Robotic renal surgery for renal cell carcinoma with inferior vena cava thrombus

Surgical management of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus is inherently complex, posing challenges for even the most experienced urologists. Until the mid-2000s, nephrectomy with IVC thrombectomy was exclusively performed using variations of the open technique initially described decades earlier, but since then several institutions have reported their robotic experiences. Robotic IVC thrombectomy was initially reported for level I and II thrombi, and more recently in higher-lever III thrombi. In general, the robotic approach is associated with less blood loss and shorter hospital stays compared to the open approach, low rates of open conversion in reported cases, relatively low rates of high-grade complications, and favorable overall survival on short-term follow-up in limited cohorts. Operative times are longer, costs are significantly higher, and left-sided tumors always require intraoperative repositioning and usually require preoperative embolization. To date, criteria for patient selection or open conversion have not been defined, and long-term oncologic outcomes are lacking. While the early published robotic experience demonstrates feasibility and safety in carefully selected patients, longer-term follow-up remains necessary. Patient selection, indications for open conversion, logistics of conversion particularly in emergent settings, necessity and safety of preoperative embolization, the value proposition, and long-term oncologic outcomes must all be clearly defined before this approach is widely adopted.     

Heat shock protein 70 subunit vaccination against bovine paratuberculosis does not interfere with current immunodiagnostic assays for bovine tuberculosis

Paratuberculosis or Johne's disease in ruminants is an infectious disease of the small intestine caused by Mycobacterium avium spp. paratuberculosis, and a global problem of the livestock industry. No therapy is available and the use of a whole bacterin vaccine is limited due to interference with tuberculosis diagnostics.     

Magnesium sulphate and amiodarone prophylaxis for prevention of postoperative arrhythmia in coronary by-pass operations

Background  

The aim of this study was to investigate the use of prophylactic magnesium sulphate and amiodarone in treating arrhythmias that may occur following coronary bypass grafting operations.     

Chromosome and sister chromatid exchange studies in Behcet's patients

Behcet's disease is a chronic multisystemic disease of unknown pathogenesis characterized by four major symptoms: oral aphthous ulcers, skin lesions, ocular symptoms and genital ulcerations. The disease is spread throughout the world, but it is most frequent in Turkey, Japan, Korea and China. Although HLA-Bw51 has been found to predominate in Behcet's cases, the genetic etiology has not yet been clarified. In this study, we investigated the chromosomal abnormalities and sister chromatid exchange rates in patients with Behcet's diseases. Thirty-eight patients with Behcet's disease (diagnosed for the first time) and 30 healthy subjects (as controls) were included in this study. Although numerical and structural chromosomal abnormalities were not detected in our patients, we found an increased rate of sister chromatid exchange in patients over the control groups (P < 0.01). On the basis of these results, we discuss the genetic etiology of Behcet's disease.     

Transfusion-transmitted virus prevalence in Turkish patients with thalassemia

In hematology patients on chronic transfusion regimes, liver diseases are frequent, and mostly related to the agents transmitted by blood products and concominant iron deposition in liver. Besides hepatitis B (HBV) and C (HCV) viruses, new viral agents like hepatitis G virus (HGV) and TorqueTeno virus (TTV) are identified in these patients, although their association with any pathology or disease is not yet proved. In the present work, the authors studied the clinical importance of TTV in Turkish multitransfused patients with thalassemia. Forty-six healthy and 57 thalassemic patients were enrolled in the study. TTV was detected in serum samples by 3'-UTR nested PCR. Transaminase and ferritin levels, hepatitis B and C virus markers and number of transfusions were interpreted for possible association with TTV infection. As a result, TTV was detected in 63% of the thalassemia and 54% of the control patients. Prevalence of TTV infection, clinical features, laboratory data, and annual transfusion numbers of TTV-positive and -negative patients were not observed to be statistically significant. In conclusion, in Turkish patients with thalassemia, TTV infection cannot be considered as a risk factor for liver disease.     

Enhanced Absorption of Insulin Aspart as the Result of a Dispersed Injection Strategy Tested in a Randomized Trial in Type 1 Diabetic Patients

OBJECTIVE

We investigated the impact of two different injection strategies on the pharmacokinetics and pharmacodynamics of insulin aspart in vivo in an open-label, two-period crossover study and verified changes in the surface-to-volume ratio ex vivo.

RESEARCH DESIGN AND METHODS

Before the clinical trial, insulin aspart was injected ex vivo into explanted human abdominal skin flaps. The surface-to-volume ratio of the subcutaneous insulin depot was assessed by microfocus computed tomography that compared 1 bolus of 18 IU with 9 dispersed boluses of 2 IU. These two injection strategies were then tested in vivo, in 12 C-peptide–negative type 1 diabetic patients in a euglycemic glucose clamp (glucose target 5.5 ± 1.1 mmol/L) for 8 h after the first insulin administration.

RESULTS

The ex vivo experiment showed a 1.8-fold higher mean surface-to-volume ratio for the dispersed injection strategy. The maximum glucose infusion rates (GIR) were similar for the two strategies (10 ± 4 vs. 9 ± 4; P = 0.5); however, times to reach maximum GIR and 50% and 10% of the maximum GIR were significantly reduced by using the 9 × 2 IU strategy (68 ± 33 vs. 127 ± 93 min; P = 0.01; 38 ± 9 vs. 49 ± 16 min; P < 0.01; 23 ± 6 vs. 30 ± 10 min; P < 0.05). For 9 × 2 IU, the area under the GIR curve was greater during the first 60 min (219 ± 89 vs. 137 ± 75; P < 0.01) and halved until maximum GIR (242 ± 183 vs. 501 ± 396; P < 0.01); however, it was similar across the whole study period (1,361 ± 469 vs. 1,565 ± 527; P = 0.08).

CONCLUSIONS

A dispersed insulin injection strategy enhanced the effect of a fast-acting insulin analog. The increased surface-to-volume ratio of the subcutaneous insulin depot can facilitate insulin absorption into the vascular system.Fast-acting insulin analogs have been developed to avoid postprandial glucose peaks (1,2). Some studies suggest that postprandial hyperglycemia can contribute to elevated levels of hemoglobin A_1c (3,4) and lead to the development of short- and long-term diabetes complications (5,6). Although currently available fast-acting insulin analogs have been designed for a better match with meal-induced glucose excursions, insulin absorption and insulin action still lag behind (7,8). Even bolus administration of fast-acting insulin analogs immediately before meals does not completely avoid postprandial glucose peaks. Modern fast-acting insulin analogs still only insufficiently mimic physiological insulin profiles; however, their effect could be further improved by accelerating insulin absorption from the injection site into the vascular system.Accelerated insulin absorption in response to an increased blood flow has been described for heated injection sites (9) or coadministered adjuvants such as hyaluronidase (10–12) but also for a larger distribution of the subcutaneous insulin depot achieved with a modified injection strategy. Human insulin absorption has been tested with a “sprinkler needle” that has 14 holes in its walls and a sealed tip, thus dispersing the insulin bolus at the injection site. With the sprinkler needle, insulin was absorbed more rapidly and glucose levels were less raised relative to a regular injection needle (13). A dispersed insulin bolus should have an increased surface-to-volume ratio and could further contribute to even faster insulin absorption of modern already fast-acting insulin analogs.The aim of our study was to test whether the absorption rate of a fast-acting insulin analog (insulin aspart) could be further accelerated through the dispersion of a single predefined insulin bolus into nine separate insulin injections. We compared the two different injection strategies ex vivo by using microfocus computed tomography (micro-CT) to assess the increase in the surface-to-volume ratio and in vivo by assessing the pharmacokinetic and pharmacodynamic response in a clinical trial.     

Evaluation of the serodia Treponema pallidum particle agglutination, the Murex Syphilis ICE and the Enzywell TP tests for serodiagnosis of syphilis

We evaluated the Treponema pallidum haemagglutination assay (TPHA), a treponemal test, with three other treponemal tests, the Serodia T. pallidum particle agglutination assay, the Murex Syphilis ICE IgG + IgM enzyme immunoassay (EIA) and the Enzywell TP IgG + M EIA (a new rapid EIA) for use in conjunction with the rapid plasma reagin test (RPR), a non-treponemal test, for serodiagnosis of syphilis. In all, 124 serum samples were found reactive with RPR and/or TPHA after testing by the routine laboratory protocol. Twenty-three (18.5%) of them were positive only by RPR test and were evaluated as biologically false-positive, 16 were positive only by the TPHA and 84 by both the RPR and TPHA tests; one sample was non-specific (heterophile reaction) in the TPHA.Agreements of the TPHA with the Serodia TPPA, the Murex Syphilis ICE and the Enzywell TP tests were 96.7%, 100% and 99.1%, respectively.We conclude that each one of the tests, the Serodia TPPA, the Murex Syphilis ICE and the Enzywell TP, is an appropriate substitute for screening for serodiagnosis of syphilis.     

Prophylactic treatment of mycotic mucositis in radiotherapy of patients with head and neck cancers

BACKGROUND: Patients undergoing radiotherapy for head and neck cancer are at increased risk of developing oral candidiasis. The objective of this study was to investigate the clinical Candida mucositis and interruptions in radiotherapy in patients suffering from head and neck cancer, receiving fluconazole in comparison with a control group without specific prophylaxis. METHODS: Eighty consecutive patients were randomized in a prospective double-blind trial of prophylactic oral fluconazole or treatment with the same drug when mycotic infections appeared. Adult head and neck cancer patients who were undergoing treatment with radiotherapy and/or chemotherapy, radiotherapeutic coverage of the entire oropharynx and oral cavity at least 3 cm anterior to the retromolar trigone and receiving a total dose of more than 6000 cGy and Karnofsky Performance Status (KPS) >70 were included in the study. Group A received radiation therapy plus fluconazole (Fluzole 100 mg/day) starting from the sixth irradiation session throughout the treatment; 40 patients in group B received the same baseline treatment, but were given fluconazole only when mycotic infections appeared. RESULTS: We evaluated 37 patients in group A and the first 37 patients were evaluated in group B. Three of the patients in group A (8.1%) and 14 of the patients in group B (37.8%) demonstrated clinical candidasis. Radiotherapy was interrupted in all of these patients. The differences between the two groups were statistically significant with respect to clinical candidiasis (P = 0.005). The median discontinuation time was 5 days (range, 3-7 days) in group A and 7 days (range, 4-10 days) in group B. The median dose resulting in clinical candidiasis was 3200 cGy (range, 2200-5800 cGy) in all groups. In the fluconazole group it was 4200 cGy and in the control group 2800 cGy. CONCLUSION: These results suggest that patients undergoing head and neck radiation therapy are at risk of developing candidiasis and that fluconazole may be used to reduce the frequency of mycotic infections and to improve the radiotherapy schedule in head and neck cancer patients.