Partial nephrectomy for renal cell carcinoma in long-term renal allografts: operative and post-operative considerations

The majority of immunosuppressive agents used to prevent rejection in transplant patients have also been shown to increase malignancy risk. Renal transplant patients are dependent upon their solitary allograft kidney in order to remain dialysis free, and the discovery of a primary malignancy within the allograft poses a therapeutic dilemma. We describe two cases of primary renal allograft malignancies and discuss nephron-preserving surgical treatment. Furthermore, we discuss the potential anti-tumor role of the immunosuppressive agent sirolimus in the treatment of these complex patients.     

Partial nephrectomy vs. radical nephrectomy for stage I renal cell carcinoma in the presence of predisposing systemic diseases for chronic kidney disease

Aim of this study is to compare the effects of partial nephrectomy (PN) and radical nephrectomy (RN) for stage I renal cell carcinoma (RCC) on renal functions in patients with diabetes mellitus (DM) and/or hypertension (HT). Charts of patients who underwent surgery for stage I RCC in our department were retrospectively reviewed and patients with DM and/or HT were enrolled. Preoperative and postoperative estimated glomerular filtration rates (eGFR) were calculated according to the Modification of Diet in Renal Disease (MDRD) formulation for both RN and PN groups. Groups were compared for patient demographics, preoperative eGFR, postoperative eGFR and ΔeGFR [(preoperative eGFR) – (postoperative eGFR)] which reflects the renal functional loss. There were 85 patients in the RN and 33 patients in the PN groups. Demographic data were similar but the patients in the PN group had smaller tumor size compared to RN group (32.2 ± 11.8 mm vs 47.1 ± 15.2 mm, p < 0.001). Preoperative eGFR did not differ between groups (75 ± 28.4 mL/min/1.73 m² vs 75.5 ± 23.8 mL/min/1.73 m² in RN and PN groups, p = 0.929). However, there were significant differences between groups in terms of postoperative eGFR (57.5 ± 21.7 mL/min/1.73 m² vs 74 ± 27.5 mL/min/1.73 m² in RN and PN groups, p < 0.001) and ΔeGFR (17.5 ± 4.2 mL/min/1.73 m² vs 1.5 ± 0.4 mL/min/1.73 m² in RN and PN groups, p < 0.001). Our findings favor the use of PN over RN for stage I RCC whenever feasible in patients with predisposing systemic diseases for chronic kidney disease for better preservation of renal functions.     

Absence of ageism in access to critical care: a cross-sectional study

BACKGROUND: in recent years, the NHS has been accused of ageism frequently and from many fronts. Previous studies have shown that the number of critical care beds in the UK is inadequate to meet the needs of the population. This study asks whether there is discrimination against older people in access to these critical care beds. METHODOLOGY: all sick patients in five hospitals in a South Wales Health Authority were studied every 12th day for one calendar year. Demographic, clinical and physiological data were collected. Ten members of the Welsh Intensive Care Society subsequently judged the optimum location of care for each of these individuals. This was based on a summary of diagnoses, procedures and physiological/biochemical results, but without access to the age of the patient or type of ward or hospital where the patients was actually treated. These data were analysed to determine whether the likelihood of being treated in the most appropriate setting, based on the consensus decision, was influenced by the patient's age. RESULTS: 4058 patients met the study criteria, of whom 2287 patients (56.4% of the total) were being cared for on a general ward and 1769 in critical care areas. The intensivist panel determined that 1085 (53%) ward based patients were more suitable for care on intensive care or high dependency units and 220 (12.4%) critical care patients were suitable for ward care. The proportion of patients considered to be in an inappropriate ward varied little in different age groups. DISCUSSION: many patients on general wards have needs that may be more appropriately addressed on critical care units but there is no relationship between these unmet needs and the age of the patient.     

Hand-assisted laparoscopic live donor nephrectomy: a case report

Live donor renal transplantation offers significant advantages over cadaveric renal transplantation. It yields significantly better patient and graft survival on both short-term and long-term follow-up. Laparoscopic donor nephrectomy minimizes the morbidities associated with the surgical procedure and allows a speedy return to normal daily activities. The operation also provides an atraumatic kidney subjected to minimal warm ischemia time and with adequate length of artery and vein, resulting in immediate functioning of the kidney after transplantation with a low rate of ureteral complications. A 37-year-old man was referred as a kidney donor for his brother. Both donor and recipient were hepatitis-B surface antigen carriers. Cross-matching and human leukocyte antigen test showed good compatibility. Left donor nephrectomy was performed successfully by hand-assisted laparoscopy. The warm ischemic time was 4.5 minutes and the graft kidney functioned immediately after transplantation. The donor was discharged from the hospital on postoperative Day 3 with good recovery.     

ALLHAT: a critical assessment

The ALLHAT study has attracted considerable attention in the media and in the research community, partly due to the study's unexpected and controversial conclusions. However, the study has several serious shortcomings. The primary end-points in ALLHAT were negative and the conclusions are based entirely on secondary end-points and subgroup analyses. Moreover, there is good reason for skepticism concerning the findings on heart failure in ALLHAT, because of ambiguity in the diagnosis, lack of information on blood pressure and absence of a “washout” period. The study design was severely flawed and does not reflect clinical reality. Also, blood pressure differences between groups severely complicate interpretation. From a patient perspective in ALLHAT, there are drug safety concerns with the thiazides, as there was evidence of excess diabetes development. The ALLHAT results are difficult to generalize and have limited relevance in European settings. Thus, the ALLHAT study suffers from several major shortcomings and there is a huge body of evidence that contradicts the ALLHAT interpretations.     

Electrophysiologic study in the management of cardiac arrest survivors: a critical review

This review discusses the value and limitations of EPS in the management of cardiac arrest survivors. Uncertainties associated with EPS include a lack of consensus with respect to stimulation protocol, end points for VT suppression during drug testing, significance of induced polymorphic VT or VF, and timing of EPS after myocardial infarction. Despite methodologic shortcomings in most clinical studies, a useful body of knowledge has emerged. In cardiac arrest survivors, incidence of inducible sustained VT ranged from 35% to 75%. Where induced VT (sustained or nonsustained) was successfully suppressed, recurrent arrhythmic events occurred in 0% to 33% of patients over a 1- to 5-year follow-up period. Failed regimens correlated with a high risk of arrhythmic recurrence. EPS also helps to select patients for the implantable defibrillator or electrocardiac surgery. In conclusion, EPS appears empirically useful in the management of cardiac arrest survivors with coronary artery disease; its value in other disease entities is uncertain.     

Partial atrial standstill: a case report

Twelve-lead electrocardiograms revealed no atrial activity and a wide QRS escape rhythm at 38 beats/min in a 20-year-old man who presented with syncope. Doppler echocardiography documented the absence of A wave both in the tricuspid and mitral valve flow. The only mechanical activity was documented at the left atrial appendage. An electrophysiologic study demonstrated electrical inactivity in the right atrium and an atrial tachycardia in the left atrium. Atrial pacing with maximum output did not capture the atria. Our case represents an advanced stage of partial atrial standstill, with a mechanical and electrical atrial activity confined only to the left trial appendage. The patient remained asymptomatic after receiving a VVIR pacemaker and anticoagulation therapy.     

Critical thinking and clinical decision making in critical care nursing: a pilot study

OBJECTIVE: This pilot study examined the relationship of education level, years of critical care nursing experience, and critical thinking (CT) ability (skills and dispositions) to consistency in clinical decision making among critical care nurses. Consistency was defined as the degree to which intuitive and analytical decision processes resulted in similar selection of interventions in tasks of low and high complexity. DESIGN: The study was nonexperimental and correlational. SAMPLE: Critical care nurses (n = 54) from adult critical care units in 3 private teaching hospitals. The majority of nurses held a BSN or MSN and had an average of 9 years of direct clinical experience in the care of the critically ill. RESULTS: Decision-making consistency decreased significantly between low-complexity and high-complexity tasks. Both intuitive and analytical decision processes produced clear intervention selections in the low-complexity task, although the analytical process resulted in a more complete specification of interventions. In the high-complexity task, however, only the intuitive process resulted in a clear, plausible, and safe specification of interventions. Education and experience were not related to CT ability, nor was CT ability related to decision-making consistency. Only greater years of critical care nursing experience increased the likelihood of decision-making consistency. CONCLUSIONS: Overall, intuitive decision processes resulted in more clinically consistent selection of interventions across tasks. More investigation is needed to examine the influence of decision heuristics, and the conceptualization and measurement of CT abilities among practicing nurses.