Efficacy of the lithotripsy in treating lower pole renal stones

Use of extracorporeal lithotripsy is declining in North America and many European countries despite international guidelines advocating it as a first-line therapy. Traditionally, lithotripsy is thought to have poor efficacy at treating lower pole renal stones. We evaluated the success rates of lithotripsy for lower pole renal stones in our unit. 50 patients with lower pole kidney stones ≤15 mm treated between 3/5/11 and 19/4/12 were included in the study. Patients received lithotripsy on a fixed-site Storz Modulith SLX F2 lithotripter according to a standard protocol. Clinical success was defined as stone-free status or asymptomatic clinically insignificant residual fragments (CIRFs) ≤3 mm at radiological follow-up. The mean stone size was 7.8 mm. The majority of stones (66 %) were between 5 and 10 mm. 28 % of stones were between 10 and 15 mm. For solitary lower pole stones complete stone clearance was achieved in 63 %. Total stone clearance including those with CIRFs was achieved in 81 % of patients. As expected, for those with multiple lower pole stones the success rates were lower: complete clearance was observed in 39 % and combined clearance including those with CIRFs was 56 %. Overall, complete stone clearance was observed in 54 % of patients and clearance with CIRFs was achieved in 72 % of patients. Success rate could not be attributed to age, stone size or gender. Our outcome data for the treatment of lower pole renal stones (≤15 mm) compare favourably with the literature. With this level of stone clearance, a non-invasive, outpatient-based treatment like lithotripsy should remain the first-line treatment option for lower pole stones. Ureteroscopy must prove that it is significantly better either in terms of clinical outcome or patient satisfaction to justify replacing lithotripsy.     

Arthroscopic-assisted hook plate fixation for acromioclavicular joint dislocation

Purpose

We present a new technique of arthroscopic-assisted AC-hook plate fixation for acromioclavicular joint dislocation with all the advantages of minimally invasive surgery and the possibility to treat concomitant pathologies.

Methods

Initially a glenohumeral arthroscopy is performed to address concomitant intra-articular injuries. Under subacromial visualisation the drill hole for the hook of the plate can be exactly positioned in the acromion. The hook plate is put in place under visual control.

Results

The initial results (n = 3) are promising with good to excellent results in the Constant score [90.5 (range 82–100)] in all cases studied. The cross-body test was slightly positive in one case. The median follow-up time after the index procedure was seven months (range five to ten).

Conclusions

In conclusion, arthroscopic-assisted reconstruction of acromioclavicular joint separation is feasible and may provide patients with all the benefits of AC-hook fixation with decreased risks related to open surgery. The described technique is recommended for all surgeons familiar with arthroscopic surgery.     

Sclerostin antibody improves skeletal parameters in a Brtl/+ mouse model of osteogenesis imperfecta

Osteogenesis imperfecta (OI) is a genetic bone dysplasia characterized by osteopenia and easy susceptibility to fracture. Symptoms are most prominent during childhood. Although antiresorptive bisphosphonates have been widely used to treat pediatric OI, controlled trials show improved vertebral parameters but equivocal effects on long‐bone fracture rates. New treatments for OI are needed to increase bone mass throughout the skeleton. Sclerostin antibody (Scl‐Ab) therapy is potently anabolic in the skeleton by stimulating osteoblasts via the canonical wnt signaling pathway, and may be beneficial for treating OI. In this study, Scl‐Ab therapy was investigated in mice heterozygous for a typical OI‐causing Gly→Cys substitution in col1a1. Two weeks of Scl‐Ab successfully stimulated osteoblast bone formation in a knock‐in model for moderately severe OI (Brtl/+) and in WT mice, leading to improved bone mass and reduced long‐bone fragility. Image‐guided nanoindentation revealed no alteration in local tissue mineralization dynamics with Scl‐Ab. These results contrast with previous findings of antiresorptive efficacy in OI both in mechanism and potency of effects on fragility. In conclusion, short‐term Scl‐Ab was successfully anabolic in osteoblasts harboring a typical OI‐causing collagen mutation and represents a potential new therapy to improve bone mass and reduce fractures in pediatric OI. © 2013 American Society for Bone and Mineral Research     

Left‐Sided High‐Flow Arteriovenous Hemodialysis Fistula Combined with a Persistent Left Superior Vena Cava Causing Coronary Sinus Dilatation

We present an interesting case illustrating the possible hemodynamic consequences when a left‐sided arteriovenous hemodialysis fistula is combined with the congenital anomaly of a persistent left superior vena cava (PLSVC). Our case illustrates the importance of an echocardiographic examination with attention to the coronary sinus (CS) caliber—raising suspicion of a PLSVC—in the assessment for the hemodialysis access in end‐stage renal disease patients. The causes and symptoms of CS dilatation, as well as the literature on PLSVC, are also discussed in detail.     

Surgeons blinded by enhanced navigation: the effect of augmented reality on attention

Background

Advanced image-guidance systems allowing presentation of three-dimensional navigational data in real time are being developed enthusiastically for many medical procedures. Other industries, including aviation and the military, have noted that shifting attention toward such compelling assistance has detrimental effects. Using the detection rate of unexpected findings, we assess whether inattentional blindness is significant in a surgical context and evaluate the impact of on-screen navigational cuing with augmented reality.

Methods

Surgeons and trainees performed an endoscopic navigation exercise on a cadaveric specimen. The subjects were randomized to either a standard endoscopic view (control) or an AR view consisting of an endoscopic video fused with anatomic contours. Two unexpected findings were presented in close proximity to the target point: one critical complication and one foreign body (screw). Task completion time, accuracy, and recognition of findings were recorded.

Results

Detection of the complication was 0/15 in the AR group versus 7/17 in the control group (p = 0.008). Detection of the screw was 1/15 (AR) and 7/17 (control) (p = 0.041). Recognition of either finding was 12/17 for the control group and 1/15 for the AR group (p < 0.001). Accuracy was greater for the AR group than for the control group, with the median distance from the target point measuring respectively 2.10 mm (interquartile range [IQR], 1.29–2.37) and 4.13 (IQR, 3.11–7.39) (p < 0.001).

Conclusion

Inattentional blindness was evident in both groups. Although more accurate, the AR group was less likely to identify significant unexpected findings clearly within view. Advanced navigational displays may increase precision, but strategies to mitigate attentional costs need further investigation to allow safe implementation.     

Incidence and Consequence of Close Margins in Patients with Ductal Carcinoma-In Situ Treated with Mastectomy: Is Further Therapy Warranted?

Background

The impact of close margins in patients with ductal carcinoma-in situ (DCIS) treated with mastectomy is unclear; however, this finding may lead to a recommendation for postmastectomy radiotherapy (PMRT). We sought to determine the incidence and consequences of close margins in patients with DCIS treated with mastectomy.

Methods

The records of 810 patients with DCIS treated with mastectomy from 1996 through 2009 were reviewed. Clinical and pathologic factors were analyzed with respect to final margin status. Median follow-up was 6.3 years.

Results

Overall, 94 patients (11.7 %) had close margins (positive, n = 5; negative but ≤1 mm, n = 54; 1.1–2.9 mm, n = 35). Independent risk factors for close margins included multicentricity, pathologic lesion size ≥1.5 cm, and necrosis, but not age, use of skin-sparing mastectomy, or immediate reconstruction (p > 0.05). Seven patients received PMRT, and none had a locoregional recurrence (LRR). Among the remaining 803 patients, the 10-year LRR rate was 1 % (5.0 % for margins ≤1 mm, 3.6 % for margins 1.1–2.9 mm, and 0.7 % for margins ≥3 mm [p < 0.001]). The 10-year rate of contralateral breast cancer was 6.4 %. On multivariate analysis, close margins was the only independent predictor of LRR (p = 0.005).

Conclusions

Close margins occur in a minority of patients undergoing mastectomy for DCIS and is the only independent risk factor for LRR. As the LRR rate in patients with close margins is low and less than the rate of contralateral breast cancer, PMRT is not warranted except for patients with multiple close/positive margins that cannot be surgically excised.     

Estimating Renal Survival Using the ANCA-Associated GN Classification

A histopathological classification system for ANCA-associated vasculitis was recently published, but whether this system predicts renal outcome requires validation. Here, we analyzed data from 164 consecutive patients with biopsy-proven renal involvement of ANCA-associated vasculitis. The ANCA-associated GN (AGN) classification categorizes patients as having focal, mixed, crescentic, or sclerotic GN. Five-year renal survival rates by categories of the AGN classification scheme were 91% for focal, 69% for mixed, and 64% for crescentic (log-rank P<0.0001). Only one patient was classified as sclerotic. Furthermore, the percentage of normal glomeruli found on biopsy estimated renal survival with the same precision as did the AGN classification scheme. Patients classified as crescentic or mixed, however, had worse survival when the percentage of normal glomeruli was <25%. In conclusion, the AGN classification for renal biopsy specimens is a practical and informative scheme with which to categorize patients with ANCA-associated vasculitis, but adding the percentage of normal glomeruli to the system seems to improve its predictive value.Necrotizing crescentic GN is a common feature in ANCA-associated vasculitis (AAV).¹ Histologically, renal lesions in AAV are characterized by cellular crescents, fibrinoid necrosis, and interstitial inflammation. Recently, an international vasculitis working group proposed a histopathologic classification of GN in patients with AAV to assess its predictive value for renal survival.²To validate the ANCA-associated GN classification system (AGN classification), we scored all AAV renal biopsy specimens from patients with AAV who participated in the Limburg Renal Registry, a prospective renal biopsy study on glomerular diseases.^3,4 The database was searched for patients with pauci-immune necrotizing crescentic GN.⁵Two hundred twenty-one consecutive patients who underwent renal biopsy between January 1, 1979, and August 31, 2011, in the province of Limburg, The Netherlands, were identified as having pauci-immune necrotizing crescentic GN. Eight of these patients were excluded for concomitant renal disease (six with diabetic nephropathy and two with thin glomerular basement membrane nephropathy). Forty-nine patients were excluded because <10 glomeruli were found in the renal biopsy specimen.²Thus, 164 patients with a mean age ± SD of 61.0±14.6 years were included (113 men and 52 women) with a mean follow-up of 8.5 years (range, 1 day–33 years). Eighty-three patients were positive for proteinase-3 ANCA and 81 were positive for myeloperoxidase (MPO) ANCA. Mean baseline serum creatinine was 349.7 ± 242.6 µmol/L, and median baseline proteinuria was 1.3 g per 24 hours (range, 0–11).Before 2000, patients received corticosteroids in combination with oral cyclophosphamide. Since 2000, all patients have been treated according to the European League Against Rheumatism (EULAR) guidelines:⁵ induction therapy with steroids and oral cyclophosphamide, 2 mg/kg per day, over 3–6 months and maintenance therapy with azathioprine and low-dose corticosteroids.⁶ Since 2009, induction therapy consisted of corticosteroids with intravenous cyclophosphamide at a dose of 15 mg/kg per cycle over three to six pulses with 2-week intervals, or with oral cyclophosphamide.⁷ Patients with a serum creatinine >500 μmol/L or alveolar lung hemorrhage at the time of renal biopsy were considered to have severe or life-threatening vasculitis and received 1000 mg of prednisolone per day for 3 days or plasma exchange in addition to the standard treatment as described above.⁵Eighty-one (49.4%) biopsy specimens were classified as focal, 43 (26.2%) as crescentic, and 39 (23.8%) as mixed. Only one biopsy specimen was classified as sclerotic (i.e., >50% sclerotic glomeruli). Baseline characteristics (at the time of renal biopsy) are presented in

Mildly elevated thyroid-stimulating hormone is associated with endothelial dysfunction and severe preeclampsia among pregnant women with insufficient iodine intake in Eastern Cape province,South Africa

BackgroundPreeclampsia and hypothyroidism are associated with endothelial dysfunction. Iodine deficiency is a risk factor for subclinical hypothyroidism in pregnancy. However, there is a paucity of data on the relationship between iodine nutrition state in pregnancy, the degree of endothelial dysfunction, and the risk of preeclampsia.MethodsNinety-five normotensive pregnant women, 50 women with preeclampsia with no severe features, and 50 women with severe preeclampsia were enrolled into the current study from the maternity units of Nelson Mandela Academic Hospital and Mthatha Regional Hospitals in Eastern Cape Province, South Africa. Urinary iodine concentration (UIC), serum markers of thyroid function, aortic augmentation index, and pulse wave velocity (PWV) were compared.ResultsMedian UIC was 167.5, 127.7, and 88.5 µg/L, respectively for normotensive pregnant women, those with preeclampsia and severe preeclampsia (p = .150). Participants with severe preeclampsia had significantly higher median thyroid-stimulating hormone (TSH) and oxidized LDL than normotensive and preeclamptic women without severe features (respectively 3.0, 2.3, and 2.3 IU/L; 1.2, 1.0, and 1.0 IU/L, p < .05). The median Aortic augmentation index was 7.5, 19.0, and 21.0 (p < .001), and the pulse wave velocity 5.1, 5.7, and 6.3, respectively for normotensive, preeclampsia, and severe preeclampsia participants (both p < .001). In linear regressions, TSH, age, and hypertensive disease were independent predictors of elevated PWV.ConclusionUpper normal-range TSH levels in women with severe preeclampsia were associated with markers of endothelial dysfunction. The low UIC and trend towards the elevation of thyroglobulin suggest that inadequate iodine intake may have increased TSH levels and indirectly caused endothelial dysfunction.