Open Management of the Renal Vein Is a Safe Modification in Right-Sided Laparoscopic Living Donor Nephrectomy to Maximize Graft Vein Length.

BACKGROUND: The primary objective in living donor kidney transplantation is donor safety. In laparoscopic living donor nephrectomy, most centers prefer the left kidney for donation given the shorter renal vein, higher rate of thromboses, and more difficult surgical procedure for right kidney retrieval. The goal of this study was to demonstrate the feasibility of a hybrid technique using a Satinsky clamp in right-sided living donor nephrectomy to obtain maximal renal vein and to compare the outcome with standard left-sided laparoscopic donor nephrectomies. MATERIAL AND METHODS: Between 2005 and 2013, 77 patients underwent a left (group L) and 54 a right (group R) living donor nephrectomy. In group R, after laparoscopic dissection and mobilization of the right kidney, two 12-mm trocar incisions in the right upper quadrant were connected in a 5-7 cm subcostal incision. The caval vein was partially clamped under direct vision prior to dissection of the renal vein. The venotomy was then closed with a running 4-0 Prolene suture. The two groups were compared with regard to surgical complications, graft function, and graft survival. RESULTS: Using this technique, no significant difference with regard to complications or graft function was observed. Serum creatinine at discharge in donor group L was 1.23 (±0.43) mg/dL and in donor group R 1.21 (±0.37) mg/dL (P = .71). Graft survival at one year was 100% in both groups. CONCLUSION: Open management of the renal vein is a safe alternative in laparoscopic right-sided donor nephrectomy and ensures maximal length of the vein.

Ultrasound screening for interstitial lung disease in rheumatoid arthritis.

OBJECTIVES: As interstitial lung disease (ILD) in rheumatoid arthritis (RA) patients is associated with increased mortality due to loss of diffusion capacity and pulmonary hypertension, regular screening for structural abnormalities of the lung is advised. In addition to standard radiological examination with computed x-ray tomography, ultrasound of the lung could allow non-invasive and radiation-free structural monitoring of the lung. The objective of this study was to test the frequency of abnormalities in lung sonography in patients with RA who did not have clinical signs or symptoms of lung disease. METHODS: In a prospective study of 64 consecutive patients with rheumatoid arthritis and 40 healthy volunteers, we screened the pleura and the pulmonary parenchyma for sonographic abnormalities. All RA patients underwent high resolution computer tomography of the lung. RESULTS: 28% of RA patients showed pleural nodules or B-line phenomena. In these patients, CT scans showed signs of incipient interstitial lung disease. Lung sonography showed sporadic abnormalities in 7% of the healthy controls. CONCLUSIONS: Transthoracic ultrasound of the lung is an inexpensive and safe tool to screen patients with RA for incipient pulmonary structural changes.

Pulmonary echography in systemic sclerosis.

In systemic sclerosis patients, interstitial lung disease and pulmonary hypertension are highly associated with mortality. The time point of detecting manifestations like pulmonary hypertension and interstitial lung disease (ILD) is of vital importance. High-resolution computed tomography (HRCT) to date is the gold standard to diagnose ILD. In addition, an ultrasound of the lung is suggested as a noninvasive and radiation-free method of structural monitoring of the lung. We tested the reliability of lung sonography for the assessment of patients with systemic sclerosis. In a pilot study involving 25 patients with systemic sclerosis and 40 healthy volunteers, we screened the pleura and the pulmonary parenchyma for sonographic abnormalities. The occurrence of B lines, comet tail phenomena, and pleural irregularities was scored. All systemic sclerosis (SSc) patients were subjected to computed x-ray tomography of the chest. Forty-four percent of SSc patients showed B line phenomena and pleural thickening. The diagnosis of ILD in these patients was confirmed by HRCT scan. B line phenomena and pleural irregularities were significantly more common in SSc patients. Patients with ILD had higher pleural scores and comet scores when compared to systemic sclerosis patients without radiographic ILD. If our results are confirmed in larger studies, transthoracic ultrasound of the lung might turn out to be a suitable method for screening patients with systemic sclerosis for incipient pulmonary structural changes.

Conversion from cyclosporine to everolimus at 4.5 months posttransplant: 3-year results from the randomized ZEUS study.

The long-term effect of conversion from calcineurin inhibitor (CNI) therapy to an mTOR inhibitor requires clarification. Following completion of the 12-month, open-label, multicenter ZEUS study, in which 300 kidney transplant recipients were randomized to continue cyclosporine (CsA) or convert to everolimus at 4.5 months posttransplant, outcomes were assessed at month 36 (n = 284; 94.7%). CNI therapy was reintroduced in 28.4% of everolimus patients by month 36. The primary efficacy endpoint, estimated glomerular filtration rate (Nankivell, ANCOVA) was significantly higher with everolimus versus the CsA group at month 24 (7.6 mL/min/1.73 m(2) , 95%CI 4.3, 11.0 mL/min/1.73 m(2) ; p < 0.001) and month 36 (7.5 mL/min/1.73 m(2) , 95%CI 3.6, 11.4 mL/min/1.73 m(2) ; p < 0.001). The incidence of biopsy-proven acute rejection from randomization to month 36 was 13.0% in the everolimus arm and 4.8% in the CsA arm (p = 0.015). Patient and graft survival, as well as incidences of malignancy, severe infections and hospitalization, were similar between groups. Kidney transplant patients who are converted from CsA to everolimus at month 4.5 and who remain on everolimus thereafter may achieve a significant improvement in renal function that is maintained to 3 years. There was a significantly higher rate of rejection in the everolimus arm but this did not exert a deleterious effect by 3 years posttransplant.

Diagnosis of CTEPH versus IPAH using capillary to end-tidal carbon dioxide gradients.

Chronic thromboembolic pulmonary hypertension (CTEPH) represents an important differential diagnosis to idiopathic pulmonary arterial hypertension (IPAH). We hypothesised that the capillary to end-tidal carbon dioxide gradient at rest and during exercise might help differentiate CTEPH from IPAH. Patients who presented with unequivocal IPAH or CTEPH according to ventilation/perfusion scanning, pulmonary angiography, computed tomography and right heart catheterisation were included in this retrospective study and compared with healthy controls. 21 IPAH patients and 16 CTEPH patients fulfilled the inclusion criteria. Haemodynamics and peak oxygen uptake were comparable, but respiratory rates at rest and during exercise were significantly higher in CTEPH than in IPAH. End-tidal carbon dioxide was significantly lower in CTEPH versus IPAH at rest and during exercise, while capillary carbon dioxide values were similar. Correspondingly, capillary to end-tidal carbon dioxide gradients were significantly increased in CTEPH versus IPAH at rest and during exercise (median (range) 8.6 (3.0-13.7) versus 4.4 (0.9-9.0) (p<0.001) and 9.3 (3.3-13.1) versus 4.1 (0.0-8.8) mmHg (p<0.001), respectively). Although these values were closer to normal in IPAH they were still significantly elevated compared with healthy controls (2.3 (-4.8-8.1) and -1.9 (-5.7-6.2) mmHg, respectively). Capillary to end-tidal carbon dioxide gradients may help to distinguish CTEPH from IPAH based on resting and exercise values.

Positive effect of abdominal breathing exercise on gastroesophageal reflux disease: a randomized, controlled study.

OBJECTIVES: The lower esophageal sphincter (LES), surrounded by diaphragmatic muscle, prevents gastroesophageal reflux. When these structures become incompetent, gastric contents may cause gastroesophageal reflux disease (GERD). For treatment, lifestyle interventions are always recommended. We hypothesized that by actively training the crura of the diaphragm as part of the LES using breathing training exercises, GERD can be positively influenced. METHODS: A prospective randomized controlled study was performed. Patients with non-erosive GERD or healed esophagitis without large hernia and/or previous surgery were included. Patients were randomized and allocated either to active breathing training program or to a control group. Quality of life (QoL), pH-metry, and on-demand proton pump inhibitor (PPI) usage were assessed at baseline and after 4 weeks of training. For long-term follow-up, all patients were invited to continue active breathing training and were further assessed regarding QoL and PPI usage after 9 months. Paired and unpaired t-test was used for statistical analysis. RESULTS: Nineteen patients with non-erosive GERD or healed esophagitis were randomized into two groups (10 training group and 9 control group). There was no difference in baseline patient characteristics between the groups and all patients finished the study. There was a significant decrease in time with a pH<4.0 in the training group (9.1±1.3 vs. 4.7±0.9%; P<0.05), but there was no change in the control group. QoL scores improved significantly in the training group (13.4±1.98 before and 10.8±1.86 after training; P<0.01), but no changes in QoL were seen in the control group. At long-term follow-up at 9 months, patients who continued breathing exercise (11/19) showed a significant decrease in QoL scores and PPI usage (15.1±2.2 vs. 9.7±1.6; 98±34 vs. 25±12 mg/week, respectively; P<0.05), whereas patients who did not train had no long-term effect. CONCLUSIONS: We show that actively training the diaphragm by breathing exercise can improve GERD as assessed by pH-metry, QoL scores and PPI usage. This non-pharmacological lifestyle intervention could help to reduce the disease burden of GERD.

Pulmonary arterial pressure during rest and exercise in healthy subjects: a systematic review.

According to current guidelines, pulmonary arterial hypertension (PAH) is diagnosed when mean pulmonary arterial pressure (Ppa) exceeds 25 mmHg at rest or 30 mmHg during exercise. Issues that remain unclear are the classification of Ppa values <25 mmHg and whether Ppa >30 mmHg during exercise is always pathological. We performed a comprehensive literature review and analysed all accessible data obtained by right heart catheter studies from healthy individuals to determine normal Ppa at rest and during exercise. Data on 1,187 individuals from 47 studies in 13 countries were included. Data were stratified for sex, age, geographical origin, body position and exercise level. Ppa at rest was 14.0+/-3.3 mmHg and this value was independent of sex and ethnicity. Resting Ppa was slightly influenced by posture (supine 14.0+/-3.3 mmHg, upright 13.6+/-3.1 mmHg) and age (<30 yrs: 12.8+/- 3.1 mmHg; 30-50 yrs: 12.9+/-3.0 mmHg; > or = 50 yrs: 14.7+/-4.0 mmHg). Ppa during exercise was dependent on exercise level and age. During mild exercise, Ppa was 19.4+/-4.8 mmHg in subjects aged <50 yrs compared with 29.4+/-8.4 mmHg in subjects > or = 50 yrs (p<0.001). In conclusion, while Ppa at rest is virtually independent of age and rarely exceeds 20 mmHg, exercise Ppa is age-related and frequently exceeds 30 mmHg, especially in elderly individuals, which makes it difficult to define normal Ppa values during exercise.

[Interdisciplinary point of contact between rheumatology and pneumology]. / Interdisziplinäre Berührungspunkte zwischen Rheumatologie und Pneumologie.

The lungs are involved in many inflammatory rheumatic diseases. We will focus on the most common clinical problems. In systemic sclerosis interstitial lung disease resulting in fibrosis and pulmonary arterial hypertension (PAH) resulting in right heart failure are the leading complications requiring close cooperation between specialists in rheumatology and pulmonology. In Sjogren's syndrome interstitial pneumonia, pleural and bronchial inflammation and rarely PAH will be the main pulmonary complications. Hypereosinophilic syndrome, eosinophilic pneumonia, and Churg-Strauss syndrome are conditions that show marked eosinophilia and can clinically be confused with asthma and allergic bronchopulmonary aspergillosis. These conditions mandate thorough investigation of the lungs including bronchoscopy and possibly open lung biopsy. Finally, patients for whom treatment with tumour necrosis factor blocking agents is planned should undergo interdisciplinary management to prevent tuberculosis activation or infection.

Pulmonary histoplasmosis in three Austrian travelers after a journey to Mexico.

Three Austrian travelers (a 37-year-old woman, a 47-year-old woman and a 47-year-old man) presented with fever, dyspnea, thoracodynia, cephalea, arthralgia and fatigue 4 weeks after visiting a bat cave in Mexico. Computed tomography of the lungs showed bilateral nodular infiltrates in all three patients and enlarged mediastinal lymph nodes in two patients. In all patients, specific IgM antibodies against Histoplasma capsulatum could be detected. After treatment with itraconazole 200 mg q.d. orally for 2 months, the patients had no further complaints and the pulmonary infiltrates had resolved.

Spin-wave dispersion in orbitally ordered La1/2Sr3/2MnO4.

The magnon dispersion in the charge, orbital, and spin ordered phase in La1/2Sr3/2MnO4 has been studied by means of inelastic neutron scattering. We find excellent agreement with a magnetic interaction model based on the CE-type superstructure. The magnetic excitations are dominated by ferromagnetic exchange parameters revealing a nearly one-dimensional character at high energies. The strong ferromagnetic interaction in the charge or orbital ordered phase appears to be essential for the capability of manganites to switch between metallic and insulating phases.

Rectification in Luttinger liquids.

We investigate the rectification of an ac bias in Luttinger liquids in the presence of an asymmetric potential (the ratchet effect). We show that a strong repulsive electron interaction enhances the ratchet current in comparison with Fermi-liquid systems, and the dc I-V curve is strongly asymmetric in the low-voltage regime even for a weak asymmetric potential. At higher voltages the ratchet current exhibits an oscillatory voltage dependence.

Effect of sildenafil on oesophageal motor function in healthy subjects and patients with oesophageal motor disorders.

BACKGROUND AND AIMS: Sildenafil blocks phosphodiesterase type 5 which degrades nitric oxide (NO) stimulated 3'5'-cyclic monophosphate (cGMP), thereby relaxing smooth muscle cells in various organs. We used sildenafil as a tool to investigate the role of the NO-cGMP pathway in the oesophagus of healthy volunteers and patients with hypercontractile oesophageal motility disorders. METHODS: Six healthy male volunteers participated in a randomised double blind study on two separate days before and one hour after oral intake of either sildenafil 50 mg or placebo. Oesophageal manometry was performed to determine vector volume of the lower oesophageal sphincter (LOS) and pressure amplitudes of the oesophageal body. Four of the volunteers underwent 12 hour ambulatory oesophageal manometry on two separate days, once with sildenafil 50 mg and once with placebo. An activity index for spontaneous swallowing was calculated for every hour of the study. Eleven patients with hypercontractile oesophageal motility disorders took part in an open study of the effect of 50 mg sildenafil on manometric features of their disorder and on the clinical response to sildenafil taken as required. RESULTS: In healthy subjects, sildenafil significantly reduced LOS pressure vector volume and pressure amplitudes in the distal half of the oesophageal body. In three of four subjects the inhibitory effect of sildenafil lasted at least eight hours. In nine of 11 patients, manometric improvement after sildenafil was observed but only four had an improvement in oesophageal symptoms with sildenafil taken as required. Two of these four patients however experienced side effects and did not want to continue treatment. CONCLUSIONS: Sildenafil lowers LOS pressure and propulsive forces in the body of the oesophagus of healthy subjects as well as in patients with nutcracker oesophagus, hypertensive LOS, and achalasia. The effect of sildenafil on the oesophageal body may last for up to eight hours in healthy volunteers. A subset of patients with hypertensive LOS or nutcracker oesophagus may benefit from sildenafil but side effects are a limiting factor.

Sufentanil potentiates the inhibitory effect of epinephrine on intestinal motility.

OBJECTIVE: The aim of our study was to evaluate the effect of the combination of different catecholamines and sufentanil on peristalsis of the isolated guinea pig small bowel in vitro. DESIGN: In vitro study on excised guinea pig small-bowel segments (8-10 segments per substance tested). SETTING: Laboratory for experimental studies at the University. SUBJECTS: Isolated guinea pig small-bowel segments. INTERVENTIONS: Excised segments of guinea pig small bowel were mounted in a tissue bath (37 degrees C) in Tyrode's solution and bubbled with carbogen (95% O2/5% CO2). The lumina were perfused with Tyrode's solution at 0.5 ml/min. The test drugs (epinephrine, norepinephrine, dobutamine, sufentanil, and a combination of these catecholamines with sufentanil) were added to the tissue bath and peristalsis recorded via changes in the intraluminal pressure. One-way and two-way ANOVA were used for statistical analysis. MEASUREMENTS AND RESULTS: All the tested substances, both individually and in combination, inhibited intestinal peristalsis in a dose-dependent manner. High doses resulted in a complete blockade of peristalsis. Preexposure of the segments to sufentanil at 0.1 nM barely influenced the effects of the catecholamines on peristalsis. However, sufentanil at 0.3 nM enhanced the antiperistaltic activity of epinephrine in a supraadditive manner, whereas the effect on norepinephrine and dobutamine was less pronounced. CONCLUSIONS: Our experimental data suggest that the combination of epinephrine and sufentanil might be the worst choice for the intensive care setting. This is due to its pronounced inhibitory effect on peristalsis in vitro at moderate and higher concentrations.

Low potential of dobutamine and dopexamine to block intestinal peristalsis as compared with other catecholamines.

OBJECTIVE: Catecholamines are frequently used in critically ill patients to restore stable hemodynamics and to improve organ perfusion. One effect of short-term or long-term administration of catecholamines may be inhibition of propulsive motility in the intestine. We therefore analyzed the effect of dopexamine, dobutamine, and dopamine on ileal peristalsis and compared their action with that of epinephrine and norepinephrine, which have long been known to suppress intestinal peristalsis. DESIGN: In vitro study on excised guinea pig ileum segments. SETTING: Laboratory for experimental studies at the University. SUBJECTS: Isolated guinea pig ileum. INTERVENTIONS: Segments of ileum excised from guinea pigs were mounted in a tissue bath in Krebs-Henseleit solution and bubbled with 95% oxygen/5% CO2. Luminal perfusion with the same solution was performed at a rate of 0.35 mL/min. The bath temperature was kept at 36.5 degrees C. Peristalsis was recorded via changes in the intraluminal pressure. The drugs under investigation (dopamine, epinephrine, norepinephrine, dobutamine, and dopexamine) were added to the tissue bath. MEASUREMENTS AND MAIN RESULTS: Low concentrations of each catecholamine, except epinephrine, caused a decrease in the pressure threshold, which reflects a stimulatory effect on peristalsis. Higher catecholamine concentrations caused a concentration-related increase in the threshold, cumulating in a complete block of peristalsis. The rank order of inhibitory potency was epinephrine > norepinephrine > dopamine > dobutamine approximately dopexamine. Dobutamine and dopexamine were about 500-fold less active than epinephrine in suppressing peristalsis. CONCLUSIONS: This study shows that dobutamine and dopexamine have the least potential to block propulsive motility in the intestine, whereas epinephrine demonstrates the most adverse inhibitory effect. Because at low concentrations dobutamine and dopexamine even stimulate peristalsis, these drugs appear to be superior compared with other catecholamines with regard to their direct effects on intestinal motility.