and non-ST groups, respectively, achieved CR (p = 0.032). Cox proportional hazards models revealed that TSP led to CR more effectively than non-TSP by a factor of about threefold (hazard ratio, 2.74; p = 0.008).

Conclusion

TSP therapy has potential for inducing CR in patients with IgAN and mild proteinuria (<1.0 g/day).

     

Role of metastasectomy for recurrent/metastatic gastrointestinal stromal tumors based on an analysis of the Kinki GIST registry

Purpose

To define the role of surgery for metastatic/recurrent lesions after resection of primary gastrointestinal stromal tumors (GISTs).

Methods

Based on data obtained from the Kinki GIST registry, patients with recurrence or metastasis were divided into a surgical treatment group (ST group), comprised those treated with surgery in addition to tyrosine kinase inhibitor (TKI) therapy; and a drug treatment group (DT group), comprised those treated with TKI therapy alone. We compared the baseline characteristics and survival outcomes of the groups.

Results

Metastasis or recurrence developed in 93 of the 737 patients with GISTs treated between 2003 and 2007, 50 (53.8 %) of whom were assigned to the ST group and 43 (46.2 %) to the DT group. In the ST group, the 5-year overall survival rate was significantly higher for patients who underwent R0/R1 resection than for those who underwent R2 resection (82.2 vs. 47.0 %, p = 0.018). Survival time after recurrence was correlated with the duration of total TKI therapy in both the ST and DT groups (r = 0.766 and r = 0.932, respectively, p < 0.001).

Conclusions

Continuous TKI therapy appears to be important primarily for the prognostic improvement of patients with recurrent/metastatic GISTs. R0/R1 resection may have benefits when combined with TKI therapy for patients with stable disease or disease responsive to TKI therapy, less than four metastatic lesions, and lesions <100 mm in total.

     

Hamstring graft tibial insertion preservation versus detachment in anterior cruciate ligament reconstruction: a prospective randomized comparative study

Background

Anterior cruciate ligament (ACL) reconstruction with hamstring graft (HG) is a commonly performed procedure. Despite the type of reconstruction chosen, the detached HG undergoes a remodeling process known as ligamentization. In order to shorten the ligamentization process, the maintenance of HG tibial insertion, aimed to spare the tendons vascular supply, has been postulated. The aim of this paper is to report the results of a prospective randomized study comparing clinical and MRI results between two different ACL reconstructive procedures with and without HG tibial insertion preservation.

Methods

Forty patients (mean age 27.5 ± 9.5 years) were enrolled and randomly divided into two groups. The study group underwent an ACL reconstruction using a distally inserted HG, while the control group underwent a technique encompassing HG tibial detachment. Subjective and objective IKDC score was administered preoperatively and at 3-, 6-, 12- and 24-month follow-up. Graft morphology was assessed through MRI evaluation performed at 6-month follow-up.

Results

Clinical results were excellent in both groups. Regarding MRI results, a better intra-articular graft morphology was observed in the study group (Tau = 0.313, p = 0.024). No differences in graft integration were noticed.

Conclusion

The main finding of this preliminary study is that preservation of the hamstring tibial insertion seems to enhance graft ligamentization with improved morphology of the intra-articular portion of the graft compared to a detachment of the hamstring tendons from the tibial side. Further well-designed studies with higher number of patients as well as more serial MRI evaluations are required to validate these preliminary findings.

     

The Effects of Laparoscopic Sleeve Gastrectomy on Obesity-Related Hypertriglyceridemia-Induced Acute Pancreatitis

Background

Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is a significant clinical problem and is characterized by high recurrence rate compared with non-HTG-AP. The objective of this study was to investigate the effects of laparoscopic sleeve gastrectomy (LSG) on obesity-related HTG-AP.

Methods

Twenty-nine patients with obesity-related HTG-AP were admitted to our hospital and treated with the conventional therapy or LSG surgery according to the wishes of patients. Clinical data and the recurrence rate of AP were collected at baseline and at four different time points (3, 6, 9, and 12 months) after the treatments for all patients.

Results

Of the 29 patients, 28 patients (19 patients with conventional therapy and 9 patients with LSG surgery) completed the 12-month follow-up. Clinical data and the severity scores of AP were comparable at baseline when the patients were admitted to the intensive care unit. The LSG group experienced a large weight loss (percent total weight loss, 26.87?±?1.44%; percent excess weight loss, 79.56?±?1.37%) and triglyceride reduction (from 15.77?±?1.02 to 1.36?±?0.09 mmol/L), and no recurrence was observed at 12 months after the surgery. In the conventional treatment group, however, body weight was not changed although triglyceride was significantly decreased (from 17.34?±?1.29 to 8.25?±?1.12 mmol/L), and more importantly, 47.4% of the patients had at least one recurrence of AP in 12 months after the treatment.

Conclusions

LSG might be an effective way to cure obesity-related HTG-induced AP since it prevents the recurrence of this disease. Further randomized studies will be needed to standardize this way of treatment.

     

Potentially curable recurrent disease after surgically managed non-metastatic renal cell carcinoma in low-, intermediate- and high-risk patients

Purpose

Guidelines recommend risk-adapted follow-up (FU) strategies after (partial) nephrectomy in non-metastatic renal cell carcinoma (RCC). Since current systemic therapy does not cure metastatic RCC, only timely detected recurrence accessible for local therapy is potentially curable. This study analyzed the rate and management of potentially curable recurrences per risk group.

Methods

This is a retrospective study including non-metastatic RCC patients who underwent (partial) nephrectomy from 2004 to 2011, with a minimum follow-up of 4 years. Risk stratification was by Leibovich score (clear cell subtype) and UICC/AJCC grading (other subtypes). Recurrence, time to recurrence, symptoms and detection method were documented. Isolated local recurrence, solitary- and oligometastases (≤3 lesions, single site) were considered potentially curable.

Results

Among 234 patients, followed during a median of 61.9 months, 68 patients (29.1 %) developed a recurrence of which 28 (41.2 %) were considered potentially curable. The 5-year risk of recurrence for low-, intermediate- and high-risk patients was 7.8, 26.3 and 59.1 % of which 71.4, 52.2 and 23.1 % were considered potentially curable, respectively. In high-risk patients, incurable recurrence was detected after a median of 7.9 (3.7–17.2) months versus 13.9 (6–41.3) months for potentially curable lesions. Only 13 of potentially curable lesions (46 %) received local therapy.

Conclusion

FU protocols should be adapted to the recurrence pattern of potentially curable disease. Most of the benefit may be achieved in intermediate-risk and high-risk-patients free of recurrence 1 year after surgery. Despite frequent imaging, only 13 patients (5.6 % of all patients followed) were managed with local therapy of whom only 4 remained free of disease.

     

Feasibility,safety, and short-term efficacy of the laparoscopic Nissen–Hill hybrid repair

Background

A novel antireflux procedure combining laparoscopic Nissen fundoplication and Hill repair components was tested in 50 patients with paraesophageal hernia (PEH) and/or Barrett’s esophagus (BE) because these two groups have been found to have a high rate of recurrence with conventional repairs.

Methods

Patients with symptomatic PEH and/or non-dysplastic BE underwent repair. Quality of life (QOL) metrics, manometry, EGD, and pH testing were administered pre- and postoperatively.

Results

Fifty patients underwent repair. There was no mortality and four major complications. At 13-month follow-up, there was one (2 %) clinical recurrence, and two (4 %) asymptomatic fundus herniations. Mean DeMeester scores improved from 57.2 to 7.7 (p < 0.0001). Control of preoperative symptoms was achieved in 90 % with 6 % resumption of antisecretory medication. All QOL metrics improved significantly.

Conclusions

The hybrid Nissen–Hill repair for patients with PEH and BE appears safe and clinically effective at short-term follow-up. It is hoped that the combined structural components may reduce the rate of recurrence compared to existing repairs.

     

Cross-cultural adaptation and validation of the Italian versions of the Kujala,Larsen, Lysholm and Fulkerson scores in patients with patellofemoral disorders

Background

The Kujala, Fulkerson, Larsen and Lysholm questionnaires have been demonstrated to be reliable and sensitive in assessing patients with patellofemoral pathology. The purpose of this study is to translate and cross-culturally adapt into Italian the English versions of the Kujala, Fulkerson, Larsen and Lysholm questionnaires, and undertake reliability and validity evaluations of the Italian versions of these scores in patients with patellofemoral pathology.

Materials and methods

The cross-cultural adaptation process was carried out following the simplified Guillemin criteria. The questionnaires were administered to 63 patients with either patellar instability or painful patella syndrome. To assess the validity of the questionnaires, they were compared with the Oxford knee score. The questionnaires were administered to a subsample of 33 patients 5 days later to assess test–retest reliability.

Results

The interclass coefficient correlation was 0.96 for the Kujala score, 0.92 for the Larsen score, 0.96 for the Lysholm score, 0.94 for the Fulkerson score (P < 0.01), and 0.83 for the Oxford score. Pearson’s correlation was0.96 between the Kujala and Oxford scores, 0.90 between the Larsen and Oxford scores, 0.94 between the Lysholm and Oxford score, and 0.93 between the Fulkerson and Oxford scores. Responsiveness, calculated by standardized response mean, was 1.2, and effect size was 1.4.

Conclusions

The Italian versions of the Kujala, Larsen, Lysholm and Fulkerson scoring systems were shown to be equivalent to their English versions and demonstrated good validity, reliability and responsiveness to surgical treatment of patellofemoral pathology. To the best of the authors’ knowledge, this is the first attempt to adapt four of the most common patellofemoral-specific scoring scales to the Italian language.

Level of evidence

Level II.

     

CyberKnife stereotactic radiotherapy for isolated recurrence in the prostatic bed

Purpose

To report a clinical experience of stereotactic body radiation therapy (SBRT) for isolated recurrence in the prostatic bed from prostate cancer.

Materials and methods

Between November 2011 and November 2013, 16 patients were treated with SBRT for a macroscopic isolated recurrence of prostate cancer in the prostatic bed. All patients were initially treated with radical prostatectomy, and half of them also received radiotherapy. Two schedules of SBRT were used: 30 Gy in 5 fractions in previously irradiated patients, 35 Gy in five fractions in radiotherapy-naïve patients.

Results

At a median follow-up of 10 months (range 2–21 months), a significant biochemical response was found in all but one patient. At imaging evaluation, no local progression was noted: 10 patients showed partial response while four stable disease. At the moment of analysis, all 16 patients were alive. Seven of them experienced distant relapse, while nine maintained biochemical control, with no further therapy. Median time to relapse was 9.3 months (range 3–15.2 months). The treatment was well tolerated: One patient experienced G2 acute genitourinary and gastrointestinal toxicity.

Conclusions

Our experience shows that SBRT with CyberKnife for isolated nodal relapse is a safe and well-tolerated treatment.

     

Ranula: Current Concept of Pathophysiologic Basis and Surgical Management Options

Background

There is no consensus opinion on a definitive surgical management option for ranulas to curtail recurrence, largely from the existing gap in knowledge on the pathophysiologic basis.

Aim

To highlight the current scientific basis of ranula development that informed the preferred surgical approach.

Design

Retrospective cohort study.

Setting

Public Tertiary Academic Health Institution.

Method

A 7-year 7-month study of ranulas surgically managed at our tertiary health institution was undertaken—June 1, 2008–December 31, 2015—from case files retrieved utilising the ICD-10 version 10 standard codes.

Results

Twelve cases, representing 0.4 and 1.2% of all institutional and ENT operations, respectively, were managed for ranulas with a M:F = 1:1. The ages ranged from 5/12 to 39 years, mean = 18.5 years, and the disease was prevalent in the third decade of life. Main presentation in the under-fives was related to airway and feeding compromise, while in adults, cosmetic facial appearance. Ranulas in adults were plunging (n = 8, 58.3%), left-sided save one with M:F = 2:1. All were unilateral with R:L = 1:2. Treatment included aspiration (n = 2, 16.7%) with 100% recurrence, intra-/extraoral excision of ranula only (n = 4, 33.3%) with recurrence rate of 50% (n = 2, 16.7%), while marsupialisation in children (n = 1, 8.3%) had no recurrence. Similarly, transcervical approach (n = 5, 41.7%) with excision of both the ranula/sublingual salivary gland recorded zero recurrence. Recurrence was the main complication (n = 4, 33.3%).

Conclusion

With the current knowledge on the pathophysiologic basis, extirpation of both the sublingual salivary gland and the ranula by a specialist surgeon is key for a successful outcome.

     

The effect of renin–angiotensin system blockade on the incidence of end-stage renal disease in IgA nephropathy

Background

The impact of renin–angiotensin system blockade (RASB) on the incidence of end-stage renal disease (ESRD) remains unclear in IgA nephropathy (IgAN).

Methods

This study assessed associations between RASB treatment and the incidence of ESRD in IgAN using propensity score approaches. We retrospectively analyzed 1273 patients with IgAN biopsied between 1979 and 2010. Propensity scores were calculated using logistic regression. Associations between RASB and ESRD were examined using a Cox regression model adjusted by inverse probability of treatment weighted, regression, stratification and matching.

Results

During follow-up (median 5.1 years), 130 patients developed ESRD. With Cox regression adjusted by inverse probability of treatment weighted, RASB use was significantly associated with a lower risk of ESRD (hazard ratio 0.58; 95 % confidence interval 0.42–0.80). Significant associations were observed for other propensity score-based approaches. In stratified analysis, a beneficial association between RASB and ESRD was observed in patients ≥35 years, with hypertension, reduced estimated glomerular filtration rate (<60 mL/min/1.73 m²), mesangial proliferation and segmental glomerulosclerosis (P for interaction <0.05), and tended to be greater in patients with proteinuria (≥1.0 g/24 h), extracapillary proliferation and receiving methylprednisolone pulse therapy (P for interaction <0.10).

Conclusion

Treatment with RASB was associated with a lower incidence of ESRD in the real-world practice of IgAN.