Robot-assisted partial nephrectomy using the novel Hugo™ RAS system: Feasibility, setting and perioperative outcomes of the first off-clamp series.

INTRODUCTION: Hugo Robot-Assisted Surgery (RAS) System has been conceived with enhanced modularity but its role for nephron-sparing surgery setting still remains poorly explored. We aimed to describe our experience in robot-assisted partial nephrectomy (RAPN) with a three-arms setting for the first off-clamp series using the new Hugo RAS System. METHODS: Patients were placed on an extended flank position at the margin of the surgical bed with a slightly flexion (45°). The first 11 mm robotic trocar (camera port) was placed along the pararectal line 14 ± 2 cm far from the umbilicus. The pneumoperitoneum was then induced through the AirSeal system (SurgiQuest, Milford, Connecticut, USA©). Two more 8 mm operative robotic ports were placed under direct vision, either 8 ± 1 cm far from optic's port. Two 12 mm laparoscopic ports for bed-assistant were placed between robotic ports. Monopolar curved shears, fenestrated grasper, and large needle driver were used in a three-instruments configuration. RESULTS: Off-clamp RAPN was successfully performed in seven patients with cT1 renal masses using a trans-peritoneal route. Median port placement and docking time was 6 min (IQR, 4-8 min). Hemostasis was achieved through renorraphy using a single transfix stitch with sliding clips technique. There was no need for additional ports placement. No intraoperative complications occurred, no clashing of robotic instruments or between the robotic arms was observed. No technical failures of the system occurred. Median console time was 83 min (IQR, 68-115 min). Median estimated blood loss were 200 ml (IQR, 50-400 ml). All patients were discharged between post-operative day 2 and 3, without the need of hospital readmission. No complications were recorded within the first 30 post-operative days. CONCLUSIONS: We performed the first series of off-clamp RAPN using the novel HUGO RAS System. This novel robotic platform showed an easy-friendly docking system, providing excellent perioperative outcomes with a simple three-arms configuration.

AMI in (bi)ventricular pacing - do not discard the ECG.

BACKGROUND: There is a growing number of patients with ventricular paced rhythm, who present to the emergency department with chest pain. The diagnosis of ST-segment elevation myocardial infarction (STEMI) and subsequent percutaneous coronary intervention (PCI) is often postponed, as the 12 leads-electrocardiogram (ECG) is discarded as not interpretable. There is a growing body of literature that suggests that Smith-modified Sgarbossa criteria can be applied for the diagnosis of STEMI in patients with paced rhythms. These criteria were originally developed for the interpretation of ECGs in patients with a left bundle branch block (LBBB) and chest pain, but have been expanded to paced ECGs. METHODOLOGY: We present three case reports with chest pain and right ventricular or biventricular pacing. FINDINGS: In all three cases, the Smith-modified Sgarbossa was positive and the diagnosis of STEMI could have been made early on. IMPLICATIONS: It remains important to look for ST-segment deviations and to compare the symptomatic ECG with previous asymptomatic ECGs. As the number of patients with potential acute myocardial infarction (AMI) and paced rhythms is likely to rise in the future, these criteria should be known to emergency physicians and cardiologists.

Wolff Parkinson White and recreational (meth)amphetamine use: a potentially lethal combination.

Cardiac arrest in Wolff-Parkinson-White (WPW) is a rare event, and although some patients appear to be at greater risk, there is no consensus on clear risk factors. We present a case of a 23-year-old male patient, with a known history of WPW pattern, who suffered an out of hospital ventricular fibrillation after the consumption of rather small dose of (meth)amphetamines. The use of illegal drug can predispose WPW patients to fatal arrhythmia and cardiac arrest. Patients with WPW pattern should be well informed about the risks of (meth)amphetamines and some might be considered for medical therapy or catheter ablation.

European Biological Variation Study (EuBIVAS): within- and between-subject biological variation estimates of ß-isomerized C-terminal telopeptide of type I collagen (ß-CTX), N-terminal propeptide of type I collagen (PINP), osteocalcin, intact fibroblast growth factor 23 and uncarboxylated-unphosphorylated matrix-Gla protein-a cooperation between the EFLM Working Group on Biological Variation and the International Osteoporosis Foundation-International Federation of Clinical Chemistry Committee on Bone Metabolism.

We have calculated the biological variation (BV) of different bone metabolism biomarkers on a large, well-described cohort of subjects. BV is important to calculate reference change value (or least significant change) which allows evaluating if the difference observed between two consecutive measurements in a patient is biologically significant or not. INTRODUCTION: Within-subject (CVI) and between-subject (CVG) biological variation (BV) estimates are essential in determining both analytical performance specifications (APS) and reference change values (RCV). Previously published estimates of BV for bone metabolism biomarkers are generally not compliant with the most up-to-date quality criteria for BV studies. We calculated the BV and RCV for different bone metabolism markers, namely ß-isomerized C-terminal telopeptide of type I collagen (ß-CTX), N-terminal propeptide of type I collagen (PINP), osteocalcin (OC), intact fibroblast growth factor 23 (iFGF-23), and uncarboxylated-unphosphorylated Matrix-Gla Protein (uCuP-MGP) using samples from the European Biological Variation Study (EuBIVAS). METHODS: In the EuBIVAS, 91 subjects were recruited from six European laboratories. Fasting blood samples were obtained weekly for ten consecutive weeks. The samples were run in duplicate on IDS iSYS or DiaSorin Liaison instruments. The results were subjected to outlier and variance homogeneity analysis before CV-ANOVA was used to obtain the BV estimates. RESULTS: We found no effect of gender upon the CVI estimates. The following CVI estimates with 95% confidence intervals (95% CI) were obtained: ß-CTX 15.1% (14.4-16.0%), PINP 8.8% (8.4-9.3%), OC 8.9% (8.5-9.4%), iFGF23 13.9% (13.2-14.7%), and uCuP-MGP 6.9% (6.1-7.3%). CONCLUSIONS: The EuBIVAS has provided updated BV estimates for bone markers, including iFGF23, which have not been previously published, facilitating the improved follow-up of patients being treated for metabolic bone disease.

Systematic review of the biological variation data for diabetes related analytes.

BACKGROUND: Objective interpretation of laboratory test results used to diagnose and monitor diabetes mellitus in part requires the application of biological variation data (BVD). The quality of published BVD has been questioned. The aim of this study was to quality assess publications reporting BVD for diabetes-related analytes using the Biological Variation Data Critical Appraisal Checklist (BIVAC); to assess whether published BVD are fit for purpose and whether the study design and population attributes influence BVD estimates and to undertake a meta-analysis of the BVD from BIVAC-assessed publications. METHODS: Publications reporting data for glucose, HbA1c, adiponectin, C-peptide, fructosamine, insulin like growth factor 1 (IGF-1), insulin like growth factor binding protein 3 (IGFBP-3), insulin, lactate and pyruvate were identified using a systematic literature search. These publications were assessed using the BIVAC, receiving grades A, B, C or D, where A is of highest quality. A meta-analysis of the BVD from the assessed studies utilised weightings based upon BIVAC grades and the width of the data confidence intervals to generate global BVD estimates. RESULTS: BIVAC assessment of 47 publications delivered 1 A, 3 B, 39C and 4 D gradings. Publications relating to adiponectin, C-peptide, IGF-1, IGFBP-3, lactate and pyruvate were all assessed as grade C. Meta-analysis enabled global BV estimates for all analytes except pyruvate, lactate and fructosamine. CONCLUSIONS: This study delivers updated and evidence-based BV estimates for diabetes-related analytes. There remains a need for delivery of new high-quality BV studies for several clinically important analytes.

Correlación de hallazgos preoperatorios en la tomografía axial computarizada con la presencia de vía aérea difícil en pacientes intervenidos mediante cirugía otorrinolaringológica de cabeza y cuello / Correlation of preoperative findings in computed axial tomography with the presence of difficult airway in patients undergoing head and neck otorhinolaryngological surgery

Objetivos: Establecer una correlación entre 4 mediciones realizadas en la tomografía axial computarizada preoperatoria y la presencia de vía aérea difícil, y con la predicción clínica de la misma, en pacientes intervenidos mediante cirugía otorrinolaringológica. Material y métodos: Se realizó un estudio observacional, retrospectivo, usando como fuente de información las historias clínicas de 104 pacientes intervenidos bajo anestesia general e intubación endotraqueal por enfermedad oncológica durante un periodo de 36 meses. Sobre la base de los hallazgos obtenidos en las pruebas de imagen preoperatorias se realiza un análisis de regresión logística multivariante, donde las variables dependientes son grados extremos de visualización de la glotis (Cormack III-IV) o la presencia de predictores de intubación dificultosa (Mallampati III-IV). Se introdujeron en dicho modelo un total de 4 factores tomográficos y clínicos de vía aérea difícil. Resultados: En el grupo Cormack III-IV, en el modelo multivariante los resultados no fueron estadísticamente significativos cuando se comparaban con los predictores tomográficos (p>0,05; IC 95% distancia de la epiglotis a la pared faríngea posterior 0,030-2,31; distancia de la base de la lengua a la pared faríngea posterior 0,018-1,37). En el grupo Mallampati III-IV, en el modelo multivariante únicamente la distancia de las cuerdas vocales a la pared faríngea posterior muestra resultados clínicamente significativos (p<0,05; IC 95% 0,104-8,53). Conclusiones: En el abordaje de la vía aérea actualmente nos podemos apoyar en los predictores correspondientes al examen físico para adelantarnos a situaciones que pongan en riesgo la oxigenación y la ventilación de nuestros pacientes. Aunque aún los datos son insuficientes para recomendar las pruebas de imagen en este ámbito, parece que en un futuro pueden sumarse al examen físico para aumentar el rendimiento diagnóstico

Objectives: To establish a correlation between 4 measurements made on preoperative computed axial tomography and the presence of difficult airway, as well as its clinical prediction in patients undergoing otorhinolaryngological surgery. Material and methods: A retrospective, observational study was carried out using the information gathered from the clinical notes of 104 patients undergoing general anaesthesia and endotracheal intubation for oncological otorhinolaryngological surgery over a period of 36 months. Based on the findings in the preoperative imaging tests, a multivariate logistic regression analysis was performed, where the dependent variable was the presence of extreme grades of visualization of the glottis visualisation (Cormack III-IV) or the presence of predictors of difficult intubation (Mallampati III-IV). This resulted in a total of 4 tomographic and clinical factors of difficult airway being introduced in this model. Results: In the Cormack III-IV group, the results were not statistically significant in the multivariate model when compared to the tomography predictors, distance from epiglottis to posterior pharyngeal wall (95% CI; 0.030 - 2.31, P<.05), and the distance from the base of the tongue to the posterior pharyngeal wall (95% CI; 0.018-1.37, P<.05). In the Mallampati III-IV group, in the multivariate model only the distance from the vocal cords to the posterior pharyngeal wall showed clinically significant results (95% CI; 0.104 - 8.53, P<.05). Conclusions: In the approach to the airway, reliance on predictors is based on physical examination to anticipate situations that put oxygenation and ventilation of the patients at risk. There are still insufficient data to recommend imaging tests in this area, however it seems that in the future they may be added to the diagnostic performance of physical examination as predictors of difficult airway

Correlation of preoperative findings in computed axial tomography with the presence of difficult airway in patients undergoing head and neck otorhinolaryngological surgery. / Correlación de hallazgos preoperatorios en la tomografía axial computarizada con la presencia de vía aérea difícil en pacientes intervenidos mediante cirugía otorrinolaringológica de cabeza y cuello.

OBJECTIVES: To establish a correlation between 4 measurements made on preoperative computed axial tomography and the presence of difficult airway, as well as its clinical prediction in patients undergoing otorhinolaryngological surgery. MATERIAL AND METHODS: A retrospective, observational study was carried out using the information gathered from the clinical notes of 104 patients undergoing general anaesthesia and endotracheal intubation for oncological otorhinolaryngological surgery over a period of 36 months. Based on the findings in the preoperative imaging tests, a multivariate logistic regression analysis was performed, where the dependent variable was the presence of extreme grades of visualization of the glottis visualisation (Cormack III-IV) or the presence of predictors of difficult intubation (Mallampati III-IV). This resulted in a total of 4 tomographic and clinical factors of difficult airway being introduced in this model. RESULTS: In the Cormack III-IV group, the results were not statistically significant in the multivariate model when compared to the tomography predictors, distance from epiglottis to posterior pharyngeal wall (95% CI; 0.030 - 2.31, P<.05), and the distance from the base of the tongue to the posterior pharyngeal wall (95% CI; 0.018-1.37, P<.05). In the Mallampati III-IV group, in the multivariate model only the distance from the vocal cords to the posterior pharyngeal wall showed clinically significant results (95% CI; 0.104 - 8.53, P<.05). CONCLUSIONS: In the approach to the airway, reliance on predictors is based on physical examination to anticipate situations that put oxygenation and ventilation of the patients at risk. There are still insufficient data to recommend imaging tests in this area, however it seems that in the future they may be added to the diagnostic performance of physical examination as predictors of difficult airway.

Cambio espontáneo en un nevus melanocítico común / Spontaneous Change in a Common Melanocytic Nevus

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Experimental study showed that adding fortifier and extra-hydrolysed proteins to preterm infant mothers' milk increased osmolality.

AIM: Measuring milk osmolality after adjustable fortification is clinically relevant, as values exceeding recommended safety thresholds might result in gastrointestinal consequences. The aim of this study was to evaluate the effect of four fortification levels and storage time on the osmolality of human milk. METHODS: This was an experimental study using 71 spare samples of fresh breastmilk collected from 31 mothers of preterm infants. Osmolality was measured before and after adding commercial human milk fortifier containing dextrinomaltose and hydrolysed proteins at four different concentrations. Measurements were performed at various points during the 23 hours after fortification. RESULTS: The mean basal osmolality of the 71 human milk samples was 296 ± 14 milliosmoles (mOsm)/kg, and these remained stable over a period of 23 hours. Just after fortification, the four fortified formulas showed higher osmolalities than the nonfortified human milk, ranging between 384 ± 14 and 486 ± 15 mOsm/kg, respectively (p < 0.01). This osmolality increased significantly from 20 minutes to 23 hours after fortification (p < 0.05). CONCLUSION: Adding fortifier and extra-hydrolysed proteins to human preterm milk increased osmolality, and these osmolality levels also increased with time. We recommend evaluating the risk of hyperosmolality when a higher fortification level is needed, to avoid gastrointestinal problems.

Alcohol-related emergency department admissions among adolescents in the Ghent and Sint-Niklaas areas.

Alcohol abuse is a major health concern. The aim of this retrospective study was to analyse the alcohol-related emergency department (ED) admissions among adolescents in all hospitals of distinct areas during a 1-year period. In each hospital, all ED patients with a blood alcohol concentration (BAC) of at least 0.5 g/l were surveyed in a standardised way. Of the 3918 included patients, only 146 (3.7%) were < 18  years. The male-to-female ratio was 1.5:1. There was a strong preponderance of weekend and night time admissions. Most of the patients were transported by ambulance (77% of 138 patients with information on this item). The main reason for ED admittance was depressed level of consciousness (64%), trauma (12%), vomiting and/or abdominal pain (12%), agitation or aggression (4%), syncope (4%) and psychological problems (4%). The context of the alcohol intoxication was related to some kind of festivity in 85%, mental problems in 14% and chronic abuse in 1%. Median BAC values (and range) were 2.08 g/l (0.73-3.70 g/l) for boys and 1.51 g/l (0.73-2.90 g/l) for girls. Most patients (87%) could be discharged home within 24  hours. Our study confirms that problematic alcohol use leading to ED admissions starts in adolescence. Although the numbers of cases below 18 years are low when compared to adults, the phenomenon is alarming as it is associated with substantial health problems. Therefore, Belgium urgently needs a global national alcohol plan, with youngsters being one of the target groups.

Fiabilidad de la teledermatología de almacenamiento en un escenario real / Interobserver Reliability of Store-and-Forward Teledermatology in a Clinical Practice Setting

INTRODUCCIÓN Y OBJETIVOS: Aunque existen múltiples estudios de fiabilidad diagnóstica en teledermatología de almacenamiento (TDA), aún no se ha demostrado una fiabilidad elevada para enfermedad general cutánea en un escenario real. DERMATEL-2 fue un estudio aleatorizado de concordancia diagnóstica en TDA en condiciones de práctica clínica. MATERIAL Y MÉTODOS: Pacientes remitidos desde atención primaria fueron aleatorizados en 3 grupos: TDA; híbrida videoconferencia-almacenamiento (VC-TDA) y grupo control (GC). Este artículo se centra en el grupo de almacenamiento. Médicos de atención primaria tomaron datos y fotografías clínicas remitiéndolas a distancia. Cada consulta de TDA fue evaluada por 3 dermatólogos diferentes (D1, D2, D3). Todos los pacientes fueron finalmente vistos por el mismo dermatólogo (D1) en la consulta presencial (CP). Dos dermatólogos adicionales (D4, D5) evaluaron las concordancias TDA-CP. RESULTADOS: Se aleatorizaron un total de 457 pacientes 4-4-2: 192 TDA, 176 VC-TDA y 89 GC; 200 varones y 257 mujeres, 0-86 años. Se incuyó enfermedad tumoral (49,4%), inflamatoria (25,7%), anexial (11%), infecciosa (9,4%) y otros (4,4%). Hubo 170 pacientes de TDA válidos para el análisis, rindiendo 510 teleconsultas-TDA. La imagen (71,2%), la historia clínica (91,2%) y la confianza diagnóstica (81,4%) fueron de calidad alta. En el 58,4% fue posible el manejo exclusivo on-line. Los acuerdos interobservador (completo/agregado) TDA-CP fueron 0,72/0,90 para el diagnóstico y 0,61/0,80 en el tratamiento. El acuerdo diagnóstico se correlacionó con la calidad de la imagen (p < 0,001), la confianza diagnóstica (p < 0,001), la necesidad de consulta presencial (p < 0,001) y la calidad de la historia clínica (p = 0,013). CONCLUSIÓN: La fiabilidad diagnóstica de la TDA en condiciones de práctica clínica es elevada. Los dermatólogos pueden predecir errores diagnósticos analizando su confianza diagnóstica y la calidad de las fotografías

INTRODUCTION AND OBJECTIVES: Although many studies have evaluated the diagnostic reliability of store-and-forward (SF) teledermatology, the reliability of the technique for the diagnosis of general skin conditions in a clinical practice setting has never been demonstrated. We evaluated the reliability of SF teledermatology in clinical practice by analyzing the diagnostic agreement achieved in a subgroup of patients from the DERMATEL-2 study. MATERIAL AND METHODS: Patients referred from primary care settings were randomized to 3 groups: SF, a combination of videoconferencing and SF technology (VC-SF), and a control group. This article focuses on the SF group. Clinical data were recorded and photographs taken by primary care physicians, who forwarded the data digitally. Each SF consultation package was assessed by 3 dermatologists (D1, D2, D3). Subsequently all the patients were assessed by a single dermatologist (D1) in a face-to-face (FF) consultation. Finally, 2 other dermatologists (D4,D5) assessed the agreement between the diagnoses obtained by SF and FF. RESULTS: In total, 457 patients (200 males and 257 females) aged between 2 months and 86 years were randomized (192 to SF, 176 to VC-SF, and 89 to the control group). The diagnostic categories were as follows: tumors (49.4%), inflammatory (25.7%), adnexal (11%), infectious (9.4%) and other processes (4.4%). Since 170 patients had SF consultations deemed valid for analysis, the study included a total of 510 SF assessments. Most of the images and clinical records were of high quality (71.2% and 91.2% respectively), and diagnostic confidence was high in 81.4% of the cases studied. In 58.4% of cases the condition was managed exclusively by teledermatology. Levels of complete and aggregate interobserver agreement between SF and FF evaluators were 0.72 and 0.90, respectively, for diagnosis and 0.61 and 0.80 for treatment. Diagnostic agreement correlated with the image quality (P < 0.001), diagnostic confidence (P < 0.001), felt need for conventional consultation (P < .001), and the quality of the clinical record (P = 0.013). CONCLUSION: The interobserver reliability of SF diagnosis in clinical practice is good. Dermatologists are able to predict errors in diagnosis by analyzing their own diagnostic confidence and evaluating the quality of the images