Achievement of trifecta in minimally invasive partial nephrectomy correlates with functional preservation of operated kidney: a multi-institutional assessment using MAG3 renal scan

Purpose

To validate and compare the values of “MIC” and “trifecta” as predictors of operated kidney functional preservation in a multi-institutional cohort of patients undergoing minimally invasive PN.

Methods

We retrospectively reviewed records of consecutive cases of minimally invasive PN performed for cT1 renal masses in 4 centers from 2009 to 2013. Inclusion criteria consisted of availability of a renal scan obtained within 2 weeks prior to surgery and follow-up renal scan 3–6 months after the surgery. The primary endpoint of the study was to compare the degree of ipsilateral renal function preservation assessed by MAG3 renal scan in relation to achievement of MIC and trifecta.

Results

Total of 351 patients met our inclusion criteria. The rates of trifecta achievement for cT1a and cT1b tumors were 78.9 and 60.6 %, respectively. The rate of MIC achievement for cT1a tumors and cT1b tumors was 60.3 and 31.7 %, respectively. On multivariable linear regression model, only the degree of tumor complexity assessed by R.E.N.A.L nephrometry score [coefficient B ?1.8 (?2.7, ?0.9); p < 0.0001] and the achievement of trifecta [coefficient B 6.1 (2.4,9.8); p = 0.014] or MIC (coefficient B 7.2 (3.8,0.6); p < 0.0001) were significant clinical factors predicting ipsilateral split function preservation.

Conclusions

Achievement of both MIC and “trifecta” is associated with higher proportion of split renal function preservation for cT1 tumors after minimally invasive PN. Thus, these outcome measures can be regarded not only as markers of surgical quality, but also as reliable surrogates for predicting functional outcome in the operated kidney.

     

Laparoendoscopic single‐site (LESS) vs laparoscopic living‐donor nephrectomy: a systematic review and meta‐analysis

The aim of this study was to provide a systematic review and meta‐analysis of reports comparing laparoendoscopic single‐site (LESS) living‐donor nephrectomy (LDN) vs standard laparoscopic LDN (LLDN). A systematic review of the literature was performed in September 2013 using PubMed, Scopus, Ovid and The Cochrane library databases. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta‐analyses criteria. Weighted mean differences (WMDs) were used to measure continuous variables and odds ratios (ORs) to measure categorical ones. Nine publications meeting eligibility criteria were identified, including 461 LESS LDN and 1006 LLDN cases. There were more left‐side cases in the LESS LDN group (96.5% vs 88.6%, P < 0.001). Meta‐analysis of extractable data showed that LLDN had a shorter operative time (WMD 15.06 min, 95% confidence interval [CI] 4.9–25.1; P = 0.003), without a significant difference in warm ischaemia time (WMD 0.41 min, 95% CI –0.02 to 0.84; P = 0.06). Estimated blood loss was lower for LESS LDN (WMD ?22.09 mL, 95% CI –29.5 to –14.6; P < 0.001); however, this difference was not clinically significant. There was a greater likelihood of conversion for LESS LDN (OR 13.21, 95% CI 4.65–37.53; P < 0.001). Hospital stay was similar (WMD –0.11 days, 95% CI –0.33 to 0.12; P = 0.35), as well as the visual analogue pain score at discharge (WMD –0.31, 95% CI –0.96 to 0.35; P = 0.36), but the analgesic requirement was lower for LESS LDN (WMD –2.58 mg, 95% CI –5.01 to –0.15; P = 0.04). Moreover, there was no difference in the postoperative complication rate (OR 1.00, 95% CI 0.65–1.54; P = 0.99). Renal function of the recipient, as based on creatinine levels at 1 month, showed similar outcomes between groups (WMD 0.10 mg/dL, –0.09 to 0.29; P = 0.29). In conclusion, LESS LDN represents an emerging option for living kidney donation. This procedure offers comparable surgical and early functional outcomes to the conventional LLDN, with a lower analgesic requirement. However, it is more technically challenging than LLDN, as shown by a greater likelihood of conversion. The role of LESS LDN remains to be defined.     

Dietary Ca2+ increases natriuretic and diuretic responses to volume loading in NaCl-sensitive spontaneously hypertensive rats

The present study tests the hypothesis that dietary Ca2+ supplementation increases acute diuretic and natriuretic responses to volume loading in the NaCl-sensitive spontaneously hypertensive rat (SHR-S). Seven week old male SHR-S and normotensive Wistar-Kyoto rats (WKY) were fed one of the following diets for 2.5 weeks: basal (0.75% NaCl, 0.68% Ca2+); high NaCl (8% NaCl, 0.68% Ca2+); high Ca2+ (0.75% NaCl, 2.0% Ca2+); and high NaCl and Ca2+ (8% NaCl, 2.0% Ca2+). SHR-S on high Ca2+ and on high NaCl and Ca2+ diets for 2 weeks displayed significantly lower systolic arterial pressures (SAP) than SHR-S on basal and high NaCl diets, respectively. WKY displayed no diet-related change in SAP at any time during the study. After 2.5 weeks on the diets, pre-instrumented, conscious SHR-S and WKY received an intravenous infusion (5% body weight) of isotonic NaCl, and urine was collected through a bladder catheter for a period of 90 min. The infusion did not alter the heart rate or the mean arterial pressure in any group. WKY on the high NaCl diet excreted a significantly greater percentage of the volume and Na+ load than WKY on the basal diet. In contrast, SHR-S on the high NaCl (compared to basal) diet did not display significantly enhanced natriuresis or diuresis. SHR-S on the basal diet displayed excretion rates similar to WKY on the basal diet. Dietary Ca2+ supplementation significantly increased the natriuretic and diuretic responses to saline infusion in SHR-S on the high NaCl diet, but not in SHR-S on the basal diet or in WKY on either diet.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of exposure to balanced salt solution upon the hardness of the crystalline lens

· Background: The nucleus confers most of the hardness upon the lens, water content decreases towards the centre of the nucleus and a relative dehydration accompanies increased hardness in some cataractous lenses. It is a possibility that exposure and incubation of the inner layers of the nucleus to balanced salt solution (BSS) can result in the softening of the nucleus. · Purpose: This study aimed to investigate the effect of BSS upon the lens hardness. · Methods: Nuclear colour element of cataract was graded biomicroscopically. Following extracapsular cataract surgery the lens nucleocortex was divided into two equal parts and each half was allocated randomly to incubation in BSS or air for 5 min before the hardness of each section was assessed by an automated guillotine. · Results: Following incubation with BSS the mean force necessary to bisect the lens was 0.50 N and in the control air group the mean force was 0.64 N. The lenses in the BSS-treated group were consistently softer than those in the control group, with a mean softening of 18.3% (P=0.001). The amount of softening was not related to the nuclear colour (P=0.6) or age (P=0.1). · Conclusion: Softening of the lens through physical disruption has previously been reported. This study describes the phenomenon of nuclear softening following exposure to BSS, indicating that lens softening can occur through biochemical means. Received: 3 April 1997 Revised version received: 18 August 1997 Accepted: 9 September 1997     

Treatment patterns of hypertension and dyslipidaemia in hypertensive patients at higher and lower risk of cardiovascular disease in primary care in the United Kingdom

Few studies have investigated the presence of dyslipidaemia in hypertensive individuals. In addition, few data exist on the concurrent treatment of both conditions for the prevention of cardiovascular disease (CVD). This retrospective cohort study examined treatment patterns for hypertension and dyslipidaemia among hypertensive patients in UK primary care. We defined a population of patients aged > or =40 years from the UK General Practice Research Database. Hypertensive individuals with > or =3 additional cardiovascular risk factors (ARFs) were compared with a cohort comprising hypertensive patients with < or =2 ARFs. We analysed the prevalence of risk factors and the prevalence and incidence of treatment for hypertension, dyslipidaemia and for both conditions between January 1997 and December 2001. A total of 117 840 hypertensive patients were identified (23 655 with > or =3 ARFs, 94 185 with < or =2 ARFs) in 1997; in 2001, the number diagnosed as hypertensive was 133 683 (40 248 > or =3 ARFs, 93 435 < or =2 ARFs). The prevalence of antihypertensive treatment in the hypertensive patients with > or =3 ARFs increased during the study. In 2001, approximately one-third of hypertensive patients with > or =3 ARFs were not receiving antihypertensives. Among those patients who received such treatment, the majority received > or =2 separate agents in accordance with current guidelines. Treatment for concurrent hypertension and dyslipidaemia was initiated in <8% of patients with hypertension and > or =3 ARFs in each year. These findings demonstrate the under-recognition/undertreatment of cardiovascular risk factors in UK primary care among patients at risk of CVD.     

Total chordal augmentation in a child with Marfan syndrome and severe mitral insufficiency

Mitral valve repair has become an established treatment in adults, but there is limited experience with the procedure in children, in whom the avoidance of a valve prosthesis is particularly advantageous. Repair of the mitral valve in children who have Marfan syndrome is especially difficult due to the presence of generalized connective tissue disorder, which may lead to future elongation and rupture of chordae tendineae that were unaffected at the time of mitral valve repair. We performed a total augmentation of all segments of the mitral valve, using artificial chordae tendineae. Herein, we describe the procedure and the positive outcome in a 10-year-old girl.     

Duration of untreated psychosis and pathways to care in patients with first-episode psychosis in Iran

Aim: This is the first study on the duration of untreated psychosis and pathways to care among patients with first‐episode psychosis in Iran as a developing country. Methods: Ninety‐one patients with a first episode of non‐organic psychosis admitted to a university‐affiliated psychiatric hospital in Iran were assessed for duration of untreated psychosis (DUP), pathways to care and mode of onset. Results: Median DUP was 11 weeks (mean = 52.3 weeks). Following the onset of psychosis, most patients were first seen by a psychiatrist (n = 23, 25.3%), a traditional healer (n = 21, 23.1%) or a general practitioner (n = 16, 17.6%). Most referrals to the psychiatric hospital were made by the family (n = 30, 33.1%), or health professionals (n = 29, 31.9%). Acute onset and rural place of residence were associated with shorter DUP in multivariate analysis. Conclusions: Median DUP was not long in an inpatient sample with first‐episode psychosis, which may be due to the preponderance of affective and acute psychoses in this sample and some help‐seeking or service variables.     

Melatonin, a promising supplement in inflammatory bowel disease: a comprehensive review of evidences

Inflammation and oxidative process are associated with inflammatory bowel disease (IBD). Regarding anti-inflammatory and antioxidant potentials, melatonin has been found beneficial in several experimental and clinical studies including inflammatory bowel disease (IBD). Our objective in this study is to review and evaluate all non-clinical and clinical studies on the efficacy of melatonin in IBD. All indexing databases were searched for inflammatory bowel disease' and 'melatonin' keywords, without time limit up to May 2011. Three clinical trials and fifteen non-clinical studies are reviewed and analyzed. The majority of these studies indicate that melatonin has a positive impact on IBD with no or negligible side effects. Such results have been mostly explained through free radical scavenging and diminishing inflammation. It is yet crucial to determine the efficacy of melatonin in combination with other established drugs in more clinical trials, not only for further confirmation of its efficacy, but also to investigate its possible side effects in longer durations of therapy.