NLR is predictive of upstaging at the time of radical cystectomy for patients with urothelial carcinoma of the bladder

ObjectiveTo evaluate the ability of preoperative neutrophil-lymphocyte ratio (NLR) to predict pathologic upstaging and nonorgan-confined (NOC) (≥pT3) disease.Methods and materialsAfter institutional review board approval, the records of consecutive patients undergoing radical cystectomy (RC) for urothelial carcinoma from 2002 to 2012 at the University of Wisconsin Hospital were reviewed. A total of 102 patients with NLR within 100 days of surgery were eligible for analysis. The primary outcome was difference in stage from preoperative assessment to time of RC. Differences in preoperative NLR between groups were evaluated with an unequal variance t test. A univariate analysis assessed whether NLR, preoperative stage, grade, associated lymphovascular invasion, preoperative hydronephrosis, gender, previous pelvic radiotherapy, previous intravesical bladder cancer treatments, or nodal stage were related to upstaging. Multivariate analyses were performed to evaluate the relationship of NLR to upstaging and relative organ-confined (≤pT2) and NOC disease.ResultsOf 390 consecutive patients undergoing RC, 102 patients met study criteria. Overall, 55 (53.9%) patients were upstaged, 25 (25.5%) were unchanged, and 21 (20.6%) were downstaged. Fifty-one patients (50%) were upstaged to more advanced disease (≥pT3). NLR and preoperative hydronephrosis were significantly related to pathologic tumor staging. NLR, preoperative hydronephrosis, and preoperative tumor stage were significantly related to upstaging to NOC disease. Patients who were upstaged to≥pT3 demonstrated statistically significant greater NLRs (4.33±0.87) compared with patients who remained at≤pT2 stage (2.66±0.29) (P<0.001).ConclusionsPreoperative NLR is a simple measurement that can be used to identify high-risk patients who may be upstaged at the time of RC and may benefit from neoadjuvant chemotherapy.     

Estimation of equivalent threshold currents using different pulse widths for the epidural stimulation test in a porcine model

Background

The epidural stimulation test can help detect if a catheter is correctly positioned in the epidural space. Previous studies showed that a current of up to 16 mA was required to elicit a motor response, but few peripheral nerve stimulators can produce a current this high. Manipulating pulse width can produce a positive response at a lower current. To clarify the effects of pulse width on the epidural stimulation test, we performed a single-blinded study in a porcine model to estimate the equivalent current needed at varying pulse widths.

Methods

After obtaining local ethics approval, an 18G insulated Tuohy needle was advanced into the epidural space at the lower lumbar spinal level, and a 20G stimulating epidural catheter was advanced 30 cm cephalad. A gradually increasing electrical current was applied, and a motor response was elicited at pulse widths of 0.1, 0.2, 0.3, 0.5, and 1 msec. This was followed by a 1-2 cm catheter withdrawal, and the process was repeated for a total of 15 locations per pig.

Results

Recorded threshold currents ranged from 0.36-9.5 mA at a pulse width of 0.2 msec. Our results show a linear relationship between threshold current and pulse width.

Conclusions

In situations where different pulse widths are needed, the nomograms presented here may be useful to estimate the equivalent threshold current which is required to elicit a motor response according to previously published criteria for epidural stimulation tests.     

Comparison of Gastrojejunal Anastomosis Techniques in Laparoscopic Roux-en-Y Gastric Bypass: Gastrojejunal Stricture Rate and Effect on Subsequent Weight Loss

Background

Different gastrojejunal anastomotic (GJA) techniques have been described in laparoscopic Roux-en-Y gastric bypass (LRYGB). There is conflicting data on whether one technique is superior to the other. We aimed to compare hand-sewn (HSA), circular-stapled (CSA) and linear-stapled (LSA) anastomotic techniques in terms of stricture rates and their impact on subsequent weight loss.

Methods

A prospectively collected database was used to identify patients undergoing LRYGB surgery between March 2005 and May 2012. Anastomotic technique (HSA, CSA, LSA) was performed according to individual surgeon preference. The database recorded patient demographics, relevant comorbidities and the type of GJA performed. Serial weight measurements and percentage excess weight loss (%EWL) were available at defined follow-up intervals.

Results

Included in the data were 426 patients, divided between HSA (n?=?174, 40.8 %), CSA (n?=?110, 25.8 %) and LSA (n?=?142, 33.3 %). There was no significant difference in the stricture rates (HSA n?=?17, 9.72 %; CSA n?=?9, 8.18 %; LSA n?=?8, 5.63 %; p?=?0.4006). Weight loss was similar between the three techniques (HSA, CSA and LSA) at 3 months (40.6 %?±?16.2 % vs 35.92 %?±?21.42 % vs 48.21 %?±?14.79 %; p?=?0.0821), 6 months (61.48 %?±?23.94 % vs 58.16 %?±?27.31 % vs 60.18 %?±?22.26 %; p?=?0.2296), 12 months (72.94 %?±?19.93 % vs 69.72?±?21.42 % vs 66.05 %?±?17.75 %; p?=?0.0617) and 24 months (73.29 %?±?22.31 % vs 68.75 %?±?24.71 % vs 69.40 %?±?23.10 %; p?=?0.7242), respectively. The stricture group lost significantly greater weight (%EWL) within the first 3 months compared to the non-stricture group (45.39 %?±?16.82 % vs 39.22 %?±?21.93 %; p?=?0.0340); however, this difference had resolved at 6 months (61.29 %?±?18.50 % vs 59.79 %?±?23.03 %; p?=?0.8802) and 12 months (71.59 %?±?18.67 % vs 68.69 %?±?22.19 %; p?=?0.5970).

Conclusions

There was no significant difference in the rate of strictures between the three techniques, although the linear technique appears to have the lowest requirement for post-operative dilatation. The re-intervention rate will, in part, be dictated by the threshold for endoscopy, which will vary between units. Weight loss was similar between the three anastomotic techniques. Surgeons should use techniques that they are most familiar with, as stricture and weight loss rates are not significantly different.     

Is Nocturnal Extubation After Cardiac Surgery Associated With Worse Outcomes?

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Fourteen years of litigation claims in cardiothoracic surgery in the United Kingdom National Health Service

Approximately 36 400 cardiac and 23 100 thoracic operations are carried out in the United Kingdom between 2006 and 2015. National Health Service (NHS) resolution, as known as the NHS litigation authority, is one of the essential bodies of the Department of Health. Its purpose is to provide NHS expertise to resolve concerns fair and square share learning for improvement. We aim to evaluate and increase awareness of medicolegal cases in cardiothoracic surgery. Total numbers and details of claims coded by NHS resolution in cardiothoracic surgery from 2004 to 2017 were requested under the Freedom of Information Act 2000. The data provided in successful claims is further breakdown into damages paid to the claimant, defence cost, claimant cost paid and the sum of the three. In contrast, unsuccessful claims only include the defence cost. Moreover, data provided also includes further analysis of primary causes and primary injuries for Claims Closed/Settled with damages paid. There were 753 claims recorded from 2004 to 2017, of which 415 (55.11%) were successful. The number of claims has been steadily increasing since 2004, with two significant raises from 2009/10 to 2010/11 (37‐55, 48.64% raise) and 2012/13 to 2013/14 (49‐69, 40.82% raise). The mean successful claim ratio was 69.58% (range, 47.56%‐ 83.33%) There is also a steady increase in the successful ratio from 2004 to 2017. In summary, this is the first study published in relation to litigation claims on cardiothoracic surgery in the United Kingdom. The results have provided insight on claims made against cardiothoracic surgery.     

Complications after proctocolectomy and ileal pouch-anal anastomosis in pediatric patients: A systematic review

Background/purposeColectomy with ileal pouch-anal anastomosis (IPAA) is the standard of care for patients with familial adenomatous polyposis (FAP) and refractory ulcerative colitis (UC). The rates of postoperative complications are not well established in children. The objective of this systematic review is to establish benchmark data for morbidity after pediatric IPAA.MethodsPubMed, Embase, and The Cochrane Library were searched for studies of colectomy with IPAA in patients ≤ 21 years old. UC studies were limited to the anti-tumor necrosis factor-α agents era (1998–present). All postoperative complications were extracted.ResultsThirteen studies met the inclusion criteria (763 patients). Compared to patients with FAP, UC patients had a higher prevalence of pouch loss (10.6% vs. 1.5%). Other major complications such as anastomotic leak, abscess, and fistula were uncommon (mean prevalence 4.9%, 4.2%, and 5.0%, respectively, for patients with UC; 8.7%, 4.2%, and 4.3% for FAP). The most frequent complication was pouchitis (36.4% of UC patients).ConclusionsDevastating complications from colectomy and IPAA are rare, but patients with UC have poorer outcomes than those with FAP. Much of the morbidity may therefore stem from patient or disease factors. Multicenter, prospective studies are needed to identify modifiable risks in patients with UC undergoing IPAA.Level of evidencePrognostic, level II.     

Occult pretransplantation systemic inflammation and posttransplantation vascular changes in a primate arterial allograft model

BACKGROUND: Occult systemic inflammation, as manifested by increased levels of C-reactive protein (CRP), identify patients at increased risk for renal allograft rejection. The mechanisms linking occult systemic inflammation to these adverse outcomes remain unclear. The purpose of this study was to examine the anatomic and physiologic effects of occult pretransplantation systemic inflammation on posttransplantation allograft outcome in a nonhuman primate model. METHODS: Seventy-one healthy male Rhesus macaques were stratified into quartiles based on serum CRP. Five high quartile and six low quartile animals underwent common iliac artery transplantation from male donors. Duplex ultrasound measured graft flow at 3 weeks postoperatively; luminal narrowing was assessed by graft/femoral peak systolic velocity ratio. At 6 weeks, the grafts were harvested and morphometry studies were performed. Vessel wall changes were assessed by measuring the intimal medial area. RESULTS: The allografts placed in high CRP quartile animals had more luminal narrowing by 3 weeks than those placed in low quartile animals, as evidenced by a higher mean graft/femoral peak systolic velocity ratio (1.6 vs. 0.90, P=0.006). Morphometry studies after graft harvest showed increased vessel wall area in the high quartile group versus the low quartile group (1.39 mm vs. 1.03 mm, P=0.018). CONCLUSIONS: Occult pretransplantation systemic inflammation is associated with increased intimal thickening and stenosis after arterial allograft transplantation in a primate model. Additional studies are needed to confirm these results and to further investigate potential mechanisms linking pretransplantation systemic inflammation to adverse outcomes after transplantation.     

A decision-analytic economic evaluation of valaciclovir prophylaxis for the prevention of cytomegalovirus infection and disease in renal transplantation

OBJECTIVE: This analysis evaluates the cost-effectiveness of valaciclovir prophylaxis using clinically and economically important health outcomes including graft failure, life-years, and quality-adjusted life-years (QALYs). METHODS: A Markov model was developed using a randomized, placebo-controlled trial of valaciclovir prophylaxis, together with a published epidemiological study and national renal transplant registry data. The model's population was stratified into two risk groups by donor/recipient cytomegalovirus (CMV) serostatus at transplantation: donor-positive/recipient-negative (D+R-) and recipient-positive (R+) patients. The model estimated costs and health outcomes over a 30-yr period from the perspective of Australian health care providers. RESULTS: The total health care cost was $3619 lower for D+R- patients receiving valaciclovir prophylaxis compared with those not receiving prophylaxis. D+R- patients receiving valaciclovir gained an extra 0.33 yr of life and 0.27 QALYs. R+ patients receiving valaciclovir prophylaxis gained an extra 0.07 yr of life and 0.05 QALYs, with an incremental cost of $914. This equates to $17 127 per QALY gained, which is highly cost-effective compared with other drugs and health interventions. CONCLUSIONS: Valaciclovir for the prophylaxis of CMV disease in renal transplant recipients is a cost-effective intervention, significantly reducing the burden of CMV disease to patients and health care providers.     

Drug-induced lung injury

Lung injury is an increasing cause of morbidity and mortality in patients treated with cytotoxic and noncytotoxic drugs. Prompt diagnosis is important because early drug-induced lung injury will often regress with the cessation of therapy. Diagnosis requires a high index of suspicion because infection, radiation pneumonitis, and recurrence of the underlying disease can manifest clinically and radiologically in a similar manner. Because the lungs have only a limited number of histopathologic responses to injury, including pulmonary edema/diffuse alveolar damage, NSIP, BOOP, EP, and pulmonary hemorrhage, knowledge of these manifestations and the corresponding radiologic manifestations can often be useful in suggesting a diagnosis of drug-induced lung injury. An understanding of the drugs most commonly associated with lung injury can also facilitate diagnosis.     

Experimental diabetes mellitus inhibits prostacyclin synthesis by the rat penis: pathological implications

Summary In view of the marked increase in blood flow into the penis during erection and the association of diabetes mellitus with impotence, we used the diabetic rat model to investigate the possibility that: (a) the penis may produce prostacyclin; and (b) prostacyclin secretion may be decreased in diabetes. Rats given a high dose of streptozotocin (120 mg/kg body weight) developed acute ketotic diabetes and were killed after 48 h. Animals given a low dose of streptozotocin (65 mg/ kg body weight) developed non-ketonuric diabetes and were killed after 7 or 62 days. Aortic rings and penile tissue discs were incubated in buffer, which was assayed for 6-oxo-pros-taglandin F₁, the stable and spontaneous breakdown product of prostacyclin. Penile tissue from control, ketotic and non-ketonuric (7 days) animals released similar quantities of prostacyclin, whereas that from long-term non-ketonuric animals (62 days) produced significantly less prostacyclin. Production of this prostanoid by the aortic rings paralleled these changes. We conclude that: (a) penile tissue releases prostacyclin in quantities comparable to those of the aorta; (b) long-term diabetes leads to diminished prostacyclin release by penile and aortic tissue: the former may contribute to the pathogenesis of diabetic impotence; and (c) since short-term ketotic diabetes does not inhibit aortic or penile prostacyclin release, duration of diabetes rather than its severity is responsible for diminished prostacyclin release.