Is bowel preparation useful before radiography of the renal tract in patients with spinal cord injury?

OBJECTIVES: To assess, in a blinded study, the usefulness of bowel preparation in improving the quality of radiography of the renal tract in patients with spinal cord injury (SCI). PATIENTS AND METHODS: Plain abdominal radiographs of 56 patients with SCI were selected; 24 of the patients had received bowel preparation and 32 had not. The films were independently assessed by one radiologist and one urologist unaware of the treatment and identity of the patients. Each film was divided into five regions of interest and scores of 1-4 (1 for least and 4 for best visibility) assigned to each area. In films with a low aggregate visibility score (相似文献   

Is anthracycline-based chemotherapy alone adequate for young women with estrogen receptor-positive breast cancer?

Recent evidence suggests that young women with estrogen receptor (ER)-positive breast cancer (BC) require additional treatment because of the inadequacy of cyclophosphamide, methotrexate fluorouracil (CMF) alone. Herein we report our findings from 368 premenopausal patients given adjuvant anthracycline alone. Overall, patients had a significantly increasing risk of relapse and dying with decreasing age at diagnosis and ER-negative disease. Interestingly, ER expression was not a negative prognostic factor, even among women <35 years, the 5-year disease-free survival (DFS) tending to be higher in patients with ER-positive rather than -negative BC. The potential of combining anthracyclines and endocrine therapies is reviewed and discussed.     

Is neoadjuvant chemotherapy valid in invasive cancer of the bladder?

The role of neoadjuvant chemotherapy for invasive transitional cell carcinoma (TCC) of the bladder is not determined yet. M-VAC and CMV regimens have a complete response rate of 10-47% with an overall response reaching 80%. In 16.7-35% of all the responders and 42.9-92% of the complete responders a functioning bladder can be preserved. The influence of neoadjuvant chemotherapy on long-term survival is questionable. Nevertheless, the authors conclude that neoadjuvant chemotherapy is feasible in patients with invasive TCC as it improves the results of following surgery and in some cases enables an organ sparing operation.     

Is clinical measurement of anatomic axis of the femur adequate?

Background and purpose — The accuracy of using clinical measurement from the anterior superior iliac spine (ASIS) to the center of the knee to determine an anatomic axis of the femur has rarely been studied. A radiographic technique with a full-length standing scanogram (FLSS) was used to assess the adequacy of the clinical measurement.

Patients and methods — 100 consecutive young adult patients (mean age 34 (20–40) years) with chronic unilateral lower extremity injuries were studied. The pelvis and intact contralateral lower extremity images in the FLSS were selected for study. The angles between the tibial axis and the femoral shaft anatomic axis (S-AA), the piriformis anatomic axis (P-AA), the clinical anatomic axis (C-AA), and the mechanical axis (MA) were compared between sexes.

Results — Only the S-AA and C-AA angles were statistically significantly different in the 100 patients (3.6° vs. 2.8°; p = 0.03). There was a strong correlation between S-AA, P-AA, and C-AA angles (r > 0.9). The average intersecting angle between MA and S-AA in the femur in the 100 patients was 5.5°, and it was 4.8° between MA and C-AA.

Interpretation — Clinical measurement of an anatomic axis from the ASIS to the center of the knee may be an adequate and acceptable method to determine lower extremity alignment. The optimal inlet for antegrade femoral intramedullary nailing may be the lateral edge of the piriformis fossa.     

Is adjuvant chemotherapy for bladder cancer safer in patients with an ileal conduit than a neobladder?

OBJECTIVE: To assess the safety of adjuvant chemotherapy in patients with neobladder reconstruction in comparison to ileal conduit, as radical cystectomy and urinary diversion is an effective curative surgical treatment for muscle-invasive and high-risk superficial bladder cancer, and adjuvant chemotherapy is usually considered for patients with clinical stage > T2 and nodal metastasis. PATIENTS AND METHODS: We analysed retrospectively patients who had had a radical cystectomy and urinary diversion between 1992 and 2004. Patients with high-risk disease who had adjuvant chemotherapy were identified and stratified based on the type of urinary diversion (ileal conduit or neobladder). The chemotherapy regimen, complications from the adjuvant chemotherapy and other relevant data were analysed. RESULTS: Overall, 343 patients had radical cystectomy, 40 had adjuvant chemotherapy; 25 had an ileal conduit and 15 had a neobladder. Patient characteristics including age, stage and follow-up were similar. In all, 55% of patients had grade 1 toxicity, 23% grade 2, 18% grade 3, and 13% grade 4. No patients had serious organ toxicity and none died. There were no significant differences in the toxicity among the two groups. CONCLUSIONS: Adjuvant chemotherapy appears to be safe in patients with a neobladder and equally safe in patients with an ileal conduit. Hence neobladder reconstruction should not be denied to patients with bladder cancer who are at high risk of recurrence and who might require adjuvant chemotherapy.     

Is the GPSM scoring algorithm for patients with prostate cancer valid in the contemporary era?

PURPOSE: The GPSM (Gleason, prostate specific antigen, seminal vesicle and margin status) scoring algorithm is a user friendly model for predicting biochemical recurrence following radical retropubic prostatectomy. It was developed from patients who underwent radical retropubic prostatectomy from 1990 to 1993. We investigated the predictive ability of GPSM in the contemporary era. MATERIALS AND METHODS: We identified 2,728 patients who underwent radical retropubic prostatectomy for prostate cancer from 1997 to 2000 at our institution. Cox proportional hazard regression models were used to develop multivariate scoring algorithms. Harrell's measure of concordance was used to compare the competing models. RESULTS: In the contemporary era each GPSM feature remained significantly associated with biochemical recurrence in a multivariate model (each p <0.001). Harrell's measure of concordance for the algorithm was 0.706 vs 0.718 in the original study. After adjusting for GPSM on multivariate analysis Gleason primary 4/5 (p <0.001), DNA ploidy (p = 0.018) and tumor size (p <0.001) were associated with biochemical recurrence. However, none of these features increased Harrell's measure of concordance greater than 0.01 when added to the GPSM model. In addition, using the original 1990 to 1993 cohort, 495 patients with a GPSM score of 10 or greater were significantly more likely to die of prostate cancer compared with 2,169 with a GPSM score of less than 10 (at 15 years 13% vs 2%, HR 6.5, p <0.001). CONCLUSIONS: The GPSM scoring algorithm is a simple predictive model that remains associated with biochemical recurrence in the contemporary era. In addition, to our knowledge the GPSM algorithm is the first nomogram associated with survival in patients with prostate cancer.     

Ovarian function preservation with GnRH agonist in young breast cancer patients: Does it impede the effect of adjuvant chemotherapy?

BackgroundConcurrent endocrine therapy with chemotherapy had a concern of potential antagonism. However, gonadotropin-releasing hormone (GnRH) agonist has been used concurrently with chemotherapy to prevent premature ovarian failure for young breast cancer patients. The aim of this study was to determine the impact of concurrent use of GnRH agonists on relapse-free and overall survival, and to establish the oncologic safety of ovarian protection with GnRH agonists.MethodsPremenopausal women aged between 20 and 40 years who received adjuvant chemotherapy for breast cancer from January 2002 to April 2012 were classified into two groups; One treated with GnRH agonists for ovarian protection during chemotherapy, and the other without ovarian protection. A propensity score matching strategy was used to create matched sets of two groups with age, pathologic stage, hormone receptor, and Her2 status.ResultsA total of 101 patients treated with concurrent GnRH agonist during chemotherapy were compared with 335 propensity score matched patients. Among them, 81.2% were younger than 35 years and 58.4% were hormone responsive. Survival analysis using stratified Cox regression showed that women treated with concurrent GnRH agonists had better recurrence-free survival (adjusted Hazard ratio 0.21, p = 0.009; unadjusted Hazard ratio 0.33, p = 0.034).ConclusionsOvarian protection using GnRH agonists can be safely considered for young women with breast cancer in terms of oncologic outcomes. Further studies are needed to assess the long-term outcomes of concurrent GnRH agonist use with chemotherapy.     

Is kidney size a useful predictor of renal function in the elderly?

Despite its widespread use, the diagnostic yield of ultrasonography to detect early stages of reduced renal function in the elderly remains doubtful. METHOD: Sixty-two patients (age: 74.8 +/- 6.7 years, 30 females) attending a geriatric ward were examined. Non-insulin-dependent diabetes was present in 28 patients and 32 were hypertensive. Exclusion criteria were previously known renal failure, an elevated serum creatinine above 2 mg/dl at admission or apparent cognitive impairment. Inulin clearance (C(IN)), Cockcroft estimation and urinary albumin excretion rate (UAER) were determined. Renal parenchymal volume, renal volume and mean renal length were calculated using data obtained by ultrasonography. RESULTS: A multiple regression analysis identified C(IN) as the main determining factor on renal parenchymal volume (beta = 0.360; p = 0.004). Body height showed additional influence (beta = 0.295; p = 0.018), but age, gender, diabetes, UAER and hypertension did not. Cockcroft estimation, ultrasonographic markers of renal size and further confounding variables were evaluated in a subsequent multiple regression analysis. Cockcroft estimation explained the major part of the variance (beta = 0.783; p < 0.001) and the occurrence of diabetes showed a borderline additional effect. But there was no supplementary influence of any ultrasonographic parameter. In 11 patients, C(IN) was reduced to < or = 60 ml/min. ROC analysis revealed poor diagnostic efficacy of all ultrasonographic parameters (AUC < 0.7336) compared to Cockcroft estimation (AUC = 0.8718). CONCLUSION: Although a linear relation between C(IN) and renal parenchymal volume could be shown, ultrasonography cannot replace or complement Cockcroft estimation in order to detect early reduced renal function in the elderly. Nevertheless, reduced renal parenchymal volume may occur prior to elevation of serum creatinine in the elderly and should be noted carefully on routine ultrasonographic examinations.     

Is peritoneal dialysis adequate for hypercatabolic acute renal failure in developing countries?

BACKGROUND: Peritoneal dialysis (PD) is a therapeutic option for acute renal failure (ARF) in developing countries, despite concerns about inadequacy. Shorter and more efficient tidal peritoneal dialysis (TPD) was compared with continuous equilibrating peritoneal dialysis (CEPD) therapy in ARF by using their adequacies as accepted standards and analyzing the solute reduction indices (SRI). METHODS: A prospective, randomized crossover trial was performed in patients with mild to moderate hypercatabolic ARF who were assigned to CEPD and TPD therapy after an adequate washout period. Solute clearances (Kt/V, normalized creatinine clearances) were compared to NKF guidelines. Potassium and phosphate clearances, dextrose absorption, protein losses and costs were compared. Kt/V was compared to SRIdialysate, SRIKt/V. RESULTS: Eighty-seven patients with ARF received 236 sessions of dialysis (118 in each treatment). TPD resulted in higher clearances of solutes than CEPD (creatinine and urea clearances in mL/min of 9.94 +/- 2.93, 6.74 +/- 1.63 and 19.85 +/- 1.95, 10.63+/- 2.62, respectively, P=0.001). TPD and CEPD normalized creatinine clearances (L/week/1.73 m2 BSA) and Kt/V values were 68.5 +/- 4.43, 58.85 +/- 2.57 and 2.43 +/- 0.87, 1.80 +/- 0.32, respectively. CEPD did not meet standards of adequacy. TPD resulted in greater potassium and phosphate clearances, less dextrose absorption and was less expensive. CEPD resulted in less protein loss. Kt/V corresponded to SRIdialysate 0.88 +/- 0.12 (P=0.076). CONCLUSION: TPD produced higher solute clearances in less time with greater protein loss. CEPD just fell short to meet the dialysis adequacy standard. However, both TPD and CEPD are reasonable options for mild-moderate hypercatabolic ARF. Kt/V appropriately estimates solute removal in PD.     

Is there a role for continuous renal replacement therapies in patients with liver and renal failure?

Continuous renal replacement therapy (CRRT) has now been in use for more than a decade in the management of patients with combined renal and hepatic failure. CRRT remains the treatment of choice in this group of critically ill patients because of improved cardiovascular and intracranial stability when compared with conventional intermittent hemofiltration and/or dialysis and effective solute clearances when compared with forms of peritoneal dialysis. Over the last decade, the technique has evolved with the introduction of pumped CRRT circuits. using machines that can accurately regulate fluid balance, and the commercial introduction of bicarbonate-based or "lactate-free" substitution fluids and/or dialysates. Whether continuous dialysis or hemofiltration is the mode of treatment choice remains unanswered, with greater amino acid and ammonia losses during dialysis, whereas hemofiltration leads to increased middle molecule and cytokine removal when compared with dialysis, the latter mainly caused by membrane adsorption. Whether the improved cardiovascular stability observed during these techniques is due to the removal of inflammatory mediators or is related to cooling as a consequence of the technique remains to be determined.     

Diabetes treatment in patients with renal disease: Is the landscape clear enough?

Diabetes is the most important risk factors for chronic kidney disease(CKD). The risk of CKD attributable to diabetes continues to rise worldwide. Diabetic patients with CKD need complicated treatment for their metabolic disorders as well as for related comorbidities. They have to treat, often intensively, hypertension, dyslipidaemia, bone disease, anaemia, and frequently established cardiovascular disease. The treatment of hypoglycaemia in diabetic persons with CKD must tie their individual goals of glycaemia(usually less tight glycaemic control) and knowledge on the pharmacokinetics and pharmacodynamics of drugs available to a person with kidney disease. The problem is complicated from the fact that in many efficacy studies patients with CKD are excluded so data of safety and efficacy for these patients are missing. This results in fear of use by lack of evidence. Metformin is globally accepted as the first choice in practically all therapeutic algorithms for diabetic subjects. The advantages of metformin are low risk of hypoglycaemia, modest weight loss, effectiveness and low cost. Data of UKPDS indicate that treatment based on metformin results in less total as well cardiovascular mortality. Metformin remains the drug of choice for patients with diabetes and CKD provided that their estimate Glomerular Filtration Rate(eGFR) remains above 30 mL/min per square meter. For diabetic patients with eGFR between 30-60 mL/min per square meter more frequent monitoring of renal function and dose reduction of metformin is needed. The use of sulfonylureas, glinides and insulin carry a higher risk of hypoglycemia in these patients and must be very careful. Lower doses and slower titration of the dose is needed. Is better to avoid sulfonylureas with active hepatic metabolites, which are renally excreted. Very useful drugs for this group of patients emerge dipeptidyl peptidase 4 inhibitors. These drugs do not cause hypoglycemia and most of them(linagliptin is an exception) require dose reduction in various stages of renal disease.     

Does the endothelial function change in renal transplant patients with longer duration of exposure and with higher cumulative doses of cyclosporine?

OBJECTIVE: Administration of cyclosporine (CsA) is one potential cause of endothelial dysfunction in renal transplant patients. We sought to investigate endothelial functional changes with respect to the cumulative dose and duration of exposure to CsA. METHODS: Sixty-six renal recipients and 25 healthy controls were included in the study. The recipients were classified according to their time of CsA exposure: group 1 (0 to 36 months); group 2 (36 to 72 months); and group 3 (over 72 months). Endothelial function of the brachial artery was evaluated using high-resolution vascular ultrasound. Endothelium-dependent and -independent vasodilatation (EDD and EID, respectively) were assessed by assessing the responses to reactive hyperemia and using sublingual isosorbide dinitrate (ISDN), respectively. RESULTS: There were no statistically significant differences between the groups with regard to their demographic, clinical, and most biochemical characteristics. Baseline measurements of the diameter of the brachial artery were similar in all groups. The values of mean brachial artery EDD and EID responses in groups 1, 2, and 3 were less than those in the control group (P < .05, P < .05, and P < .05, respectively). Mean brachial artery EDD and EID in group 1 were significantly impaired compared to groups 2 and 3 (for EDD: P < .05 and P < .05, respectively; for EID: P < .05 and P < .05, respectively). In contrast there was no difference between groups 2 and 3 with respect to these parameters. There were mild to moderate positive correlations between the cumulative doses of CsA and EDD and EID (r = .26 and r = .52, P < .05, respectively). CONCLUSION: Endothelial dysfunction was more prominent in the first 36-month period than later despite the longer exposure to and higher cumulative doses of CsA. This finding may reflect an extended effect of the uremic state on endothelial function or more intense doses of CsA in early posttransplant period.