Cystatin C-based equations in renal transplantation: moving toward a better glomerular filtration rate prediction?

Creatinine-based glomerular filtration rate (GFR) estimators perform poorly in renal transplant recipients. Cystatin C might be a better alternative to serum creatinine in assessing renal graft function. We compared several cystatin C-based equations with the modification diet renal disease (MDRD) equation in 120 adult renal transplant recipients for whom the GFR was measured by the gold standard inulin clearance. Mean inulin-measured GFR was 52.6 mL/min/1.73 m (range, 13-119). The Hoek, Rule, Le Bricon, and Filler cystatin C-based formulas showed significantly better performances (accuracy 30% of 82%, 81%, 78%, and 71%), than the MDRD equation (58%, Mac Nemar test, P<0.01). Sensitivity to detect a GFR below 60 mL/min/1.73 m was significantly higher for the Hoek and the Rule equations (0.95, 95% CI 0.91-1) than for the MDRD equation (0.76, 95% CI 0.67-0.85). These data confirm that cystatin C as a GFR marker offers significant advantages over creatinine in renal transplantation.     

EMLA cream application without occlusive dressing before upper facial botulinum toxin injection: a randomized, double-blind, placebo-controlled trial

A randomized, double-blind, placebo-controlled clinical trial was conducted among 44 subjects to assess the efficacy of EMLA cream application without occlusive dressing on pain on needling (PN) and pain on injection (PI) felt during multiple botulinum toxin type A (BTA) injections for correction of hyperkinetic upper facial lines. Mean PN score was less than PI score with high correlation and no significant difference. Although both PN and PI scores (visual analog) were less in the EMLA than placebo group, the difference was only statistically significant for PN score. Time intervals between the cream application and BTA injections beyond 60 minutes did not show lower pain score in either type of the pain.     

Hygiene could affect GERD prevalence independently: a population-based study in Tehran

OBJECTIVE: Population-based data on gastroesophageal reflux disease (GERD) in Iran are limited. Current study is going to determine the prevalence of GERD in Tehran, Iran, and its association with potential risk factors. METHODS: In this cross-sectional study, a random clustered sample of Tehran province permanent households was selected from the latest postcodes. Data were collected by direct interview for each person aged 18-65 yr. GERD was defined as the existence of at least weekly episodes of heartburn and/or acid regurgitation during the last 6 months. All participants were asked about past and recent sanitary conditions, oral hygiene, and smoking. Odds ratios and 95% confidence intervals (CI) were calculated using multivariable analysis. RESULTS: Interview was performed with 2,561 eligible subjects (42.3% men). Response rate was 84.8%. The prevalence of GERD was 21.2% (95% CI 18.7-23.7). According to multivariable logistic regression analyses, individuals whose drinking water was obtained from well or tank during childhood were more prone to experience GERD symptoms (OR 1.54, 95% CI 1.03-1.77 and OR 2.46, 95% CI 1.53-3.96, respectively). We also detected significant associations with increasing number of missing teeth (P value for linear trend = 0.02) and history of unpurified water consumption during past 10 yr (P < 0.001). Current smokers had a higher prevalence of reflux (OR 1.82, 95% CI 1.32-2.51). CONCLUSION: The prevalence of GERD in our Iranian population was considerably higher than that reported from other Asian studies approaching western figures. GERD prevalence was significantly associated with the history of unpurified water consumption, poor sanitary conditions of childhood, number of missing teeth, and smoking in this population.     

False-negative PET scan with bronchioloalveolar carcinoma: an important diagnostic caveat

Positron emission tomography (PET) is becoming widely accepted as a powerful diagnostic tool for the diagnosis of lung cancer, but it has very poor sensitivity for the detection of bronchioloalveolar carcinoma (BAC) and adenocarcinoma with BAC pattern, the less common form of pulmonary neoplasia. We present a case of a patient with a negative PET scan who might have been followed by observation but was found to have bronchioloalveolar carcinoma at thoracotomy. PET has a reported sensitivity of over 98% in most series but misses almost two-thirds of BAC lesions, which might delay invasive testing and early diagnosis of this potentially lethal cancer. Although this diagnostic limitation has been well reported in the radiology literature, the high reported sensitivity and sensitivity can give clinicians a false sense of security with negative PET scans of lung nodules. The usual risk factors for bronchogenic carcinoma are less reliable for these subtypes of non-small-cell lung cancer; thus, clinicians need to have a high index of suspicion for BAC and exercise caution when making decisions on the basis of PET.     

Early and intensive fluid replacement prevents acute renal failure in the crush cases associated with spontaneous collapse of an apartment in Konya

BACKGROUND: Crush syndrome developing as a result of earthquake and other natural disasters has been investigated from many angles to date. Data are scarce, however, on cases associated with the spontaneous crash of buildings. This study presents the results on seven rhabdomyolysis patients treated in our clinics out of nine casualties who were rescued from the rubble of Zümrüt apartment after the building collapsed suddenly and spontaneously. METHODS: As a result of the sudden, spontaneous collapse of the 10-floor Zümrüt apartment in Konya at 20:15 hours on February 2, 2004, 92 out of a total of 121 persons who were inside the building lost their lives, and 29 casualties were rescued from the rubble. Nine hospitalized patients had crush syndrome, and a prophylactic mannitol-bicarbonate cocktail was started in all at admission. RESULTS: The time they remained entrapped under the rubble was 11.1 +/- 7.3 (5-24 hours) on average. The highest CPK level of the patients was 79049 +/- 75374 u/L (17478-223600 u/L), observed on the median day 1.7 +/- 1.1 (days 1-4) following the incident. ARF developed in only two cases (28.6%) owing to the prophylactic mannitol-bicarbonate cocktail administered to prevent ARF, and because of hyperpotassemia, hemodialysis (HD) treatment was administered to these patients. One patient required two sessions of HD, and another required four. In both patients who received HD treatment, the level of potassium was in excess of 7 mEq/L. A total of eight fasciotomies were performed on five (71.4%) of the seven patients with crush syndrome. Five of the fasciotomies (62.5%) were performed on two of our patients who required HD treatment. None of our patients with crush syndrome developed permanent kidney damage, and no mortality occurred. CONCLUSION: It was deduced that rapid fluid therapy accompanied by the prophylactic administration of mannitol-bicarbonate are largely effective in preventing the development of ARF in cases with crush syndrome resulting from disasters.     

Pharmacologic preconditioning of random-pattern skin flap in rats using local cyclosporine and FK-506: interaction with nitric oxide system

It has been suggested that immunophilin ligands such as cyclosporine and FK-506 (tacrolimus) affect the survival of ischemic tissues. Our objective was to show an acute effect of local cyclosporin-A (CsA) and FK-506 on ischemic protection in a random-pattern skin-flap model in rats and investigate the effect of nitric oxide (NO) pathways as a modulator of protection of these agents.Ninety male Sprague-Dawley rats were randomly assigned to treatment groups. Bipedicled dorsal flaps (2 x 8 cm) were elevated at midline. Prior to cutting the cranial pedicle to induce permanent ischemia, pharmacologic preconditioning groups received local injection of CsA (0.3, 1, or 3 nmol/flap) or FK-506 (0.01, 0.03, or 0.1 pmol/flap), and the ischemic preconditioning (IPC) group underwent temporary clamping of the cranial pedicle. At the seventh day postoperatively, the survival of the flaps was measured. In other groups, nitric oxide synthase inhibitor N omega-nitro-l-arginine methyl ester hydrochloride (L-NAME) was administered with effective CsA and FK-506, and ischemic preconditioning. Nitric oxide precursor L-arginine doses were also studied, and a systemic subeffective dose (100 mg/kg) was coadministered with subeffective CsA and FK-506.Significant increase in flap survival was obtained with CsA (1 nmol/flap), FK-506 (0.1 pmol/flap), and IPC. These protections were abolished by systemic administration of L-NAME (10 mg/kg). Coadministration of subeffective doses of CsA (0.3 nmol/flap) and FK-506 (0.03 pmol/flap), with subeffective systemic l-arginine, significantly improved flap survival.Pharmacologic preconditioning with local, single, low doses of CsA or FK-506 is shown to be even more effective than IPC. Administration of the NOS substrate l-arginine potentiates these effects.     

A comprehensive renal injury concept based on a validated finite element model of the human abdomen

BACKGROUND: The identification of abdominal injury mechanisms, development of effective countermeasures, and refinement of clinical approach to injury treatment are greatly facilitated by the employment of numerical models that can predict injuries resulting from complicated soft tissue interactions during blunt abdominal impact. METHODS: The present study introduces a detailed three-dimensional finite element model of the human abdomen that was developed specifically for the investigation of renal trauma. The model geometry and materials reflect the complex mechanical environment of the abdomen, and is validated against both published and novel experiments. RESULTS: It is shown that use of the proposed model, in combination with appropriate mechanical organ injury criteria, provides a significant step toward a comprehensive renal injury concept. Specifically, the abdominal model offers the possibility to investigate injury likelihood and identify injury mechanisms over a broad range of impact loading scenarios. CONCLUSIONS: A sophisticated numerical model of renal trauma has been developed that can be used to effectively predict renal injury outcome for lateral impact.     

Comparison of the effects of captopril, tamoxifen and L-carnitine on renal structure and fibrosis after total unilateral ureteral obstruction in the rat

OBJECTIVE: To compare the effects of captopril, tamoxifen and L-carnitine on renal structure and the collagen content of the unilateral obstructed kidney in the rat using unbiased stereological methods. MATERIAL AND METHODS: Rats (n=25) were assigned equally to one of five groups after ligation of the ureter: (i) normal controls (no hydronephrosis); (ii) positive controls (hydronephrotic rats without drug treatment); (iii) hydronephrotic rat with captopril treatment (CAP); (iv) hydronephrotic rats with L-carnitine treatment (L-CAR); and (v) hydronephrotic rats with tamoxifen treatment (TAM). Two weeks after unilateral ureteral obstruction the kidney was removed and histological sections were prepared. The kidney volume and the fractional volumes and absolute amounts of the cortex, medulla, tubules, renal corpuscles, vessels and fibrous tissue were determined using modern stereological techniques. RESULTS: Kidney volume increased in the CAP group in comparison with the other groups. The absolute volume of the tubules was the same in the CAP group compared to the normal control group. However, in the other experimental groups, the amount of tubules decreased. The absolute volumes of the renal corpuscles and vessels did not show any significant differences between groups. The absolute volume of fibrous tissue showed significant increases in all groups in comparison with the normal controls. There were no differences in the absolute amounts of fibrous tissue between the positive control, CAP and L-CAR groups, but in the TAM group the collagen content was decreased. CONCLUSIONS: Captopril preserved the amount of renal tubules and tamoxifen decreased fibrous tissue formation in unilateral obstructed kidneys but there were no differences in other hydronephrotic kidneys.