The prognostic value of elevated neutrophil–lymphocyte ratio for cardiac surgery-associated acute kidney injury: A systematic review and meta-analysis

Background

Patients undergoing cardiac surgery are at significant risk of developing postoperative acute kidney injury (AKI). Neutrophil–lymphocyte ratio (NLR) is a widely available inflammatory biomarker which may be of prognostic value in this setting.

Methods

We conducted a systematic review and meta-analysis of studies reporting associations between perioperative NLR with postoperative AKI. We searched Medline, Embase and the Cochrane Library, without language restriction, from inception to May 2022 for relevant studies. We meta-analysed the reported odds ratios (ORs) with 95% confidence intervals (CIs) for both elevated preoperative and postoperative NLR with risk of postoperative AKI and need for renal replacement therapy (RRT). We conducted a meta-regression to explore inter-study statistical heterogeneity.

Results

Twelve studies involving 10,724 participants undergoing cardiac surgery were included, with eight studies being deemed at high risk of bias using PROBAST modelling. We found statistically significant associations between elevated preoperative NLR and postoperative AKI (OR 1.45, 95% CI 1.18–1.77), as well as postoperative need for RRT (OR 2.37, 95% CI 1.50–3.72). Postoperative NLR measurements were not of prognostic significance.

Conclusions

Elevated preoperative NLR is a reliable inflammatory biomarker for predicting AKI following cardiac surgery.     

Urinary CD80 Excretion Increases in Idiopathic Minimal-Change Disease

CD80 is expressed on all antigen-presenting cells and is present on podocytes in a number of experimental models of nephrotic syndrome. We tested whether urinary soluble CD80 increased with idiopathic minimal-change disease (MCD). We collected urine and serum samples from patients with MCD in relapse and in remission, patients with nephrotic syndrome resulting from other glomerular diseases (FSGS, membranoproliferative glomerulonephritis, IgA nephropathy, and membranous nephropathy), patients with systemic lupus erythematosus, and normal control subjects. Urinary concentrations of soluble CD80 in patients with relapsed MCD were significantly higher compared with those observed in patients with MCD in remission, other glomerular diseases, and systemic lupus erythematosus with and without proteinuria and healthy control subjects. Urinary concentrations of soluble CTLA-4, which is a negative regulator of CD80, were not statistically different in patients with relapsed MCD compared with those in remission. The urinary soluble CD80/CTLA-4 ratio was >100-fold higher in patients with relapsed MCD compared with those in remission (P < 0.008). In contrast, serum concentrations of soluble CD80 and CTLA-4 did not distinguish patients with MCD in relapse and in remission. In conclusion, urinary soluble CD80 is elevated in idiopathic MCD, which could be relevant to both diagnosis and pathogenesis.Idiopathic minimal-change disease (MCD) is the most common nephrotic syndrome in children and adolescents.¹ The disease is considered a disorder of T cell function.^2,3 Although the mechanism of the proteinuria is unknown, a circulating cytokine has been postulated as the link between proteinuria and the T cell dysfunction.^2–4Podocytes are specialized and highly differentiated epithelial cells that form a layer between the glomerular basement membrane and the urinary space. In a series of experiments, Reiser et al.⁵ found that these cells could acquire dendritic cell–like functions, in which they can be induced to express CD80, a transmembrane protein that provides a co-stimulatory signal for T cell activation. Mice administered LPS developed podocyte CD80 expression and proteinuria; when LPS was administered to the CD80^−/− knockout mouse, no increase in urinary protein excretion was observed.⁵ The authors further showed that podocyte CD80 activation by LPS could occur in SCID mice that lack T cells.⁵ Furthermore, CD80 expression could be shown in both experimental models of nephrotic syndrome (e.g., aminonucleoside nephrosis) and human lupus nephritis.⁵ These findings led the authors to propose that podocyte CD80 expression might be involved in the pathogenesis of MCD.⁶Some podocyte antigens are known to be shed, where they can be found in the urine.⁷ This led us to hypothesize that soluble CD80 (sCD80) might be detected in the urine in patients with MCD. Furthermore, T regulatory cells are known to secrete soluble CTLA-4 (sCTLA-4), which can bind CD80 and block the co-stimulatory activation of T cells.^8–10 If T cells are releasing a cytokine that can induce MCD, such as IL-13,¹¹ then one might postulate that an inadequate release of sCTLA-4 might lead to continued activation of the T cells and possibly persistent CD80 expression by dendritic cells. We therefore measured urinary sCD80 and urinary sCTLA-4 levels in children with MCD and compared the findings with healthy children and children with other glomerular diseases.Clinical characteristics of the patients with MCD and control groups are shown in

Diagnostic performance of 3D standing CT imaging for detection of knee osteoarthritis features

Objective. To determine the diagnostic performance of standing computerized tomography (SCT) of the knee for osteophytes and subchondral cysts compared with fixed-flexion radiography, using MRI as the reference standard. Methods. Twenty participants were recruited from the Multicenter Osteoarthritis Study. Participants’ knees were imaged with SCT while standing in a knee-positioning frame, and with postero-anterior fixed-flexion radiography and 1T MRI. Medial and lateral marginal osteophytes and subchondral cysts were scored on bilateral radiographs and coronal SCT images using the OARSI grading system and on coronal MRI using Whole Organ MRI Scoring. Imaging modalities were read separately with images in random order. Sensitivity, specificity and accuracy for the detection of lesions were calculated and differences between modalities were tested using McNemar’s test. Results.Participants’ mean age was 66.8 years, body mass index was 29.6 kg/m² and 50% were women. Of the 160 surfaces (medial and lateral femur and tibia for 40 knees), MRI revealed 84 osteophytes and 10 subchondral cysts. In comparison with osteophytes and subchondral cysts detected by MRI, SCT was significantly more sensitive (93 and 100%; p < 0.004) and accurate (95 and 99%; p < 0.001 for osteophytes) than plain radiographs (sensitivity 60 and 10% and accuracy 79 and 94%, respectively). For osteophytes, differences in sensitivity and accuracy were greatest at the medial femur (p = 0.002). Conclusions. In comparison with MRI, SCT imaging was more sensitive and accurate for detection of osteophytes and subchondral cysts than conventional fixed-flexion radiography. Additional study is warranted to assess diagnostic performance of SCT measures of joint space width, progression of OA features and the patellofemoral joint.     

Miniature synaptic currents become neurotoxic to chronically silenced neurons

When deprived of spontaneous ongoing network activity by chronic exposure to tetrodotoxin (TTX), cultured cortical neurons retract their dendrites, lose dendritic spines, and degenerate over a period of 1-2 weeks. Electrophysiological properties of these slowly degenerating neurons prior to their death are normal, but they express very large miniature excitatory postsynaptic currents (mEPSCs). Chronic blockade of these mEPSCs by the alpha-amino-5-hydroxy-3-methyl-4-isoxazole propionic acid (AMPA) receptor antagonist 6,7-Dinitroquinoxaline-2,3-dione (DNQX) had no effect of its own on cell survival, yet, paradoxically, it protected the TTX-silenced neurons from degenerating. TTX-treated neurons also exhibited deficient Ca(2+) clearance mechanisms. Thus, upscaled mEPSCs are sufficient to trigger apoptotic processes in otherwise chronically silenced neurons.     

Treatment of resistant port wine stains (PWS) with pulsed dye laser and non-contact vacuum: a pilot study

The blanching of resistant port wine stains (PWS) with a pulsed dye laser (PDL) requires a large number of treatments, resulting in substantial discomfort to patients, many of them children. Pneumatic skin flattening (PSF - Serenity Pro) is a new technology that generates a vacuum over the skin and reduces pain in laser-based treatments of the skin, while creating contact between the skin and an upper window. The same technology can be utilized to increase skin blood fraction while operated in a non-contact mode. The objective of this study was to test the enhancement in the efficacy of PWS treatment with PDL and Serenity Pro while vacuum is being utilized in the non-contact, blood-enrichment mode. Fifteen patients with resistant PWS underwent 1–4 treatments (interval of 5–20 weeks) under general anesthesia with a 595-nm PDL at 10–14 J/cm², 1.5–3 ms pulse duration, and 7-mm spot size. Lesion blanching with DCD chilling and with vacuum were photographed and compared. Better blanching of various degrees was observed on resistant PWS with the blood-enrichment technique in seven out of 11 patients who returned for follow-up. There were no cases of decrease in efficacy. Blood enrichment with the Serenity Pro non-contact vacuum technology has the potential of enhancing the capability of treating resistant port wine stains in over 50% of cases. Further studies will better quantify the number of treatments necessary for better lesion clearance. The vacuum-assisted technique may be of particular importance in view of the fact that achieving complete lesion clearance remains a challenge in PWS treatments.     

A Novel Non-Invasive Adjuvant Biomechanical Treatment for Patients with Altered Rehabilitation after Total Knee Arthroplasty: Results of a Pilot Investigation

Background

Many factors contribute to suboptimal results after total knee arthroplasty (TKA) but little is known regarding the value of postsurgical rehabilitation after TKA. We examined the effects of an enhanced closed kinematic chain exercises program (AposTherapy) on gait patterns and clinical outcomes among patients with a lack of progress in their postsurgical rehabilitation.

Methods

Twenty-two patients were prospectively followed during the study. Gait spatiotemporal parameters were measured at the initial evaluation, after 15 minutes of therapy, and after 3 months of therapy. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the short form (SF) 36 health survey were completed by patients before treatment and after 3 months of treatment.

Results

The WOMAC and SF-36 scores improved significantly after 3 months of treatment. Gait velocity, single limb support, and step length of the operated leg improved significantly even after a single 15 minutes treatment. Normal gait velocity was observed in 36% of patients after 3 months of treatment.

Conclusions

A physiotherapy program that included enhanced closed kinematic chain biomechanical therapy was beneficial for patients who experienced a suboptimal rehabilitation course after TKA.     

Thyroid cancer in children: management and outcome experience of a referral center.

OBJECTIVE: To shed light on the discrepancy between the advanced stage at presentation and high recurrence rate of well-differentiated thyroid cancer in children and the overall good survival. DESIGN AND METHODS: The files of 75 children with well-differentiated thyroid cancer treated from 1954 to 2001 in a major tertiary-care hospital were reviewed for disease course, management, and outcome. RESULTS: Sixty patients (80%) had positive neck metastases with involvement of central compartment lymph nodes in all, lateral neck nodes in 36, and distant metastases in 4. Sixty-seven patients underwent total thyroidectomy with adjuvant radioiodine treatment and 8 underwent hemithyroidectomy; all had concomitant neck treatment. The rate of local (5%) and neck (9%) recurrence was similar to the total rate reported in adults. Total thyroidectomy led to a significantly lower recurrence rate (7.5%) than hemithyroidectomy (38%; P < 0.005). Type of neck dissection did not affect recurrence or appearance of distant metastases. All deaths (n = 2) were due to distant metastases, whereas 30% of adult deaths are due to local or neck disease. CONCLUSIONS: The treatment of choice for well-differentiated thyroid cancer in young patients is total thyroidectomy. Neither regional disease at presentation nor recurrences affect survival.     

Sexual function in patients presenting to a urogynecology practice

The purpose of this study was to evaluate sexual function in women referred to a urogynecology practice. All new patients were mailed an optional female sexual function index (FSFI) in conjunction with their history forms; other sexual function information was obtained during the physician interview. Over 6 months, four hundred fifty new patients were enrolled. Of these, 243 (54%) were not sexually active. Reasons listed for sexual inactivity included partner problems/no partner (32%), low desire (14%), prolapse (10%), and pain (10%). There were several differences between sexually active and non-sexually active participants; however, after a multivariate analysis, only age, marital status, and stage/grade 1–2 of prolapse remained significant. One hundred nine sexually active patients completed the FSFI; the majority was sexually active two to four times per month. Female sexual dysfunction was noted in 70 (64%) patients. Lowest scores were noted for the domain of desire, followed by arousal, orgasm, lubrication, satisfaction, and pain. Reduced frequency of intercourse was the only factor significantly associated with dysfunction. Ninety-four percent were not embarrassed by the survey. Overall, sexual inactivity is common in patients presenting for urogynecologic care. Those that are sexually active report low rates of sexual activity and high rates of sexual dysfunction. Most sexually active patients will accept a sexual function questionnaire as part of their routine assessment.This research was presented at the American College of Obstetricians and Gynecologists annual clinical meeting, May 10, 2005, San Francisco, CA, USA.