Clinical evaluation of hyponatremia and hypovolemia in critically ill adult neurologic patients: contribution of the use of cumulative balance of sodium

Purpose

Knowledge of the cumulative balance of sodium (CBS) is important for the diagnosis of salt disorders and water homeostasis and has the potential to predict hypovolemic status in acute neurological patients. However, an extensive application of the use of CBS is still lacking in the intensive care setting, where salt and water homeostasis represents a priority.

Methods

Records of consecutive series of acute neurological patients admitted to a neurointensive care unit over a 6-month period were retrospectively reviewed. CBS was calculated at the admission to the Emergency Department. Discrimination between cerebral salt-wasting syndrome (CSWS) and the syndrome of inappropriate antidiuretic hormone secretion (SIADH) was performed on the basis of the classical criteria. Additionally, we used the findings of a negative CBS exceeding 2 mEq/kg for the diagnosis of CSWS. Two independent clinicians who were blinded to the CBS results performed diagnosis of the causes of hyponatremia and estimated the daily volemic status of the patients on the basis of clinical parameters. Logistic regression analysis was used to determine the independent prognostic factors of hypovolemia.

Results

Thirty-five patients were studied for a total of 418 days. Four patients (11.4 %) fitted the criteria of CSWS and three patients (8.5 %) had SIADH. The unavailability of the CBS led to a wrong diagnosis in three of the eight hyponatremic patients (37.5 %). The risk of developing hypovolemia in patients with negative CBS was 7.1 times higher (CI 3.86–13.06; p < 0.001). Multivariate analysis revealed that negative cumulative fluid balance, negative CBS >2 mEq/kg, and CVP ≤5 cmH₂O were independent prognostic factors for hypovolemia.

Conclusions

CBS is likely to be a useful parameter in the diagnosis of CSWS and a surrogate parameter for estimating hypovolemia in acute neurological patients.     

Risk Factors for Graft Loss Due to Acute Vascular Complications in Adult Renal Transplantation Using Grafts Without Vascular Anomalies

BackgroundVascular complications are the main cause of early graft loss in renal transplant (RT). A graft with multiple vessels represents the most validated risk factor. The aim of the present study was to identify potential predictive factors for acute vascular complications causing graft loss when graft vascular anomalies are excluded.MethodsThis is a retrospective case-control (1:3 ratio) study extrapolated from the RT series of the Renal Transplant Unit - Udine University Hospital, during the period 1993-2017. Grafts with multiple vessels and retransplant cases were excluded.ResultsThe overall prevalence of graft loss due to acute vascular complications was 2.6% (25/961). Seventeen complicated recipients had grafts without vascular anomalies (case group). The median time between RT and complication was 6 days (interquartile range, 4-23 days). The following types of vascular complications were recorded: 5 isolated renal artery thromboses (0.5%), 4 isolated renal vein thromboses (0.4%), 4 combined renal artery and vein thromboses (0.3%), 3 renal artery ruptures due to mycotic arteritis (0.3%), and 1 renal artery nonmycotic pseudoaneurysm (0.1%). No differences were recorded between the groups in terms of donors and grafts characteristics. Complicated recipients showed a statistically higher prevalence of thromboembolism history (P = .046) and vascular atherosclerosis (P = .048). During the postoperative course, blood stream infections (P = .02), acute rejection (P = .03), bleeding from a nonmacrovascular source (P = .04), and multiple reintervention because of nonvascular complications (P = .03) were identified as significant risk factors.ConclusionsRecipient characteristics and post-RT complications rather than donor and graft characteristics are relevant risk factors for graft loss due to acute vascular complications when graft vascular anomalies are excluded.     

Randomised Controlled Trial Comparing Laparoscopic and Robot-assisted Radical Prostatectomy

Background

The advantages of robot-assisted radical prostatectomy (RARP) over laparoscopic radical prostatectomy (LRP) have rarely been investigated in randomised controlled trials.

Objective

To compare RARP and LRP in terms of the functional, perioperative, and oncologic outcomes. The main end point of the study was changes in continence 3 mo after surgery.

Design, setting, and participants

From January 2010 to January 2011, 120 patients with organ-confined prostate cancer were enrolled and randomly assigned (using a randomisation plan) to one of two groups based on surgical approach: the RARP group and the LRP group.

Intervention

All RARP and LRP interventions were performed with the same technique by the same single surgeon.

Outcome measurements and statistical analysis

The demographic, perioperative, and pathologic results, such as the complications and prostate-specific antigen (PSA) measurements, were recorded and compared. Continence was evaluated at the time of catheter removal and 48 h later, and continence and potency were evaluated after 1, 3, 6, and 12 mo. The student t test, Mann-Whitney test, χ² test, Pearson χ² test, and multiple regression analysis were used for statistics.

Results and limitations

The two groups (RARP: n = 60; LRP: n = 60) were comparable in terms of demographic data. No differences were recorded in terms of perioperative and pathologic results, complication rate, or PSA measurements. The continence rate was higher in the RARP group at every time point: Continence after 3 mo was 80% in the RARP group and 61.6% in the LRP group (p = 0.044), and after 1 yr, the continence rate was 95.0% and 83.3%, respectively (p = 0.042). Among preoperative potent patients treated with nerve-sparing techniques, the rate of erection recovery was 80.0% and 54.2%, respectively (p = 0.020). The limitations included the small number of patients.

Conclusions

RARP provided better functional results in terms of the recovery of continence and potency. Further studies are needed to confirm our results.     

A minimally invasive technique for surgical treatment of hallux valgus: simple, effective, rapid, inexpensive (SERI)

Purpose

Several bony and soft tissue procedures have been described for the treatment of hallux valgus, and currently mini-invasive surgical techniques are preferred in order to reduce surgical trauma, complications, time of surgery and to allow an earlier recovery. The aim of this study is to analyse a series of 1,000 consecutive cases of hallux valgus, surgically treated by the minimally invasive SERI technique, reporting results at mid-term follow-up.

Methods

We prospectively studied 641 patients (1,000 feet) with symptomatic hallux valgus surgically treated by SERI osteotomy. Inclusion criteria were: age between 20 and 65 years, reducible mild or moderate hallux valgus, HVA ≤ 40°, IMA ≤ 20°, and arthritis of the first metatarsophalangeal joint up to grade 2 according to the Regnauld classification.

Results

The American Orthopaedic Foot and Ankle Society (AOFAS) score rose from 46.8 ± 16.7 preoperatively to 89 ± 10.3 at last follow-up. Radiographic control at follow-up showed a complete healing of the osteotomy and remodelling of the metatarsal bone. Low rate of complication has been reported.

Conclusions

This study demonstrated that the SERI technique is effective in treating mild to moderate hallux valgus in terms of relief from symptoms and functional improvement. This technique allowed correction of the main parameters of the deformity, with durable clinical and radiographic results at a mid-term follow-up.

Electronic supplementary material

The online version of this article (doi:10.1007/s00264-013-1980-8) contains supplementary material, which is available to authorized users.     

Evidence for a role of adaptive immune response in the disease pathogenesis of the MPTP mouse model of Parkinson's disease

Parkinson's disease (PD) is the second most common neurodegenerative disease and results from the loss of dopaminergic neurons of the nigrostriatal pathway. The pathogenesis of PD is poorly understood, but inflammatory processes have been implicated. Indeed increases in the number of major histocompatibility complex II (MHC II) reactive cells have long been recognised in the brains of PD patients at post‐mortem. However whether cells expressing MHC II play an active role in PD pathogenesis has not been delineated. This was addressed utilising a transgenic mouse null for MHC II and the parkinsonian toxin 1‐methyl‐4‐phenyl‐1,2,3,6‐tetrahydropyridine (MPTP). In wild‐type mice MHC II levels in the ventral midbrain were upregulated 1–2 days after MPTP treatment and MHC II was localized in both astrocytes and microglia. MHC II null mice showed significant reductions in MPTP‐induced dopaminergic neuron loss and a significantly reduced invasion of astrocytes and microglia in MHC II null mice receiving MPTP compared with controls. In addition, MHC II null mice failed to show increases in interferon‐γ or tumour necrosis factor‐α in the brain after MPTP treatment, as was found in wild‐type mice. However, interleukin‐1β was significantly increased in both wild‐type and MHC II null mice. These data indicate that in addition to microglial cell/myeloid cell activation MHC Class II‐mediated T cell activation is required for the full expression of pathology in this model of PD. GLIA 2016;64:386–395     

Structural MRI correlates of cognitive impairment in patients with multiple sclerosis

In a multicenter setting, we applied voxel‐based methods to different structural MR imaging modalities to define the relative contributions of focal lesions, normal‐appearing white matter (NAWM), and gray matter (GM) damage and their regional distribution to cognitive deficits as well as impairment of specific cognitive domains in multiple sclerosis (MS) patients. Approval of the institutional review boards was obtained, together with written informed consent from all participants. Standardized neuropsychological assessment and conventional, diffusion tensor and volumetric brain MRI sequences were collected from 61 relapsing‐remitting MS patients and 61 healthy controls (HC) from seven centers. Patients with ≥2 abnormal tests were considered cognitively impaired (CI). The distribution of focal lesions, GM and WM atrophy, and microstructural WM damage were assessed using voxel‐wise approaches. A random forest analysis identified the best imaging predictors of global cognitive impairment and deficits of specific cognitive domains. Twenty‐three (38%) MS patients were CI. Compared with cognitively preserved (CP), CI MS patients had GM atrophy of the left thalamus, right hippocampus and parietal regions. They also showed atrophy of several WM tracts, mainly located in posterior brain regions and widespread WM diffusivity abnormalities. WM diffusivity abnormalities in cognitive‐relevant WM tracts followed by atrophy of cognitive‐relevant GM regions explained global cognitive impairment. Variable patterns of NAWM and GM damage were associated with deficits in selected cognitive domains. Structural, multiparametric, voxel‐wise MRI approaches are feasible in a multicenter setting. The combination of different imaging modalities is needed to assess and monitor cognitive impairment in MS. Hum Brain Mapp 37:1627‐1644, 2016. © 2016 Wiley Periodicals, Inc.     

Twenty-four-hour blood pressure profile,orthostatic hypotension,and cardiac dysautonomia in elderly type 2 diabetic hypertensive patients

Purpose

The aim of this study was to evaluate the relationship between orthostatic hypotension (OH), defined as a decrease in systolic blood pressure (SBP) ≥20 mmHg and/or a decrease in diastolic blood pressure (DBP) ≥10 mmHg, and 24-h ambulatory BP profile in elderly hypertensive type 2 diabetic patients.

Methods

After a 2-week antihypertensive wash-out period, 200 hypertensive well-controlled diabetic outpatients, aged 65–75 years, underwent a clinical examination, including BP measurements, ECG, 24-h ABP monitoring (ABPM), an orthostatic test, and three tests for cardiovascular autonomic function assessment [deep breathing, heart rate (HR) variability, resting HR].

Results

According to their nighttime BP profile, patients were divided into three groups: dippers (n = 86) (BP fall during nighttime ≥10 %), non-dippers (n = 80) (BP fall during nighttime 0–10 %), and reverse dippers (n = 34) (nighttime BP > daytime BP). Orthostatic test produced a significantly greater orthostatic SBP fall in dippers and even more in reverse dippers. In these latter, a significant fall was observed also in DBP. Prevalence of OH was 9.3 % in dippers, 30 % in non-dippers, and 79.4 % in reverse dippers.

Conclusions

In elderly hypertensive type 2 diabetics, a blunted nocturnal BP fall is associated with OH and autonomic dysfunction. These data suggest that ABPM should be performed in the assessment of hypertensive diabetic patients in whom the cardiovascular dysautonomia is suspected or the signs of it are present (such as OH).

     

Valgus extension femoral osteotomy to treat “hinge abduction” in Perthes’ disease

Purpose

“Hinge abduction” is a complication of Perthes’ disease caused by impingement of the extruded superolateral portion of the femoral head against the lateral lip of the acetabulum. Catterall first described femoral valgus extension osteotomy (VGEO) to treat this condition. We report the results of this operation in 16 cases of Perthes’ disease with “hinge abduction”.

Methods

Sixteen hips in 16 patients affected by Perthes’ disease and “hinge abduction” were operated on at a mean age of 10.1 years and followed up an average of 6.5 years later. Before surgery, the mean Iowa hip score was 44.4 points. Preoperative radiographs were taken with the affected hip in maximum adduction in order to calculate the amount of valgus correction. The osteotomy was performed between the greater and the lesser trochanter, and it was fixed with a hip plate.

Results

All the osteotomies healed uneventfully. At follow-up, no patient complained of pain and hip abduction ranged from 20° to 45°. Four out of the 16 patients had a moderate limp, and 12 had an improvement in gait pattern compared to preoperatively. At follow-up, the Iowa hip score totaled a mean of 83.6 points, with a statistically significant improvement in comparison to the preoperative evaluation. At follow-up, two hips were classified as Stulberg II–III, ten hips as Stulberg III, and four as Stulberg IV.

Conclusions

In our hands, VGEO was an effective procedure to treat “hinge abduction” in severe Perthes’ disease with satisfactory results. The main limitation of our study is its short follow-up.     

Hospital volume, margin status, and long-term survival after pancreaticoduodenectomy for pancreatic adenocarcinoma

An association between hospital surgical volume and short- and long-term outcomes after pancreatic surgery has been demonstrated. Identification of specific factors contributing to this relationship is difficult. In this study, the authors evaluated if margin status can be identified as a measure of surgical quality, affecting overall survival, as a function of hospital pancreaticoduodenectomy volume. A systematic review of the literature was performed. Two models for analysis were created, dividing the 18 studies identified into quartiles and two quantiles based on the average annual hospital pancreatectomy volume. Regression modeling and analysis of variance were used to find an association between hospital volume, margin status, and survival. Increasing hospital volume was associated with a significantly increased negative margin status rate: 55 per cent for low-volume, 72 per cent for medium-volume, 74.3 per cent for high-volume, and 75.7 per cent for very high-volume centers (P = 0.008). The negative margin status rates were 64 per cent and 75.1 per cent for volume centers with less and more than 12 pancreaticoduodenectomies/year, respectively (P = 0.04). Low-volume centers negatively affected both margin positive resection and 5-year survival rates, compared with high-volume centers. Margin status rate after pancreaticoduodenectomy could, therefore, be considered a measure of quality for selection of hospitals dedicated to pancreatic surgery.