Mediastinoscopy as a therapeutic tool

Mediastinoscopy is a safe and effective diagnostic modality to obtain tissue specimens from the anterior mediastinum in most patient lymph node tissue. The technique can also be applied to remove other material from the mediastinum. We describe a case in which a bullet was retrieved from the mediastinum, lying very close to the innominate artery. Important differences in using the device for this purpose are highlighted.     

Proteinuria as a therapeutic target in patients with chronic kidney disease

Patients excreting large amounts of urinary protein, who are otherwise deemed to be optimally treated, should still be considered at high risk for renal disease progression. The observation that reductions in urinary protein excretion, in a graded fashion over a relatively short period of time, correlate with long-term preservation of renal function supports the idea of using urinary protein excretion as a guide to implementation of renoprotective therapies. The association between residual proteinuria and renal outcomes suggests that minimization of proteinuria is an important therapeutic goal in the management of proteinuric chronic kidney disease patients. This article reviews the evidence for using proteinuria as a target for the implementation of therapies shown to have renal protective effects.     

Video-assisted mediastinoscopy as a therapeutic tool

Background

Video-assisted mediastinoscopy (VAM) is a well-known method for surgical exploration of superior retrovascular mediastinal disease and for determining the staging of lung cancer. This study aimed to report the authors’ experience using VAM therapeutically.

Methods

Between 1998 and 2007, 765 patients had VAM in the authors’ service. For 742 of these patients, VAM was used to diagnose or stage a disease. The remaining 23 patients (3%) had VAM as a therapeutic procedure. Two groups of patients were studied: those who had VAM alone and those who had VAM associated with another procedure. These studies focused on indications, results, and specific morbidity and mortality.

Results

The VAM alone group (14 patients) underwent mediastinal lymphadenectomy for thyroid cancer (mean number of lymph nodes/positives, 16/6) (n = 4), closure of the left post-pneumonectomy bronchopleural fistula (n = 3), mediastinal cyst resection (n = 5), ectopic hyperfunctioning parathyroid resection (n = 1), and mediastinal hematoma evacuation (n = 1). This group had an operative time of 40 to 160 min and a hospital stay of 2 to 10 days. The group that had VAM associated with another approach (9 patients) had VAM during transhiatal esophagectomy for cancer (mean number of lymph nodes, 8) (n = 7), VAM combined with video-assisted thoracoscopic surgery (n = 1), and minithoracotomy for masses in the aortopulmonary window (unique metastasis from melanoma or thyroid cancer) (n = 1). This group had an operative time of 60 to 135 min and a hospital stay of 7 to 52 days. No specific mortality or morbidity occurred. Meanwhile, three patients died: two after bronchopleural fistula (respiratory insufficiency, severe sepsis) and one because of liver insufficiency. Two patients experienced myocardial ischemia or pneumonia after transhiatal esophagectomy.

Conclusions

“Exploratory” VAM for mediastinal disease is an important training tool that can be applied further for a therapeutic purpose. The authors’ experience has shown its potential. Its surgical indications and benefits deserve better identification.     

Peritubular capillary rarefaction: a new therapeutic target in chronic kidney disease

Chronic kidney disease (CKD) has reached worldwide epidemic proportions and desperately needs new therapies. Peritubular capillary (PTC) rarefaction, together with interstitial fibrosis and tubular atrophy, is one of the major hallmarks of CKD and predicts renal outcome in patients with CKD. PTC endothelial cells (ECs) undergo apoptosis during CKD, leading to capillary loss, tissue hypoxia, and oxidative stress. Although the mechanisms of PTC rarefaction are not well understood, the process of PTC rarefaction depends on multiple events that occur during CKD. These events, which lead to an antiangiogenic environment, include deprivation of EC survival factors, increased production of vascular growth inhibitors, malfunction of ECs, dysfunction of endothelial progenitor cells, and loss of EC integrity via pericyte detachment from the vasculature. In this review, we focus on major factors regulating angiogenesis and EC survival and describe the roles of these factors in PTC rarefaction during CKD and possible therapeutic applications.     

Hepcidin: clinical utility as a diagnostic tool and therapeutic target

Iron is essential for life, yet excessive iron can damage tissues and organs. To prevent iron deficiency and overload, iron balance is regulated by the hormone hepcidin. Hepcidin levels increase in response to iron sufficiency, decreasing intestinal iron absorption and inhibiting release of iron from stores and macrophages. Iron deficiency lowers hepcidin, leading to enhanced iron absorption and mobilization of iron from stores. Hepcidin is also increased by inflammation, and has a major role in the anemia of chronic disease. Chronic kidney disease (CKD) is associated with increased hepcidin levels, and this likely contributes to the incidence and severity of anemia, and resistance to erythropoiesis-stimulating agents (ESAs). Elevated hepcidin contributes to the dysregulation of iron homeostasis in CKD. In patients with CKD, although parenteral iron in CKD can bypass some of the iron-blocking effects of hepcidin, free iron and iron stores increase, anemia is only partially corrected, and ESA dose requirements remain significantly higher than physiological replacement. Agents that lower hepcidin or inhibit its actions may be effective strategies to restore normal iron homeostasis, and overcome anemia of chronic kidney disease. We review the regulation of hepcidin, its role in CKD-related anemia, and discuss the potential for hepcidin as a clinical marker, and several investigational methods to lower hepcidin for treatment of anemia in CKD.     

Group 'liaison' psychiatry as exclusive psychiatric therapeutic tool in a new burn centre

Group work based on Balint groups and mental hospital staff meetings was used as the sole psychiatric support in a new burn unit. 38 meetings were held during which 77 "indirect consultations" were held. Results show that this method allows satisfactory treatment of more patients with less time required of the psychiatrists themselves.     

The role of ureteroscopy as a diagnostic and therapeutic tool in various indications

Ureteroscopy is now in routine use for the diagnosis and treatment of various pathologies in the upper urinary tract. We report here on our experience in diagnostic and therapeutic applications of the 11.5 F rigid ureteroscope in 85 patients and 88 ureters. An overall success rate of 68.18% (60/88) was achieved when therapeutic and diagnostic interventions were evaluated together. Success rate was 66.65% in the treatment of ureteral stones (all locations), 100% in the removal of retained catheters, and 81.82% in diagnostic interventions. Frequencies of complications like postoperative fever, stone migration, and various degrees of ureteral perforation were 5.68%, 5.68%, and 7.95%, respectively, consistent with current literature. We conclude that rigid ureteroscopy can be safely applied for appropriate indications in the hands of competent urologists.     

MicroRNAs: a new therapeutic frontier for muscle wasting in chronic kidney disease

Multiple microRNAs (miRs) are implicated in muscle cell differentiation and muscle mass regulation. Pharmacological agents targeting miR-486 and other miRs, involved in muscle mass regulation, could potentially be developed into therapeutic agents for muscle wasting. Muscle wasting is prevalent among patients with chronic kidney disease (CKD). Xu et al. showed that miR-486 mimetic ameliorated muscle wasting in mice with CKD. miR mimetics may represent a new therapeutic frontier for muscle wasting in CKD.     

Mammography as a screening tool for coronary artery disease

BACKGROUND: The leading cause of death in women over 40 y old is coronary artery disease (CAD) followed by cancer. This large retrospective study investigates the relationship between mammographic benign arterial calcifications (BAC) and a history of CAD to determine if mammography is a suitable screening tool for CAD. METHODS: To determine the incidence of BAC in our general screening population, we prospectively studied 1000 consecutive women undergoing screening mammography. We retrospectively identified a population of women with known CAD who had undergone screening mammography as our study group. These groups were compared according to age and the significance of BAC in each group was statistically evaluated using the Cochran-Mantel-Haenszel test and Cochran-Armitage test for trend. RESULTS: We prospectively evaluated the mammograms of 819 women with no history of diabetes or CAD. Eighty-six women had mammographic BAC for a baseline BAC incidence of 10.5%. We identified 395 women with CAD and 193 (49%) of these women had BAC. Vascular calcifications significantly increased with age (P < 0.0001) in both groups. Stratifying by age, women with CAD had a significant increase in BAC compared with women undergoing routine screening (P < 0.0001). The odds ratio of having CAD when BAC are present on screening mammography compared with having CAD when BAC are not present is 6.2 (95% confidence interval estimate 4.3-8.8). CONCLUSIONS: This preliminary study indicates that across age groups, the odds of having CAC are approximately 6.2 times greater if BAC are present compared with women without BAC indicating that mammography may be a useful screening tool for CAD.     

Computer templates in chronic kidney disease care: a tool for improving patient management

Templates are custom screens that physicians can use within many practice management systems to offer a more relevant and efficient form for viewing and entering patient information. The ability to customize and effectively use a template increases the physician's ability to avoid medical errors, increase quality, promote efficiency, and have a higher level of satisfaction and accomplishment when managing patients. They enable physicians and practices to collect structured data that can be used to track patient data, analyze systems, and assist in research and quality improvement. We argue that templates hold the potential to increase the efficiency and quality of medical care, especially in the management of patients with chronic kidney disease, and that physicians should embrace customizing the templates in their medical practice management systems.     

Choledochoscopy as a diagnostic and therapeutic tool for common bile duct stones

Aim-Background

The aim is to present the results of a retrospective study comparing a) choledochoscopy in open and laparoscopic Common Bile Duct Exploration (CBDE) regarding the clearance of Common Bile Duct (CBD) from stones, b) open CBDE with and without choledochoscopy, and c) transcystic vs. transductal laparoscopic choledochoscopy.

Patients-Methods

Data were extracted from the medical records of 251 patients who had undergone open or laparoscopic Common Bile Duct Exploration. We excluded all those undergoing successful ERCP and sphincterotomy. The patients were separated into the following groups Group A: 127 patients who underwent Open CBDE; subgroup A1 comprised 52 patients who underwent Open CBDE with flexible choledochoscopy and intraoperative cholangiography (open CBDE+FCS+IOC), and Subgroup A2 included 75 patients who underwent Open CBDE with cholangiography (open CBDE+IOC). Group B: 124 patients who underwent Laparoscopic CBDE; subgroup B1 included 15 patients undergoing transcystic choledochoscopy, and subgroup B2 comprised 109 patients who underwent transductal choledochoscopy.

Results

The stone clearance rate in group A1 (open CBDE +FCS+IOC) was 98%, and in group A2 (open CBDE +IOC) it was 93%. However, the difference in the success rate between the choledochoscopic and “blind” technique was of no statistical significance (p=0.235). Similarly, no statistical significance was found between the success rates of open (98%) vs. laparoscopic (94%) choledochoscopy (p=0.869), or transcystic (Group B1) vs. transductal (GroupB2) laparoscopic choledochoscopy (87% vs. 95% respectively) (p=0.207), although greater success was noted in favour of transductal choledochoscopy. The conversion rate of transductal laparoscopic CBDE was 8%, and the main reason for conversion was stone impaction.

Conclusion

No statistical difference is noted in stone clearance rate between flexible choledochoscopy (FCS) and intraoperative cholangiography. However, intraoperative cholangiography has better outcomes regarding stone clearance when it is assisted by choledochoscopy. A search of the literature found no available data comparing the success rate of open vs. laparoscopic choledochoscopy. Our study demonstrated that the difference in the stone clearance rate between the two approaches was not statistically significant. Laparoscopic transcystic CBDE is less invasive and is associated with a lower complication rate, but it has higher failure rates compared to the transductal approach, although the difference is of no statistical significance.     

Mammography as a screening tool for peripheral vascular disease

BACKGROUND: Peripheral vascular disease (PVD) is a progressive and debilitating disease often diagnosed only when patients become symptomatic. Currently there are no widespread screening tests available for the early detection of PVD. Patients with diabetes and coronary artery disease are known to have a higher incidence of PVD. Prior studies have indicated that benign vascular calcifications seen on routine screening mammogram are more prevalent in women with diabetes and coronary artery disease. The same association has not been shown for women with PVD. The purpose of this study was to identify an association between benign vascular calcifications identified on mammography and PVD. If such an association exists then screening mammography, already widely used as a screening tool for breast cancer, may identify women at high risk for PVD. METHODS: To determine the incidence of vascular calcifications in our general screening population we prospectively evaluated consecutive routine screening mammograms for the presence of benign vascular calcifications. We then identified a population of women with PVD by using a computerized database maintained by the Division of Vascular Surgery. The population of women identified with PVD was categorized further to identify those women who had received routine screening mammogram within our hospital system. These mammograms were reviewed retrospectively with particular attention to the presence of vascular calcifications. All mammograms were reviewed by our dedicated mammographers. Statistical analysis of the study group using the chi-square test was performed to determine the association of PVD and mammographic vascular calcifications. RESULTS: Prospective evaluation of 645 women undergoing consecutive routine screening mammography identified 123 (19%) with benign vascular calcifications. By using our PVD computerized database between the years 2002 and 2004 we identified 763 women with PVD. Of this group only 121 (15%) had undergone a routine screening mammogram in our hospital system. These mammograms were reviewed retrospectively by the same group evaluating the screening mammograms. On evaluation vascular calcifications were identified in 42% (51 of 121) of these women with PVD. Statistical analysis was performed using the chi-square test, odds ratio, and relative risk. A highly significant association was identified between PVD and the presence of mammographic vascular calcifications (P > .001). With a confidence interval of 95% the presence of benign vascular microcalcifications on routine screening mammogram identifies a significant risk for PVD with an odds ratio of 3.06. We showed through our analysis that women with calcifications are 2.19 times more likely to have PVD if microcalcifications are present. By using vascular calcifications identified on screening mammography as a means to identify women with PVD the sensitivity and specificity are 42% and 80%, respectively. The positive predictive value and the negative predictive value are 29% and 88%, respectively, with an accuracy of 75%. CONCLUSIONS: This initial study indicates that the presence of vascular calcifications identified on routine screening mammogram is significantly higher in women with PVD and the lack of vascular calcifications on screening mammography correlates well with a negative history of PVD. We have identified a significant association with PVD and vascular calcifications in our patient population. Further studies are indicated to determine if screening mammography may become a widespread inexpensive screening tool to identify women at risk for PVD. Additional studies are underway at our institution to evaluate the association of PVD, diabetes and coronary artery disease, and vascular calcifications identified on routine screening mammography.