The Seventh Prototype of the Mini‐Spindle‐Pump: Does It Fulfill the Expectations of a Short‐Term Pump?

According to recent trends to develop implantable nonpulsatile blood pumps for different function modes and times, our intention was and still is to build a Mini-Spindle-Pump for a pumping duration of about 14 days. Initial conception for this plan was the premise that the device in a mock circuit should move 4 L of water/min at a speed of 12,000 to 15,000 rpm against a pressure difference of 90 mm Hg between pump inlet and outlet. Despite the development of 6 different prototypes, this project was not realized. Under the above-mentioned conditions, the main problem of this type of blood pump, the blood trauma, could not be reduced to an adequate level, i.e., the Mini-Spindle-Pump is not a high speed pump. Therefore, a revision of the conception was necessary. The device in a mock circuit should transport 5 L of water/min at a speed of about 9,000 rpm against a pressure difference of 90 mm Hg between its inlet and outlet. Considering the implantability of the blood pump, the following measurements for its components were arrived at. The U-shaped blockformed plexiglas housing was enlarged to 120 x 40 x 40 mm (length of blood chamber 86 mm, inner diameter 27 mm), and the rotor with 5 windings was redesigned at a length of 64 mm (outer diameter 25 mm, inner diameter 6.7 mm). In a mock circuit, this 7th prototype transported with a speed of 9,000 rpm about 10 L of water/min at an afterload of 80 mm Hg. In acute animal experiments with calves up to 15 h of pumping duration, the device showed the expected efficiency. Experiments with a longer pumping duration are necessary to confirm that this prototype will fulfill the criteria of a short-term pump according to Dr. Y. Nosé's advice.     

Does DCD Donor Time‐to‐Death Affect Recipient Outcomes? Implications of Time‐to‐Death at a High‐Volume Center in the United States

For donation after circulatory death (DCD), many centers allow 1 h after treatment withdrawal to donor death for kidneys. Our center has consistently allowed 2 h. We hypothesized that waiting longer would be associated with worse outcome. A single‐center, retrospective analysis of DCD kidneys transplanted between 2008 and 2013 as well as a nationwide survey of organ procurement organization DCD practices were conducted. We identified 296 DCD kidneys, of which 247 (83.4%) were transplanted and 49 (16.6%) were discarded. Of the 247 recipients, 225 (group 1; 91.1%) received kidneys with a time to death (TTD) of 0–1 h; 22 (group 2; 8.9%) received grafts with a TTD of 1–2 h. Five‐year patient survival was 88.8% for group 1, and 83.9% for group 2 (p = 0.667); Graft survival was also similar, with 5‐year survival of 74.1% for group 1, and 83.9% for group 2 (p = 0.507). The delayed graft function rate was the same in both groups (50.2% vs. 50.0%, p = 0.984). TTD was not predictive of graft failure. Nationally, the average maximum wait‐time for DCD kidneys was 77.2 min. By waiting 2 h for DCD kidneys, we performed 9.8% more transplants without worse outcomes. Nationally, this practice would allow for hundreds of additional kidney transplants, annually.     

Postanal repair – do the long‐term results justify the procedure?

Objective Early outcomes after postanal repair (PAR) demonstrated excellent results but subsequent reports showed an ever declining success rate in maintaining continence. The aim of this study was to document long‐term continence after PAR and relate this to patient satisfaction and quality of life. Method Patients with neurogenic incontinence who underwent PAR from 1986 to 2002 were interviewed by telephone, utilizing a questionnaire which assessed continence, patient satisfaction, overall improvement, and quality of life. Results One‐hundred one patients from four surgeons were identified. Fifty‐four patients were excluded because of loss to follow‐up. Three had a stoma (two for incontinence), four had undergone a graciloplasty, leaving 57 patients (F = 53), mean duration of follow‐up of 9.1 years (2.2–18.7 years). Mean CCS was 11.7 (SD 7.4). 26% (n = 15) scored none to minimal incontinence (CCS 0–5), 26% moderate (CCS 6–12), and 48% (n = 27) severe incontinence (CCS 13–24). 79% (n = 45) were satisfied with the outcome. A low CCS significantly correlated with good patient satisfaction, and was influenced by high QOL score (P < 0.0001). A high CCS significantly correlated with high bowel frequency (P = 0.0007). A favourable CCS was associated with a good QOL, a shorter duration of follow‐up, and being able to distinguish flatus and stool. Conclusions In patients with neurogenic faecal incontinence selected following anorectal physiology studies, PAR remains a useful treatment. It is associated with low morbidity and results in a satisfactory long‐term subjective outcome, despite the fact that many patients have a high incontinence score.     

Liver transplant from Anti‐HBc‐positive,HBsAg‐negative donor into HBsAg‐negative recipient: is it safe? A systematic review of the literature

Avelino‐Silva VI, D′Albuquerque LAC, Bonazzi PR, Song ATW, Miraglia JL, de Brito Neves A, Abdala E. Liver transplant from Anti‐HBc‐positive, HBsAg‐negative donor into HBsAg‐negative recipient: is it safe? A systematic review of the literature.
Clin Transplant 2010: 24: 735–746. © 2010 John Wiley & Sons A/S. Abstract: Introduction: After liver transplant (LT) from Anti‐HBc+/HBsAg? donors into HBsAg? recipients, transmission of hepatitis B virus (HBV) may occur (de novo HBV infection). This study analyzes the incidence of de novo HBV infection in HBsAg? recipients of Anti‐HBc+/HBsAg? LT with respect to: (i) the recipients’ HBV serology and (ii) the type of preventive therapy adopted. Methods: A systematic review of the literature using the electronic database Medline. Results: Five hundred and fifty‐two LT in 36 articles were selected. Lamivudine, Hepatitis B immune globulin (HBIG), revaccination, and combined therapies were employed in multiple strategies as preventive interventions. Naïve recipients had a high risk of de novo HBV infection, with smaller incidences when HBIG and lamivudine were used, either alone or in association. Vaccinated recipients or those with isolated hepatitis B core antibodies (Anti‐HBc) and previous HBV infection had lower risks of viral transmission, additionally reduced by any prophylaxis adoption. Discussion: LT from Anti‐HBc+/HBsAg? donors into HBsAg? recipients is apparently safe, as long as the recipient is vaccinated or presents an isolated Anti‐HBc or previous HBV infection and some prophylaxis is employed. Currently lamivudine seems the best alternative; other nucleoside analogs and revaccination strategies should be considered in future studies. Follow‐up and preventive therapies should be maintained for five yr or preferably throughout the recipients’ life span.     

Short‐term administration of prulifloxacin in patients with nonmuscle‐invasive bladder cancer: an effective option for the prevention of bacillus Calmette‐Guérin‐induced toxicity?

OBJECTIVE

To determine whether the new fluoroquinolone prulifloxacin might improve tolerance to Bacillus Calmette‐Guérin (BCG) intravesical therapy in patients with bladder cancer.

PATIENTS AND METHODS

A series of 72 patients with intermediate‐ or high‐risk nonmuscle‐invasive bladder cancer were enrolled in this prospective, randomized, open‐label, controlled clinical trial performed at a single tertiary care institution. After complete transurethral resection, patients were randomized to receive induction treatment with BCG and three capsules of prulifloxacin 600 mg or no prophylactic treatment (control group). Adverse events (AEs) were self‐recorded by the patients after each instillation and classified by the investigator according to a classification grid considering account duration and intensity. Cystoscopy findings at 3 and 6 months were also recorded.

RESULTS

There was no significant difference in baseline symptoms between the groups. Overall, there was a significant decrease in the percentage of patients with at least one AE between instillations in prulifloxacin‐treated group. The proportion of patients with moderate to severe AEs after the fourth instillation was significantly less in the prulifloxacin‐treated group. There was a significant effect of prulifloxacin on the need for anti‐tuberculosis treatment. More patients in the control group stopped or delayed the full induction course of BCG instillations (34% vs 19%, P = 0.04). Recurrence rates were not affected by prulifloxacin treatment.

CONCLUSION

Prulifloxacin reduces the incidence of moderate to severe AEs from BCG intravesical therapy in patients with nonmuscle‐invasive bladder cancer, improving compliance to the induction BCG course. These preliminary findings warrant further clinical research.     

Wait‐and‐see policy for the N0 neck in early‐stage oral and oropharyngeal squamous cell carcinoma using ultrasonography‐guided cytology: Is there a role for identification of the sentinel node?

BACKGROUND: Management of the N0 neck in patients with head and neck squamous cell carcinoma (SCC) remains controversial. We describe the outcome of patients who underwent transoral tumor excision and a wait-and-see policy for the neck staged N0 by ultrasonography-guided cytology (USgFNAC). Because selection of lymph nodes for USgFNAC is currently based on size criteria, we investigated the additional value of sentinel node (SN) identification. METHODS: The outcome of 161 patients with T1-T2 oral/oropharyngeal SCC was determined. In a subgroup of 39 patients the SN was identified and aspirated in addition. RESULTS: SN identification and aspiration was possible in 38 of 39 patients but without decreasing the false-negative rate of USgFNAC. During follow-up (12-99 months) 34 of 161 (21%) patients developed lymph node metastases. After therapeutic neck dissection and postoperative radiotherapy, 27 of 34 (79%) could be salvaged (88% regional control). CONCLUSIONS: Wait-and-see seems justified in case of negative USgFNAC. Strict follow-up with USgFNAC is required. SN identification and aspiration is feasible but did not improve lymph node selection.     

In the era of micro‐dissection sperm retrieval (m‐TESE) is an isolated testicular biopsy necessary in the management of men with non‐obstructive azoospermia?

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? There are a number of ways to retrieve sperm from the testis however there is no universal consensus as to which is the best approach. Furthermore, there is controversy as to whether a diagnostic biopsy has a role in management of non‐obstructive azoospermia (NOA). This study gives support to the growing consensus that micro‐dissection TESE (m‐TESE) is the optimum approach to retrieve sperm in patients with NOA even when previous attempts have failed. Moreover, it strongly suggests that histology is unreliable in determining success rates with m‐TESE and therefore isolated diagnostic biopsies should not be performed.

OBJECTIVES

• ? To assess the outcome of sperm retrieval using micro‐dissection‐TESE (m‐TESE) and simultaneous diagnostic biopsy in NOA to determine if the final definitive histology correlated with the outcome of sperm retrieval by m‐TESE in men with NOA.
• ? To determine if there was a correlation between FSH levels and positive sperm retrieval rates and assessed the success rate of m‐TESE as either a primary or a salvage procedure after previous negative sperm retrieval.
• ? The EAU guidelines (2010) recommend that in men with non obstructive azoospermia ‘a testicular biopsy is the best procedure to define the histological diagnosis and the possibility of finding sperm’. However, these guidelines do not identify which patients should have a diagnostic biopsy and if this biopsy should be performed as an isolated procedure or synchronously with sperm retrieval. It is also suggested that there is a correlation between the histological diagnosis and possibility of finding sperm on testis biopsy.

PATIENTS AND METHODS

• ? 100 men with NOA underwent a m‐TESE sperm retrieval between 2005 and 2010 at a single centre.
• ? All patients underwent hormonal analysis (serum FSH, Testosterone and LH levels) and genetic analyses after full counselling including; Y‐deletion, CF‐gene analysis and karyotype.
• ? Thirty five men had previously undergone unsuccessful TESA/TESE or diagnostic biopsy at other centres. All patients underwent synchronous sperm retrieval and biopsy of the testis, which was sent for histopathological examination on the day of an ICSI cycle or as an isolated procedure.

RESULTS

• ? Mean age of patients was 37.25 (range 29–56 years). The mean serum FSH levels in the Sertoli cell only, maturation arrest and hypospermatogenesis groups were 21.3 IU/L (2.8–75), 16.18 (1.6–67) and 14.17 IU/L (0.8–42.3) respectively. SR rates in the respective groups were 42.85%, 26.6% and 75.86% (P= 0.023). There were no post‐operative complications.
• ? In the 35 men who had previously undergone unsuccessful procedures elsewhere, the SR rates were 57.1%. The overall sperm retrieval rate was 50%. There was no correlation between SR and FSH levels (P= 0.28).

CONCLUSION

• ? M‐TESE should be considered the gold standard for retrieval of testicular sperm in NOA, even in cases where there has been previously unsuccessful attempts. FSH levels and histology cannot be used to predict the success of sperm retrieval. An isolated diagnostic testicular biopsy is not recommended in men with NOA, as a significant proportion of men undergoing m‐TESE will have successful a sperm retrieval irrespective of previous histology or previous unsuccessful surgery.

     

Can we improve the definition of high‐risk,hormone naïve,non‐metastatic prostate cancer?

• To identify criteria beyond Tumour‐Node‐Metastasis (TMN)‐, prostate‐specific antigen (PSA)‐ and Gleason score‐based standard classifications to enhance the stratification of non‐metastatic high‐risk prostate cancer.
• A detailed search of the literature was performed using PubMed.
• The authors reviewed the literature and used a modified Delphi approach to identify relevant approaches to enhance standard classifications.
• Specific criteria for high‐risk prostate cancer vary across guidelines and clinical trials, reflecting the differing perspectives concerning the definition of ‘risk’ between different specialities within the urology/radiation oncology community.
• In addition to the present classifications, evidence exists that the measure of cancer volume can provide additional prognostic value.
• More accurate imaging, especially multiparametric magnetic resonance imaging can also provide information concerning staging and cancer volume, and thus may assist in the identification of patients with high‐risk prostate cancer.
• A refined definition of non‐metastatic high‐risk prostate cancer is proposed.
• Within this high‐risk cohort, patients with multiple high‐risk criteria are especially at risk of prostate cancer‐specific mortality.

     

Can thrombin‐activated platelet releasate compensate the age‐induced decrease in cell proliferation of MSC?

Mesenchymal progenitor cells (MSCs) are promising for cell‐based regeneration therapies. In elderly patients a reduced proliferation of MSCs has been described. Platelet‐rich plasma (PRP) contains important factors necessary for osteogenic regeneration. The aim of this study was to find out whether the age‐induced decrease in cell proliferation can be compensated by the use of supernatant of centrifuged, activated PRP (tPR). MSCs of donors of three age groups (A: young, 14–16 years, B: middle age, 36–46 years, C: older, 74–83 years) were expanded with 20% FCS alone or supplemented with thrombin‐activated platelet releasate (tPR) (1%, 2.5%, and 5%) or platelet‐poor plasma (PPP 5%). Cell proliferation and differentiation was measured on days 0, 3, and 7. Proliferation increased significantly in groups A and B with tPR, and non‐significantly in group C. The generation times of MSCs of elderly patients were significantly increased in group C compared to groups A and B. Addition of 1% or 2.5% tPR significantly reduced population doubling times of all age groups. Adding tPR stimulates the proliferation rate of MSCs independent of donor age. For juvenile and middle‐aged patients this influence was significant. Cells differentiation into osteoblasts was not influenced by addition of tPR. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31:1786–1795, 2013     

Are anti‐endothelial cell antibodies a pre‐requisite for the acute vascular rejection of xenografts?

Dorling A. Are anti‐endothelial cell antibodies a pre‐requisite for the acute vascular rejection of xenografts? Xenotransplantation 2003; 10: 16–23. © Blackwell Munkgaard, 2003 Background: Vascular rejection occurring within the first few weeks after transplantation is still the major immunological barrier to the long term survival of xenografts. Currently there is no consensus about what to call this type of rejection (acute vascular rejection, delayed xenograft rejection or acute humoral xenograft rejection), nor about how to prevent or treat it. Methods: A review of published evidence to define the heterogeneity of this phase of rejection and examine the role of antibodies, complement and graft‐infiltrating inflammatory cells. Results: i) antibodies are always involved in acute vascular rejection; ii) this antibody‐mediated rejection may be complement‐dependent or ‐independent; iii) inflammatory cells may mediate an antibody‐ and complement‐independent phase of rejection in some small animal models (which, in its pure form cannot be called ‘vascular rejection’) iv) there remain significant questions about the relevance of ‘accommodation’ and the importance of coagulation abnormalities. Conclusions: Without doubt, future research would be helped by distinguishing between these different forms of delayed xenograft rejection, using terminology to reflect the involvement of specific pathophysiological mechanisms. An updated classification of the stages of xenograft rejection is proposed here.     

Patient Compliance in the Setting of BI‐RADS Category 3: What Factors Impact Compliance With Short‐Term Follow‐Up Recommendations?

The study aims to define how imaging findings, patient demographics, patient–provider interactions, and health care practices may affect a woman's decision to follow‐up in the setting of a BI‐RADS Category 3. A total of 398 women from the University of Arizona Breast Imaging Center with a BI‐RADS Category 3 assessment for mammography and/or ultrasound findings were evaluated between February 2012 and June 2014. Demographic information was analyzed for all patients, regardless of follow‐up. Women who returned for follow‐up within the recommended time period were given one survey at the time of their follow‐up appointment, and women who returned for follow‐up, but later than recommended, were given a separate survey to complete. Age, palpability of a lesion, and menopause status were related to follow‐up. Self‐rated general health was the only factor found to be associated with the decision to follow‐up on time. The majority of patients who followed up on time reported that mailed reminder cards were the primary practice that prompted follow‐up. Of patients who followed up later than recommended, the major reason was “no time.” The findings suggest that additional counseling regarding the benefits of short‐interval imaging follow‐up might be advantageous for patients.