Strategies for Renal Protection in Cardiovascular Interventions

Coronary artery disease is highly prevalent in chronic kidney disease (CKD) and is a risk factor for contrast-associated acute kidney injury (CA-AKI), a complication of cardiovascular procedures that require contrast administration (e.g., coronary angiography, percutaneous coronary intervention [PCI]). CA-AKI has a major impact on morbidity, mortality, and healthcare resource utilization. The incidence of CA-AKI is particularly high in patients with pre-existing CKD, advanced age and comorbidities that increase the likelihood of CKD. The focus of the present review is to provide a brief overview on the assessment of the risk for and prevention of CA-AKI in patients undergoing angiography and PCI, including recognition of the important patient- and procedure-related factors that may contribute to CA-AKI. Preventive and treatment strategies, the mainstay of which is volume repletion by normal saline, are briefly discussed. The main focus of the review is placed on technical details of contrast minimization techniques, including ultra-low contrast angiography and zerocontrast PCI. Operator competence in such techniques is important to ensure that procedural challenges in patients with CKD, like vessel calcification, multivessel disease and complex anatomical subsets, are effectively addressed by PCI while minimizing the risk of CA-AKI.

Conservative management in hypertriglyceridemia-associated pancreatitis.

BACKGROUND: Severe hypertriglyceridemia (serum triglyceride >10 mmol L-1 ) is implicated in ~9% of acute pancreatitis cases. Certain guidelines list severe hypertriglyceridemia as an indication for plasmapheresis. OBJECTIVE: We assembled the natural trajectory of triglyceride levels in patients with acute pancreatitis due to severe hypertriglyceridemia who were managed conservatively without plasmapheresis to evaluate the effectiveness of this approach. METHODS: A retrospective chart review was performed on 22 hospital admissions for acute pancreatitis episodes considered to be caused by severe hypertriglyceridemia. Patients were managed supportively, with cessation of oral intake (NPO) and intravenous hydration. Insulin infusion was used in 12 patients to manage concurrent hyperglycaemia. RESULTS: Triglyceride levels for the group were evaluated using a mixed-effects model. The average triglyceride level fell from 45.4 mmol L-1 on presentation to 13.3 mmol L-1 within 48 h, corresponding to a mean 69.8% decrease. Regression analysis showed a triglyceride half-life of 30.6 h. Findings were similar for NPO-only and insulin infusion subgroups. CONCLUSION: Patients with severe hypertriglyceridemia and acute pancreatitis can be conservatively managed safely and effectively without plasmapheresis.

Middle East respiratory syndrome coronavirus in pediatrics: a report of seven cases from Saudi Arabia / 医学前沿

Infection with Middle East respiratory syndrome coronavirus (MERS-CoV) emerged in 2012 as an important respiratory disease with high fatality rates of 40%-60%. Despite the increased number of cases over subsequent years, the number of pediatric cases remained low. A review of studies conducted from June 2012 to April 19, 2016 reported 31 pediatric MERS-CoV cases. In this paper, we present the clinical and laboratory features of seven patients with pediatric MERS. Five patients had no underlying medical illnesses, and three patients were asymptomatic. Of the seven cases, four (57%) patients sought medical advice within 1-7 days from the onset of symptoms. The three other patients (43%) were asymptomatic and were in contact with patients with confirmed diagnosis of MERS-CoV. The most common presenting symptoms were fever (57%), cough (14%), shortness of breath (14%), vomiting (28%), and diarrhea (28%). Two (28.6%) patients had platelet counts of < 150 × 10/L, and one patient had an underlying end-stage renal disease. The remaining patients presented with normal blood count, liver function, and urea and creatinine levels. The documented MERS-CoV Ct values were 32-38 for four of the seven cases. Two patients (28.6%) had abnormal chest radiographic findings of bilateral infiltration. One patient (14.3%) required ventilator support, and two patients (28.6%) required oxygen supplementation. All the seven patients were discharged without complications.

Morbidity Profile of Cases Attended Oncology Center of Mansoura University (OCMU), Egypt: A Cross-Sectional Study

OBJECTIVES: In Egypt, the National Cancer Registry Program integrates hospital-based data from multiple Egyptian governorates to obtain representative rates. Unfortunately, Dakahlia (one of the largest Egyptian governorates) was not integrated in the National Cancer Registry Program. This research aimed to acquire malignancy rates from the Oncology Center of Mansoura University, which is one of the two oncology centers present in Dakalia Governorate in Egypt. METHODS: Electronic records of patients who attended the Oncology Center of Mansoura University during 2016 were accessed with permission. Analysis was performed to extract diagnostic categories (age, gender, and geographic distribution of cases). RESULTS: Most commonly diagnosed malignancies were breast cancer which represented about 10% of cases in the Oncology Center of Mansoura University during 2016. This was followed by leukemia (3.80%), lymphoma (3.59%), and liver cancer (3.44%). Diagnoses encountered included benign and malignant tumors as well as non-tumor diagnoses. The Mansoura district had the highest proportionate rate of breast cancer cases. Females in the age group ≥ 35 < 60 years had the highest incidence of malignancy cases across all diagnoses. CONCLUSION: The burden of breast cancer in Mansoura district is high. Risk factors need further evaluation with a recommendation to perform an environmental risk assessment.

Results of distal hypospadias repair after pediatric urology fellowship training: A comparison of junior surgeons with their mentor.

BACKGROUND: Teaching and learning hypospadias repair is a major component of pediatric urology fellowship training. Educators must transfer skills to fellows, without increasing patient complications. Nevertheless, few studies report results of surgeons during their first years of independent practice. PURPOSE: To review outcomes of distal hypospadias repairs performed during the same 2-year period by consecutive, recently matriculated, surgeons in independent practice, and to compare them to results by their mentor (with >20 years of experience). MATERIALS: Exposure to hypospadias surgery during fellowship was determined from case logs of five consecutive fellows completing training from 2007-2011. TIP was the only technique used to repair distal hypospadias. No fellow operated independently or performed complete repairs under supervision. Instead, the first 3 months were spent assisting their mentor, observing surgical methodology and decision-making. Then, each performed selected portions under direct supervision, including: degloving, penile straightening, developing glans wings, incising and tubularizing the urethral plate, creating a barrier layer, sewing the glansplasty, and skin closure. Overall fellow participation in each case was <50%. In 2011-2012, urethroplasty complications (fistula, glans dehiscence, meatal stenosis, urethral stricture, diverticulum) were recorded for consecutive patients undergoing primary distal repair by these recent graduates in their independent practices. The fellow graduating in 2011 provided 1 year of data. All patients undergoing repair during the study period were included in the analysis, except those lost to follow-up after catheter removal. Composite urethroplasty complications were compared between junior surgeons, and between junior surgeons and their mentor, with Fisher's exact contingency test. RESULTS: Training logs indicated fellow participation ranged from 76-134 hypospadias repairs, including distal, proximal and reoperative surgeries. Post-graduation case volumes ranged from 25-68 by junior surgeons versus 136 by the mentor. With similar mean follow-up, urethroplasty complication rates were statistically the same between the former fellows, and between them versus the mentor, ranging from 5-13%. Nearly all were fistulas or glans dehiscence. Junior surgeons reported they performed TIP as learned during fellowship, with one exception who used 7-0 polydioxanone rather than polyglactin for urethroplasty. DISCUSSION: This is the first study directly comparing hypospadias surgical outcomes by recently graduated fellows in independent practice with those of their mentor. We found junior surgeons achieved similar results for distal TIP hypospadias repair. Although their participation during training largely comprised observation and surgical assistance, with discrete performance of key steps, skills sufficient to duplicate the mentor's results were transferred. These data suggest there should be no learning curve for distal hypospadias after training. This report raises several considerations for surgical educators. First, mentors should review their own results, to be certain that they are correctly performing and teaching procedures. Second, programs need to determine key steps for procedures they teach, and then emphasize their optimal performance. Finally, mentors should expect former fellows to report back their initial results of hypospadias repair to be certain lessons taught were learned. Otherwise, preventable complications resulting from technical errors will be multiplied in the children operated by their trainees as they enter independent practice.

Management of major blunt pediatric renal trauma: single-center experience.

OBJECTIVE: To review the impact of major pediatric renal trauma and its management on long-term function and morphology of the injured kidney. METHODS: Thirty-six blunt trauma patients (20 males, 16 females) presented in 2004-2007 (age range 2 days to 14 years; mean 6.2 years). Thirty-seven renal units were included: 13 grade III, 14 grade IV, and 10 grade V injuries. Follow up was for 3-38 (mean 14) months. Patients were managed non-operatively unless vitally unstable. The most common causes of trauma were motor vehicle accidents and falls. Fourteen patients had associated non-renal injuries. Four patients had pre-existing renal problems. RESULTS: The surgical intervention group (13 patients, 36%) included 9/10 grade V and 4/14 grade IV renal injuries. Surgical repair of lacerations was performed in seven cases, partial nephrectomy in four cases and nephrectomy in two cases. Follow up showed no significant change in renal function, and none developed hypertension. The non-operative group (24 patients, 63.2%) included all grade III injuries, 10 grade IV injuries, and one grade V injury. There was an excellent outcome for 18/24 patients (75%) with kidney preservation, no complications from urinary extravasation and hematoma resolution. The remaining patients had lower polar infarction (1), renal atrophy (1), persistent subcapsular collection (2), recurrent hematuria requiring angioembolization (1), and there was one death related to central nervous system injury. CONCLUSION: The outcome of our management of pediatric major renal trauma was favorable overall. Longer follow up is needed with regard to renal function and development of hypertension.

Outcome of complete primary bladder exstrophy repair: single-center experience.

OBJECTIVE: Reconstruction of bladder exstrophy remains a challenge. We evaluated our experience with complete primary repair in classic bladder exstrophy. METHODS: A retrospective data review was conducted of bladder exstrophy patients presenting at our institution between May 2000 and September 2007. Fifty-one patients (21 females and 30 males) with classic bladder exstrophy were included. Age of presentation ranged from 24h to 14 months. Mean follow up was 3 years (1 month-7 years). Patients were evaluated for continence, upper tract dilatation and cosmetic result. RESULTS: Eight patients (15.6%) had failed closures and six (11.7%) had fistulae. Evaluation of continence excluded 16 patients not followed up at our center. Thirty-seven percent were continent on clean intermittent catheterization after the age of 5 years. Patients became dry only after augmentation cystoplasty. Upper tract changes were mild during our study with all patients having normal serum creatinine. CONCLUSION: Patients may require more than one procedure for reconstruction. In our series, augmentation was required to achieve acceptable dryness. Early promising results with dry intervals in young patients did not translate to continence in older patients.

Pediatric and adolescent transperineal anastomotic urethroplasty.

PURPOSE: Pediatric urethral stricture disease represents a significant surgical challenge because of smaller pelvic confines, decreased caliber and increased tissue fragility. Operative series of pediatric urethral reconstruction usually involve small numbers. In this study, we examined the outcome of open reconstructive techniques for pediatric and adolescent patients with posterior urethral distraction injuries. PATIENTS AND METHODS: Between February 2002 and September 2005, 15 patients from Kasr ElAini hospital presenting with posterior urethral distraction defects due to motor vehicle accidents were included in our study. Their age ranged between 5 and 17 years (mean 12.5). We used the progressive perineal approach to achieve a tension-free spatulated anastomosis. RESULTS: Mean follow-up was 28.4 months. Initial and ultimate success rates were 80 and 86.6%, respectively. Other than re-stricture, one child had a bladder stone treated by cystolithotomy 6 months after surgery. No penile curvature, shortening or urethral diverticulae were noted during follow-up. CONCLUSION: Using the appropriate modern guidelines of urethroplasty, consistent success can be achieved in pediatric and adolescent patients with posterior urethral injuries. Open urethral reconstruction of adolescent and pediatric strictures provides excellent long-term results with minimal morbidity. Urethral reconstruction is strongly recommended as the primary treatment option, especially in the pediatric urethral stricture population, because of the repair durability.

Left Ventricle Myocardium Volume Densities in Spontaneously Hypertensive Rats (SHR) Following Combination of Exercise and ACE Inhibitor Treatment: A Stereological Study / Densidad de Volumen del Miocardio del Ventrículo Izquierdo en Ratas Espontáneamente Hipertensas (REH) Posterior a la Combinación de Ejercicios y Tratamiento Inhibidor de la ACE: Estudio Estereológico

This study was designed to test the possible effects of a combination of physical and pharmacological therapy intervention on myocardial structure of the left ventricle in spontaneously hypertensive rats (SHR). Twelve weeks old spontaneously hypertensive rats (n = 40) were divided into four groups of sedentary, (Sed) as controls, exercise only (Exer), lisinopril only 20mg/kg/day (Lis), and exercise + lisinopril (LisExer). Exercise training was performed on a treadmill (5m/min.) for 60 minutes/day, 5 days/week for 10 weeks. At the end of 10 weeks, all the rats were terminally anaesthetised, the heart was arrested in diastole by intravenous procaine and whole animal perfusion fixation through the abdominal aorta was carried out using Karnovsky's fixative (pH 7.24). The heart was removed and left ventricle plus the interventricular septum was serially sectioned at a thickness of 3 mm. One piece was randomly chosen, and embedded in JB4 resin. Six sections were obtained from each block, stained with toluidine blue:acid fucin. Measurement of volume fraction (Vf), of myocardium, capillaries and interstitium were carried out using a stereology software (Histometrix MIL6 Kinetic imaging Ltd.). Mean Vf of capillaries in Sed group was 0.114 ± 0.01 (SEM). This was significantly increased in LisExer group. The Vf of muscle in Sed group was 0.795 ± 0.02 (SEM). This was significantly decreased in Lis but unchanged in Exer group. Capillaries Vf was significantly higher in LisExer as compared to Lis or Exer groups (p<0.05). Muscle Vf was not different betweenLisExer and Lis groups. The outcome of these changes could well be a better enhancement of cardiac performance in hypertension by combined exercise and ACE inhibitor treatment than either of the interventions alone.

Este estudio fue diseñado para probar los posibles efectos de una combinación de ejercicios y una intervención de terapia farmacológica en las estructuras del miocardio del ventrículo izquierdo, en ratas espontaneamente hipertensivas (SHR). Ratas de 20 semanas espontáneamente hipertensas (n = 40) fueron divididas en cuatro grupos: sedentarias (Sed) y controles, solamente con ejercicio (Ejer), solamente con lisinopril con 20mg/kg/día (Lis), y ejercicios + lisinopril (LisEjer). Los ejercicios fueron ejecutados en una máquina de entrenamiento (5m/min.) por 60 minutos/día, 5 días/semana por 10 semanas. Al término de las 10 semanas, las ratas fueron sacrificadas bajo anestesia, el corazón fue detenido en diástole usando procaina intravenosa. Los animales fueron perfundidos a través de la parte abdominal de la aorta, usando solución de Karnovsky (pH 7.24). El corazón fue removido y tanto al ventrículo izquierdo como al septo interventricular se les realizaron cortes seriados de 3 µm. Una pieza fue seleccionados al azar, y sumergida en resina JB4. Fueron obtenidas 6 secciones de cada bloque y luego teñidas con azul de toluidina:fucsina ácida. Las mediciones de fracción volumétrica (Vf) del miocardio, capilares, e intersticio fueron obtenidas usando un software de estereología (Histometrix MIL6 Kinetic imaging Ltd.). El promedio Vf de capilares en el grupo Sed, fue 0.114 ± 0.01 (SEM). Éste fue significativamente mayor en el grupo LisExer. El Vf de músculo en Sed fue 0.795 ± 0.02 (SEM). Éste fue significativamente menor en Lis pero no varió en el grupo Ejer. Vf capilares fue significativamente alto en LisExjr, si es comparado con los grupos Lis o Ejer (p<0.05). En Vf músculo no hubo diferencias entre los grupos LisEjer y Lis. El resultado de estos cambios pudo deberse a un mejor funcionamiento cardiaco en ratas hipertensa,s producto de ejercicios combinados y tratamiento con inhibidor ACE, que en aquellos en que se efectó un solo procedimiento.

Changes in serum concentration of antioxidants following treadmill exercise testing in patients with suspected ischaemic heart disease.

Twenty-four subjects with suspected ischaemic heart disease underwent a treadmill exercise stress test (TEST). Nine individuals developed ischaemia as defined by standard criteria. Total plasma antioxidant status (TPAS), and serum concentrations of vitamin E were measured pre-TEST, and 0, 1, 2, 4, 8 and 24 h following the treadmill test. Mean serum vitamin E concentrations fell by 33% in the group as a whole (from 9.53 +/- 0.92 mg/L pre-TEST to 6.39 +/- 1.06 mg/L immediately post stress test, P < 0.02) and rose to baseline over the subsequent 24 h. The levels of serum vitamin E fell by 34% in the group of patients who had a positive TEST, and 32% in those who did not develop ischaemia during the TEST. Serum cholesterol concentrations also fell significantly during the TEST. In the total group serum cholesterol fell by 6.5% (P = 0.0052), and in the subgroup who were positive for ischaemia the fall in serum cholesterol was 10.3% (P = 0.004). The reduction in serum cholesterol was 4.1% in the subgroup who did not develop ischaemia (P > 0.05). Mean total plasma antioxidant status showed no significant temporal change for the group as a whole, although there was a nonsignificant decrease immediately post-TEST in the ischaemic group and a slight rise at 8 h in the group negative for ischaemia.

Impact of different variables on the outcome of patients with clinically confined prostate carcinoma: prediction of pathologic stage and biochemical failure using an artificial neural network.

BACKGROUND: The advent of advanced computing techniques has provided the opportunity to analyze clinical data using artificial intelligence techniques. This study was designed to determine whether a neural network could be developed using preoperative prognostic indicators to predict the pathologic stage and time of biochemical failure for patients who undergo radical prostatectomy. METHODS: The preoperative information included TNM stage, prostate size, prostate specific antigen (PSA) level, biopsy results (Gleason score and percentage of positive biopsy), as well as patient age. All 309 patients underwent radical prostatectomy at the University of Colorado Health Sciences Center. The data from all patients were used to train a multilayer perceptron artificial neural network. The failure rate was defined as a rise in the PSA level > 0.2 ng/mL. The biochemical failure rate in the data base used was 14.2%. Univariate and multivariate analyses were performed to validate the results. RESULTS: The neural network statistics for the validation set showed a sensitivity and specificity of 79% and 81%, respectively, for the prediction of pathologic stage with an overall accuracy of 80% compared with an overall accuracy of 67% using the multivariate regression analysis. The sensitivity and specificity for the prediction of failure were 67% and 85%, respectively, demonstrating a high confidence in predicting failure. The overall accuracy rates for the artificial neural network and the multivariate analysis were similar. CONCLUSIONS: Neural networks can offer a convenient vehicle for clinicians to assess the preoperative risk of disease progression for patients who are about to undergo radical prostatectomy. Continued investigation of this approach with larger data sets seems warranted.

Changes in serum concentrations of markers of myocardial injury following treadmill exercise testing in patients with suspected ischaemic heart disease.

BACKGROUND: The treadmill exercise test (TEST) is frequently used in patients with suspected ischaemic heart disease to establish a diagnosis and estimate future risk. However, its predictive value is poor. We aimed to investigate whether measurement of biochemical markers of myocardial injury could improve the diagnostic value of the procedure. MATERIAL AND METHODS: Twenty-four subjects with suspected acute coronary syndrome underwent a treadmill exercise stress test. Of these 13 had had a previous myocardial infarction and two had a past history of coronary artery bypass grafting. Nine subjects were found to be positive for coronary ischaemia during the treadmill test. Serum cardiac markers (total creatine kinase [CK], CK-MB, Troponin I and Troponin T) were measured pre-TEST, and 0, 1, 2, 4, 8 and 24 hours following the treadmill test. RESULTS: Total CK remained within the reference range for all subjects and showed no significant rise. However, mean serum concentrations of CK-MB were significantly higher than pre-test values at 2 hours (p < 0.03) following treadmill exercise testing in subjects who had a positive exercise stress test, but not in those with a negative test. In the subjects with a positive stress test, CK-MB levels returned to pre-Test value by 24 hours. Levels of neither serum troponin I, nor troponin T altered significantly at any point. CONCLUSION: The measurement of CK-MB, but not cardiac troponins may add to the diagnostic utility of the TEST.

Blood pressure and its reactivity in the offspring of first cousin hypertensive and first cousin normotensive parents: a preliminary report.

The aim of this preliminary study was to determine whether young offspring of first cousin hypertensive parent(s), have higher blood pressure (BP) reactivity in response to their first BP measurement, as compared to the offspring of first cousin normotensive parents. The BP of 135 boys aged 9-10 years was measured, for the first time ever, after a 10-min supine rest, and subsequently, twice at 10-min intervals. The offspring of first cousin hypertensive parent(s) reacted with significantly higher systolic and diastolic BP than the offspring of normotensive first cousin parents in all three measurements. This study indicates that at an early age, the offspring of first cousin hypertensive parents, react with exaggerated BP response at their first casual BP measurement. We hypothesise that familial aggregation of BP may show more expression amongst the offspring of consanguineous marriage of hypertensive parent(s).

Exaggerated blood pressure reactivity in the offspring of first-cousin hypertensive parents.

OBJECTIVE: To study blood pressure and blood pressure reactivity in young offspring of normotensive or hypertensive parents who are consanguineous (first cousins) or are not blood-related. METHOD: Blood pressure, heart rate and body mass index (BMI) were measured in 9-10 year-old male offspring of 19 pairs of first-cousins normotensive, 16 pairs of first-cousin hypertensive and 12 pairs of non-blood-related hypertensive parents. RESULTS: The offspring of first-cousin hypertensive parents exhibited the greatest systolic and diastolic blood pressure reactivity to their first casual blood pressure measurement, while the offspring of first-cousin normotensive parents showed the least reactivity. The offspring of the hypertensive parents who were not blood-related showed an intermediate reactivity. Basal systolic blood pressure (SBP) was also highest in the offspring of first-cousin hypertensive parents, and their basal diastolic blood pressure (DBP) was higher than that in offspring of first-cousin normotensive parents. CONCLUSION: The augmented blood pressure response in the offspring of hypertensive parents may have prognostic implications and serve as an important and significant indicator of predisposition to hypertension later in life.

Advanced prostate cancer: an update.

A number of therapeutic options are available or on the horizon for patients for whom initial treatment of localized prostate cancer has failed. Currently under study are time of therapy, maximum androgen blockade, and palliative and adjunctive therapies.