Robotic versus laparoscopic versus open nephrectomy for live kidney donors

BACKGROUND

Waiting lists for kidney transplantation continue to grow. Live kidney donation significantly reduces waiting times and improves long-term outcomes for recipients. Major disincentives to potential kidney donors are the pain and morbidity associated with surgery. This is an update of a review published in 2011.

OBJECTIVES

To assess the benefits and harms of open donor nephrectomy (ODN), laparoscopic donor nephrectomy (LDN), hand-assisted LDN (HALDN) and robotic donor nephrectomy (RDN) as appropriate surgical techniques for live kidney donors.

SEARCH METHODS

We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 31 March 2024 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing LDN with ODN, HALDN, or RDN were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Thirteen studies randomising 1280 live kidney donors to ODN, LDN, HALDN, or RDN were included. All studies were assessed as having a low or unclear risk of bias for selection bias. Five studies had a high risk of bias for blinding. Seven studies randomised 815 live kidney donors to LDN or ODN. LDN was associated with reduced analgesia use (high certainty evidence) and shorter hospital stay, a longer procedure and longer warm ischaemia time (moderate certainty evidence). There were no overall differences in blood loss, perioperative complications, or need for operations (low or very low certainty evidence). Three studies randomised 270 live kidney donors to LDN or HALDN. There were no differences between HALDN and LDN for analgesia requirement, hospital stay (high certainty evidence), duration of procedure (moderate certainty evidence), blood loss, perioperative complications, or reoperations (low certainty evidence). The evidence for warm ischaemia time was very uncertain due to high heterogeneity. One study randomised 50 live kidney donors to retroperitoneal ODN or HALDN and reported less pain and analgesia requirements with ODN. It found decreased blood loss and duration of the procedure with HALDN. No differences were found in perioperative complications, reoperations, hospital stay, or primary warm ischaemia time. One study randomised 45 live kidney donors to LDN or RDN and reported a longer warm ischaemia time with RDN but no differences in analgesia requirement, duration of procedure, blood loss, perioperative complications, reoperations, or hospital stay. One study randomised 100 live kidney donors to two variations of LDN and reported no differences in hospital stay, duration of procedure, conversion rates, primary warm ischaemia times, or complications (not meta-analysed). The conversion rates to ODN were 6/587 (1.02%) in LDN, 1/160 (0.63%) in HALDN, and 0/15 in RDN. Graft outcomes were rarely or selectively reported across the studies. There were no differences between LDN and ODN for early graft loss, delayed graft function, acute rejection, ureteric complications, kidney function or one-year graft loss. In a meta-regression analysis between LDN and ODN, moderate certainty evidence on procedure duration changed significantly in favour of LDN over time (yearly reduction = 7.12 min, 95% CI 2.56 to 11.67; P = 0.0022). Differences in very low certainty evidence on perioperative complications also changed significantly in favour of LDN over time (yearly change in LnRR = 0.107, 95% CI 0.022 to 0.192; P = 0.014). Various different combinations of techniques were used in each study, resulting in heterogeneity among the results.

AUTHORS' CONCLUSIONS

LDN is associated with less pain compared to ODN and has comparable pain to HALDN and RDN. HALDN is comparable to LDN in all outcomes except warm ischaemia time, which may be associated with a reduction. One study reported kidneys obtained during RDN had greater warm ischaemia times. Complications and occurrences of perioperative events needing further intervention were equivalent between all methods.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Sustainability analysis of bioethanol production from grain and tuber starchy feedstocks

A comparative sustainability study of bioethanol production from selected starchy feedstocks that are abundantly available was carried out in this work. This is to ensure the safe, reliable, and efficient production and consumption of fuel-grade bioethanol. The analysis utilised the established economic minimum bioethanol plant capacity of 158,000 m³/annum. The processing flowsheet model utilised was the same for each feedstock. The sustainability study's economic, environmental, and energy perspectives were investigated. The economic and environmental indices were assessed using Superpro Designer and openLCA sustainability software, respectively. Exergy and lost work were subsequently estimated manually with Microsoft Excel. The economic analyses showed that the plants using cassava and sweet potato initially had the highest return on investment (ROI) of 64.41 and 41.96% respectively at a minimum of 80% plants' capacity utilisation. The break-even point occurs at a bioethanol price of $3.27 per gallon, beyond which positive net present values were obtained for the four processes. The least profitable plant was based on sorghum recording an ROI value of 34.11%. The environmental assessment on the four selected feedstocks showed that the processes based on cassava, corn, sweet potato, and sorghum recorded encouraging global warming potential (GWP) of 0.2452, 0.2067, 2.5261, and 0.2099 kg CO₂ equivalent respectively. Cassava and corn emerged as the two most economically viable feedstocks when economic parameters were adjusted to include pollutants emission/discharge costs but with a slight decrease in profitability indices. The lost work analyses showed that distillation columns were the least energy-efficient units in the four bioethanol production routes assessed, recording loss work of about 61, 68, 34, and 49 MW for cassava, sweet potato, corn, and sorghum processing plants respectively. However, the net energy balance (NEB) and energy renewability results of the four production routes showed that the processes utilising the four selected starchy biomass feedstocks are more sustainable compared to fossil fuels.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Sourdough Bread from the Blend of Cassava, Sweet Potato, and Soybean Flours Using Lactobacillus Plantarum and Pichia Kudriavzevii

Sourdough is specialty bread made from a combination of flour, lactic acid bacteria, and yeasts. Composite flour of cassava, sweet potato, and soybean was used for the production of sourdough bread employing autochthonous lactic acid bacteria and yeasts isolated from the composite dough. The flour samples were assessed for functional properties, while the sourdough breads were evaluated for nutritional composition and organoleptic properties. The flour samples possessed good proximate profiles and phenolic contents. The lactic acid bacterium and yeast with the most desirable properties were identified as Lactobacillus plantarum and Pichia kurdriazevii. Fermentation improved the nutritional indices of the composite sourdough bread samples. Lactobacillus plantarum SLC21 and P. kudriavzevii SYD17 bread had a shelf life of 7 days, while the control bread lasted for at least 4 days. Lactobacillus plantarum SLC21 and Pichia kudriavzevii SYD17 bread had the best overall acceptability. Utilisation of these local crops in a composite blend for sourdough will increase commercial profit for local farmers and developing economy. The composite blend will be of great importance in the preparation of pastries that do not require high gluten content. The strains exhibited great potentials for a better nutritional composition of the composite sourdough bread.

Abstract PD8-05: Comparative analysis of the genomic landscape of breast cancers from women of African and European ancestry

Objectives: Paucity of data on populations of African Ancestry in clinical trials continues to limit our ability to design and implement innovative solutions to narrow the breast cancer survival gap amongst Africans, African Americans, and European Americans. We have developed a cross-continent research infrastructure to examine the spectrum of genomic alterations in breast tumors from West Africa and subsequently, to compare them to tumors from African American women and women of European Ancestry in The Cancer Genome Atlas (TCGA) database.

Methods: Consecutive women with breast cancer presenting for treatment at the University College Hospital, Ibadan and at Lagos State University Teaching Hospital, Lagos, Nigeria gave informed consent and were recruited to the West African Breast Cancer Study (WABCS) between 2013-2016. Tumor-normal pairs were subjected to exome and/or high-depth (90x) genome sequencing. High confidence somatic mutations (substitutions, insertions/deletions and structural variants) were obtained by using multiple variant callers. Furthermore, 1,089 exomic and 80 genomic breast tumor-normal pairs from TCGA were harmonized with WABCS samples, resulting in a cohort of 147 West Africans (147 exome; 40 genome), 154 African Americans (154 exome; 31 genome), and 776 Caucasians (776 exome; 43 genome).

Results: Across the exomes, genes commonly altered in breast cancer in TCGA are also altered in women of African ancestry, but the mutational spectrum is quite different, demonstrating overrepresentation of tumors with aggressive phenotypes. Overall, TP53 (65%), ERBB2 (27%), and GATA3 (17%) showed statistically significant higher alteration frequencies in West Africans and African Americans. In contrast, PIK3CA (24%) was less frequently mutated. Of note, GATA3 mutation was statistically significantly more frequent in Nigerians (39%) and African Americans (16.7%) compared to Caucasians (10.5%), in ER-positive cancers. Analysis on Structural Variants (SV), on the other hand, has shown that the genome-wide SV counts among three populations are comparable in ER-negative cancers, while Nigerians have significantly more SV counts compared to African Americans (P=0.0013) or European Americans (P=2.9x10-5) in ER-positive cancers. Similarly, genome-wide substitution patterns in ER+ and ER- cancers varied widely by race/ethnicity. In ER- cases, West Africans carried the highest proportion of canonical APOBEC-associated substitutions, particularly C&gt;T transitions. Conversely, European Americans with ER+ disease showed a higher proportion of C&gt;T than both West Africans (Welch t-test P = 0.044) and African Americans (Welch t-test P = 0.011). Mutation signature analyses highlighted multiple APOBEC signatures, with notable contribution differences across ancestry and ER status. A signature likely corresponding to DNA damage repair correlated with the proportion of genetic ancestry, being most prevalent in European Americans and least common in Nigerians, particularly in ER-negative cancers, with African Americans showing a degree of this signature's contribution in between the two populations (linear model adjusted for age, P=1.0x10-10).

Conclusions: Overall, our data suggests mutation spectra differences in across race/ethnicity and geography. Identification of molecular characteristics such as higher rates of HER2 enriched tumors and higher rates of GATA3 mutations in ER positive tumors are beginning to reveal the genomic basis of race-associated phenotypes and outcomes in breast cancer. Population differences in frequency and spectrum of mutations should now inform the design of innovative clinical trials that improve health equity and accelerate Precision Oncology care in diverse populations.

Citation Format: Olopade OI, Pitt JJ, Riester M, Odetunde A, Yoshimatsu T, Labrot E, Ademola A, Sanni A, Okedere B, Mahan S, Nwosu I, Leary R, Ajani M, Johnson RS, Sveen E, Zheng Y, Wang S, Fitzgerald DJ, Grundstad J, Tuteja J, Clayton W, Khramtsova G, Oludara M, Omodele F, Benson O, Adeoye A, Morhason-Bello O, Ogundiran T, Babalola C, Popoola A, Morrissey M, Chen L, Huo D, Falusi A, Winckler W, Obafunwa J, Papoutsakis D, Ojengbede O, White KP, Ibrahim N, Oluwasola O, Barretina J. Comparative analysis of the genomic landscape of breast cancers from women of African and European ancestry [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD8-05.

Abstract P6-03-17: Genomic landscape of breast cancers from women of African ancestry across the diaspora

Objectives: Of all ethnic/racial groups, age-standardized mortality rate from breast cancer is highest for African American women in the US for reasons that remain understudied. The paucity of genomic studies of breast tumors across the African Diaspora further restricts our understanding of the biology of breast cancer in underserved populations. To gain a better understanding of the genomic landscape of breast cancer in women of African Ancestry, we have developed a cross continent translational research infrastructure to examine the spectrum of genetic alterations in breast tumors from West Africa compared to the spectrum of alterations observed in tumors from African-American and other women who are predominantly white in The Cancer Genome Atlas (TCGA) dataset.

Methods: Peripheral blood and breast cancer biopsy tissues were collected from 214 patients enrolled in the West Africa Breast Cancer Study (WABCS) at the University of Ibadan/University College Hospital (UI/UCH) and at Lagos State University Teaching Hospital (LASUTH). Blood DNA as well as breast cancer tissue DNA and RNA were extracted at the Novartis Institutes for Biomedical Research (NIBR), UI/UCH, and LASUTH using a modified protocol of PAXgene Tissue DNA and RNA extraction method. Whole-exome (WES) and transcriptome (RNA-seq) sequencing were performed on the Illumina HiSeq2000 platform at NIBR. Single Nucleotide Variants (SNVs) and insertions/deletions (indels) were called using MuTect and Pindel, while Copy Number Alterations (CNAs) were called using an in-house implementation of the ABSOLUTE method. Observed mutations were compared against those reported in the TCGA dataset. ER, PR and HER2 status were determined by immunohistochemistry (IHC) at UI/UCH, LASUTH and UChicago.

Results: WES data for 95 tumors have been analyzed thus far. Genes commonly mutated in breast cancer in TCGA are also mutated in WABCS but the mutational spectrum is vastly different. TP53 (64%), MYC (31%), and GATA3 (26%), showed significantly higher alteration frequencies in WABCS and African Americans. In contrast, PIK3CA (20%), CDH1 (2%), and MAP3K1 (2%) were less frequently mutated in women of African ancestry. In addition to the high proportion with TP53 mutations, the proportion with HER2 positive subtype of 42.1% and triple-negative subtype of 37.9% suggest that tumors with the most aggressive features are overrepresented in breast cancer patients in West Africa.

Conclusions: In the first study of its kind, high throughput genomic analysis of the largest cohort of women of African ancestry has uncovered alterations in cancer genes, some of which may be amenable to treatment with targeted therapies. Furthermore, we provide evidence that population differences in frequency and spectrum of mutations should drive the design and deployment of precision medicine initiatives. Only then can we develop innovative interventions to reduce the unacceptably high rates of mortality from breast cancer in underserved and under resourced populations.

Citation Format: Olopade OI, Odetunde A, Riester M, Yoshimatsu T, Labrot E, Ademola A, Sanni A, Okedere B, Mahan S, Nwosu I, Leary R, Ajani M, Johnson RS, Sveen E, Zheng Y, Clayton W, Khramtsova G, Oludara M, Omodele F, Benson O, Adeoye A, Morhason-Bello O, Ogundiran T, Babalola C, Popoola A, Morrissey M, Huo D, Falusi A, Winckler W, Obafunwa J, Papoutsakis D, Ojengbede O, Ibrahim N, Oluwasola O, Barretina J. Genomic landscape of breast cancers from women of African ancestry across the diaspora. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-03-17.

Does single-port laparoscopic sleeve gastrectomy result in improved short-term perioperative outcomes compared to conventional multi-port laparoscopic sleeve gastrectomy?

A best evidence topic in bariatric surgery was written according to a structured protocol. The question asked whether single-port laparoscopic sleeve gastrectomy produces better short-term perioperative outcomes compared to the conventional multi-port laparoscopic sleeve gastrectomy in the treatment of morbid obesity. A Pubmed search generated 82 papers, 6 of which represented the best evidence to answer the clinical question. Of the 6, 1 paper was an updated analysis of the same patient cohort. The evidence on this subject is good. Five papers were level III, nonrandomized studies, 2 of which were prospective and 3 were retrospective cohort studies. The sixth paper was a level II, randomized, prospective study. We conclude that single-port laparoscopic sleeve gastrectomy results in less use of postoperative analgesia and better cosmetic satisfaction compared to multi-port laparoscopic sleeve gastrectomy in the short-term. The two groups showed comparable results in terms of mean operative time, mean hospitalization, and percentage excess weight loss. There was no difference in rate of postoperative complications including trocar site incisional hernia, staple line leaks, and bleeding.

Postoperative complications in bariatric surgery using age and BMI stratification: a study using ACS-NSQIP data

BACKGROUND

Bariatric surgery results in long-term weight loss and significant morbidity reduction. Morbidity and mortality following bariatric surgery remain low and acceptable. This study looks to define the trend of morbidity and mortality as it relates to increasing age and body mass index (BMI) in patients undergoing bariatric surgery.

METHODS

We queried the ACS/NSQIP 2010-2011 Public Use File for patients who underwent elective laparoscopic adjustable banding (LAGB), sleeve gastrectomy (LSG) and gastric bypass (LGBP). Total morbidity and 30-day mortality were evaluated. Logistic regression models were created to estimate the effect of increasing age and BMI on morbidity for these bariatric procedures.

RESULTS

A total of 20,308 laparoscopic bariatric procedures were reviewed (11617 LGBP, 3069 LSG and 5622 LAGB). Overall mortality and morbidity rates were 0.11 and 3.84%, respectively. The odds of postoperative complications increased by 2% with each additional year of age (OR 1.02, 95% CI 1.02-1.03) and every point increase in BMI (OR 1.02, 95% CI 1.01-1.03). Multiple logistic regression identified COPD, Diabetes, Hypertension, and Dyspnea as major risk factors for postoperative morbidity. Postoperative complications were three times more likely after LGBP (OR 2.87, 95% CI 2.31-3.57) and two times more likely after LSG (OR 2.06, 95% CI 1.57-2.72) when compared to patients undergoing LAGB.

CONCLUSION

Morbidity and mortality increase on a predictable trend with increasing age and BMI. There is increased risk of morbidity for stapling procedures when compared to gastric banding, but this must be considered in context of surgical efficacy when choosing a bariatric procedure. These data can be used in preoperative counseling and evaluation of surgical candidacy of bariatric surgical patients.

Association of radiographic morphology with early gastroesophageal reflux disease and satiety control after sleeve gastrectomy

BACKGROUND

Variable gastric morphology has been identified on routine upper gastrointestinal series after laparoscopic sleeve gastrectomy. This test might give us useful information beyond the presence of leak and obstruction. The aim of this study is to standardize a morphologic classification of gastric sleeve based on water-soluble contrast upper gastrointestinal series, and to determine possible clinical implications.

STUDY DESIGN

One hundred morbidly obese patients underwent laparoscopic sleeve gastrectomy and had routine upper gastrointestinal on postoperative day 1 or 2. Images were reviewed by 4 radiologists who were blinded to outcomes, and sleeve shape was classified as upper pouch, lower pouch, tubular, or dumbbell. Inter-observer agreement was calculated. Clinical outcomes including weight loss, satiety control, and reflux symptoms were recorded. Comparisons were determined by 1-way ANOVA and t-test.

RESULTS

Mean age was 46 ± 12 years and mean BMI was 45.1 ± 6 kg/m(2). Overall inter-observer agreement level for the sleeve shape classification was 76.3%. Sleeve shapes were tubular in 37%, dumbbell in 32%, lower pouch in 22%, and upper pouch in 8%. Mean excess body weight loss at 1, 3, and 6 months was 16.8%, 29.9%, and 39.1%, respectively. Excess body weight loss was not associated with sleeve shape. Mean hunger score was 213 ± 97, and patients with dumbbell shape had higher hunger scores (p = 0.003). Mean reflux score was 5.7 ± 8. Upper pouch shape was associated with greater severity of reflux symptoms (p = 0.02).

CONCLUSIONS

This study suggests a standardized radiographic classification of gastric sleeve morphology. Although sleeve shape is not correlated with weight loss, gastric sleeves with retained fundus result in lower satiety control and higher severity of reflux symptoms. An adequate resection of the gastric fundus might avoid this potential complication.

Analysis of the contrast between natural occurrence of toxigenic Aspergilli of the Flavi section and aflatoxin B1 in cassava

Aflatoxin B1 (AFB1) is a carcinogenic mycotoxin produced by Aspergilli of the section Flavi that may contaminate food, in the field or during storage. Cassava represents an important staple food in sub-Saharan Africa. The analysis of aflatoxigenic fungi in 36 cassava samples obtained from producers in Benin indicated that 40% were contaminated by Aspergilli of the section Flavi. Upon morphological and molecular characterization of the 20 isolates, 16 belonged to Aspergillus flavus, 2 to Aspergillus parvisclerotigenus and 2 to Aspergillus novoparasiticus. This is the first time that this latter species is isolated from food. Although most of these isolates were toxigenic on synthetic media, no AFB1 contamination was observed in these cassava samples. In order to determine the action of cassava on AFB1 synthesis, a highly toxigenic strain of A. flavus, was inoculated onto fresh cassava and despite a rapid development, no AFB1 was produced. The anti-aflatoxin property was observed with cassava from different geographical origins and on other aflatoxigenic strains of the section Flavi, but it was lost after heating, sun drying and freezing. Our data suggest that fresh cassava is safe regarding AFB1 contamination, however, processing may alter its ability to block toxinogenesis leading to secondary contamination.

A review on aflatoxin contamination and its implications in the developing world: a sub-Saharan African perspective

Mycotoxins contamination in some agricultural food commodities seriously impact human and animal health and reduce the commercial value of crops. Mycotoxins are toxic secondary metabolites produced by fungi that contaminate agricultural commodities pre- or postharvest. Africa is one of the continents where environmental, agricultural and storage conditions of food commodities are conducive of Aspergillus fungi infection and aflatoxin biosynthesis. This paper reviews the commodity-wise aetiology and contamination process of aflatoxins and evaluates the potential risk of exposure from common African foods. Possible ways of reducing risk for fungal infection and aflatoxin development that are relevant to the African context. The presented database would be useful as benchmark information for development and prioritization of future research. There is need for more investigations on food quality and safety by making available advanced advanced equipments and analytical methods as well as surveillance and awareness creation in the region.

Pericecal hernia: a rare form of internal hernias

We report a rare and interesting case of a pericecal hernia. A 34-year-old male presented to the emergency department with severe periumbilical pain, emesis and a prior syncopal episode. He noted a 3-month history of intermittent, colicky periumbilical pain. His abdominal examination demonstrated a palpable mass in the right lower quadrant, involuntary guarding and rebound tenderness. CT demonstrated dilated small-bowel loops and findings suggestive of ischemia. The patient was immediately taken to the operating room where a diagnosis of pericecal hernia was made. The patient underwent a reduction of the hernia and a repair of the mesenteric defect.

Ileal diverticulitis: an uncommon diagnosis for right lower quadrant pain

We report an interesting case of ileal diverticulitis which posed a diagnostic challenge. A 75-year-old female presented to the emergency department with severe right lower quadrant pain for 3 days. The clinical history, examination and imaging suggested a diagnosis of acute appendicitis. The patient was taken to the operating room for an open appendectomy. The intra-operative findings demonstrated a large mass at the ileocecal junction involving the appendix as well as multiple nodular masses in the ileum and cecum. The patient underwent a right hemicolectomy with ileocecal anastomosis. The pathology result revealed Ileal diverticulitis. Ileal diverticulitis is a rare form of diverticulitis. It can often mimic other processes such as acute appendicitis. Once ileal diverticulitis is diagnosed, it should be treated with the same principles as for sigmoid diverticulitis. Though rare, ileal diverticulitis should be considered in the differential diagnosis of a patient who presents with right lower quadrant pain, and a computed tomography scan that shows an inflammatory process in the right lower quadrant, in the setting of a normal appendix.

Technological properties and probiotic potential of Enterococcus faecium strains isolated from cow milk

AIM

To identify enterococci from the fermentation of milk for the production of nono, an African fermented dairy product, to determine the technological properties for suitability as starter cultures and safety as probiotics.

METHODS AND RESULTS

Enterococcus faecium CM4 and Enterococcus faecium 2CM1 were isolated from raw cow's milk. The strains were phenotypically and genotypically identified. Technological properties, safety investigations, in vitro adherence properties and antimicrobial characteristics were carried out. Strong acidification and tolerance to bile salts were recorded. The strains were bile salts hydrolytic positive and no haemolysis. There was no resistance to clinically relevant antibiotics. The strains exhibited adherence to human collagen type IV, human fibrinogen and fibronectin. The bacteriocins were active against Bacillus cereus DSM 2301, Bacillus subtilis ATCC 6633, Micrococcus luteus and Listeria monocytogenes. Bacteriocins were stable at pH 4-9 and on treatment with lipase, catalase, α-amylase and pepsin, while their activity was lost on treatment with other proteases. The bacteriocins produced were heat stable at 100°C for 10 min. The bacteriocin produced by the strains was identified as enterocin A.

CONCLUSIONS

The E. faecium strains in this study exhibited probiotic activity, and the safety investigations indicate their suitability as good candidates for a starter culture fermentation process.

SIGNIFICANCE AND IMPACT OF THE STUDY

The use of bacteriocin-producing E. faecium strains as starter cultures in fermented foods is beneficial but, however, their safety investigations as probiotics must be greatly emphasized.

[Major salmonellosis in Benin]

Although salmonellosis is a common endemo-epidemic disease in Benin, there is a paucity of data about it. The purpose of this cross-sectional study was to determine the incidence of major salmonellosis requiring hospitalizaton and to describe its epidemiological, clinical, and serologic features as well as treatment and outcome. Consecutive cases observed at the Medical Department of Parakou University Hospital in Benin between January 1, 2005 and December 31 2007 were included. Salmonellosis was defined on the basis of clinical and serological criteria. Among the 2,520 patients hospitalized during the study period, salmonellosis was diagnosed in 135 (5.4% [95% CI 4.5%-6.3%]). Highest incidences were observed in January, July, October and November. The main symptoms were headache, fever, fatigue and abdominal pain. The Salmonella typhi serotype was identified in 94.8% of patients. Two patients presented co-infection, i.e., Salmonella typhi with paratyphi A in one case and Salmonella typhi with paratyphi B in the other. Fluoroquinolones were used for treatment in 79.3% of patients. Outcome was favorable in 62.2%. The main complications were,typhoid digestive perforation in 11.1%, and gastrointestinal bleeding in 8.1%. The mortality rate was 4.4% (n=6). These data are consistent with previous reports in the literature and confirm the frequency and severity of salmonellosis in Benin.

Laparoscopic versus open nephrectomy for live kidney donors

BACKGROUND

Waiting lists for kidney transplantation continue to grow and live organ donation has become more important as the number of brain stem dead cadaveric organ donors continues to fall. The major disincentive to potential kidney donors is the pain and morbidity associated with open surgery.

OBJECTIVES

To identify the benefits and harms of using laparoscopic compared to open nephrectomy techniques to recover kidneys from live organ donors.

SEARCH METHODS

We searched the online databases CENTRAL (in The Cochrane Library 2010, Issue 2), MEDLINE (January 1966 to January 2010) and EMBASE (January 1980 to January 2010) and handsearched textbooks and reference lists.

SELECTION CRITERIA

Randomised controlled trials comparing laparoscopic donor nephrectomy (LDN) with open donor nephrectomy (ODN).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for eligibility, assessed study quality, and extracted data. We contacted study authors for additional information where necessary.

MAIN RESULTS

Six studies were identified that randomised 596 live kidney donors to either LDN or ODN arms. All studies were assessed as having low or unclear risk of bias for selection bias, allocation bias, incomplete outcome data and selective reporting bias. Four of six studies had high risk of bias for blinding. Various different combinations of techniques were used in each study, resulting in heterogeneity in the results. The conversion rate from LDN to ODN ranged from 1% to 1.8%. LDN was generally found to be associated with reduced analgesia use, shorter hospital stay, and faster return to normal physical functioning. The extracted kidney was exposed to longer warm ischaemia periods (2 to 17 minutes) with no associated short-term consequences. ODN was associated with shorter duration of procedure. For those outcomes that could be meta-analysed there were no significant differences between LDN or ODN for perioperative complications (RR 0.87, 95% CI 0.47 to 4.59), reoperations (RR 0.57, 95% CI 0.09 to 3.64), early graft loss (RR 0.31, 95% CI 0.06 to 1.48), delayed graft function (RR 1.09, 95% CI 0.52 to 2.30), acute rejection (RR 1.41, 95 % CI 0.87 to 2.27), ureteric complications (RR 1.51, 95% CI 0.69 to 3.31), kidney function at one year (SMD 0.15, 95% CI -0.11 to 0.41) or graft loss at one year (RR 0.76, 95% CI 0.15 to 3.85).

AUTHORS' CONCLUSIONS

LDN is associated with less pain compared with open surgery; however, there are equivalent numbers of complications and occurrences of perioperative events that require further intervention. Kidneys obtained using LDN procedures were exposed to longer warm ischaemia periods than ODN-acquired grafts, although this has not been reported as being associated with short-term consequences.

Antibacterial activity and phytochemical study of six medicinal plants used in Benin

The ethanol extracts obtained from Psidium guajava, Flacourtia flavescens Boswellia dalzielii, Ficus exasperata, Pavetta corymbosa and Hybanthus enneaspermus, six species traditionally used in Benin to treat several infectious diseases, were evaluated for their in vitro antimicrobial activity against Staphylococcus aureus, Enteroccocus feacalis, Escherichia coli and Pseudomonas aeruginosa. The minimum inhibitory concentration of extracts was determinate using the microplate dilution method. The presence of major phytoconstituents was detected qualitatively. The diphenylpicrylhydrazine radical scavenging activity was also performed. The extracts exhibited antibacterial activities against the tested bacteria. Boswellia dalzielii, Psidium guayava, Pavetta corymbosa and Flacourtia flavescens exibited the lowest minimum inhibitory concentration values (0.313-2.5 mg mL(-1)). Pseudomonas aeruginosa was the lest sensitive microorganism with MIC values higher than 10 mg mL(-1). In antioxidant assay the crude extracts of B. dalzielii and P. corymbosa appeared to be as potent as quercetol with an inhibition percentage of 83 and 75.3% at 10 microg mL(-1) which is comparable to 75.9% for quercetol at the same concentration.

[Production lead time of coagulase in 180 Staphylococcus aureus strains collected at Abidjan]

INTRODUCTION

The pathogenic capacity of S. aureus is related.to the production of many virulence factors of which the coagulase. Several genotypes of coagulase were described and are associated to various populations of S. aureus. According the susceptibility to methicillin, methicillin-resistant strains of S. aureus, are described. The aim of this subject was to study the coagulase expression of Staphylococcus aureus according to the site of infection, patient origin and the resistance against methicillin.

MATERIAL AND METHODS

The study is related about 180 strains of S. aureus collected in the three University Teaching Hospital of Abidjan. S. aureus are identified with laboratory classical methods. Coagulase delay was determined by the test of the coagulase on citrated rabbit plasma at 2, 4 and 18 hours. The resistance against methicillin was researched by disc diffusion agar technique.

RESULTS

In 60% of cases, the bacterial strains gave a coagulum at the end of four hours, fast coagulase, against 40% of strains whose coagulating activity appeared at 18 h, slow coagulase. Fast coagulase strains are isolated from the majority of infections (55% to 71%), in hospital patients (66%) and in paediatrics (58%). Fast coagulase strains are methicillin-resistant in 65% of cases against 48.5% of methicillin-susceptible and low coagulase strains (p < 0.0001).

CONCLUSION

According to the production lead time of the coagulase, fast coagulase and slow coagulase variants of S. aureus coexisted. The expression of the coagulase is not related to the site of infection and the origin of the patients. On the other hand, the type of coagulase is associated to resistance of methicillin. However, the time of formation of the coagulum typed by the test of the coagulase, didn't constitute a sufficient discriminating factor in the medical following and the treatment of infections caused by S. aureus.

Incidence d'infections liées à Escherichia coli producteur de bêta lactamase à spectre élargi au Centre hospitalier départemental du Zou et Collines au Bénin

OBJECTIVES

Over a 6-month period, extended-spectrum betalactamase (ESBL)-producing isolates of Escherichia coli (EC) were collected from in-patients and their environment at the Zou-Collines Hospital Centre (CHDZ/C) in Benin. The aim of this study was to determine the incidence of ESBL and to describe their phenotypic susceptibility to antibiotics in a secondary hospital (500 beds) in Benin.

METHODS

From 15 May to 15 November 2005, clinical informations and samples were collected from patients suspected to have nosocomial infections. The isolates were identified, tested for antimicrobial susceptibility and analysed for the presence of ESBL genes blaTEM and blaSHV by PCR.

RESULTS

One hundred ninety-seven enterobacteria were isolated from the clinical samples of 342 patients, these isolates included 143 EC and 32/143 (22%) of these isolates produced ESBL. Forty-six EC were isolated from the environment and 7 (15%) of them produced ESBL. Except for Imipenem for which the difference was not significant, the isolates producing ESBL were more resistant to the other antibiotics (especially to third generation cephalosporins: Ceftriaxone, Cefotaxime, Ceftazidime (P<0.00001)) than non-ESBL producing isolates. Both ESBL genes blaSHV and blaTEM were identified in the EC ESBL strains from patient and from the environment.

CONCLUSION

This study shows the presence of ESBL genes among EC in various wards of the CHDZ/C hospital proving that there is a need to implement a strict hospital infection control program and a regular surveillance of resistance to antimicrobial agents.

Is transmyocardial revascularisation of benefit to people with 'no option' angina?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of transmyocardial revascularisation is of benefit in patients with severe angina but ungraftable areas of myocardium. Altogether 345 papers were found using the reported search, of which 11 represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that in selected stable patients with 'no option' CCS grade III-IV angina, TMR can significantly reduce the grade of angina at the cost of a perioperative mortality of around 5%.

Is transmyocardial revascularisation of benefit in addition to coronary artery bypass grafting for patients with diffuse coronary disease?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of transmyocardial revascularisation (TMR) in addition to coronary artery bypass grafting (CABG) is of benefit in patients with ischaemic heart disease with areas of ungraftable myocardium. Altogether 233 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We conclude that while the society of thoracic surgeons now recommend TMR+CABG, and the available studies indicate that mortality is not increased by this additional procedure, it is currently not clear whether TMR reduces symptoms of angina in addition to CABG alone.

Diabetic donors as a source of non-heart-beating renal transplants

Due to the organ shortage, many renal transplantation centers attempt to increase the donor pool by using non-heart-beating donors (NHBDs). These kidneys are generally regarded as "marginal" grafts. Many centers do not consider transplantation from an NHBD with a history of diabetes as it is a more suboptimal donor. We began our NHBD program in 1998 and have performed 5 renal transplants from diabetic NHBDs. Viability testing identified kidneys suitable for single or dual transplantation. Although kidneys from brain stem dead donors with diabetes have been used successfully, our data suggested that kidneys from diabetic NHBDs can also be used although we still need long-term results.

Donor risk factors for renal graft thrombosis

Graft thrombosis is one of the most devastating complications of transplantation. In obtaining consent prior to transplant, it is useful to share potential risk factors with the recipient. In order to do this, we explored the impact of different risk factors that could contribute to this complication. Using multivariate analysis we found that neither multiple vessels nor vascular injury had a bearing on the risk of graft thrombosis but atheroma did (P < .02).

Donation after cardiac death kidneys with low severity pre-arrest acute renal failure

The widening gap between supply and demand for renal transplantation has prompted many centers to use donors after cardiac death. Some of these donors exhibit signs of acute renal failure (ARF) prior to cardiac arrest. Concern has been expressed about poor quality of graft function from such donors. In response to this perception, we reviewed 49 single renal transplant recipients from category III donors after cardiac death between 1998 and 2005, at our center. All kidneys but one had hypothermic machine perfusion and viability testing prior to transplantation. According to the RIFLE criteria, nine recipients had kidneys from donors with "low severity pre-arrest ARF". The remainder of the recipients were used as control group. There was no statistical significant difference in delayed graft function and rejection rates between these two groups. Recipients GFR at 12 months was 44.4 +/- 17.1 and 45.2 +/- 14.7 (mL/min/1.73m(2)) from donors with ARF and without ARF, respectively (p = 0.96). In conclusion, low severity ARF in kidneys from controlled after cardiac death donors can be a reversible condition after transplantation. Short-term results are comparable to the kidneys from same category donors without renal failure, providing that some form of viability assessment is implemented prior to transplantation.

Renal transplants from category III non-heart-beating donors with evidence of pre-arrest acute renal failure

Kidneys transplanted from non-heart-beating donors (NHBDs) have been exposed to varying degrees of ischemic damage after death. Category III donors have invariably been managed, treated, and investigated in a hospital setting prior to arrest and death. Some therefore exhibit evidence of renal dysfunction and even acute renal failure (ARF) before death. Many surgeons would regard a NHBD with pre-arrest evidence of ARF as too marginal for renal transplantation. This retrospective study examines five Maastricht category III NHBD donors with evidence of pre-arrest ARF. We compare 3- and 12-month GFR outcome data from the nine resulting transplants with 40 category III NHBD transplants with normal pre-arrest renal function. The mean GFR at 3 months was 45.4 and 43.8 for the ARF and normal group, respectively. At 12 months the GFR was 42.2 and 44.7 in the ARF and normal groups, respectively. Thus evidence of ARF pre-arrest does not preclude successful category III NHBD renal transplantation.

Dual renal transplantation for kidneys from marginal non-heart-beating donors

Kidneys transplanted from non-heart-beating donors (NHBD) are generally regarded as marginal or extended criteria grafts due to the associated period of warm ischemia. The most prolonged periods occurring in the category II (uncontrolled) donor. This potential for injury can adversely affect the glomular filtration rate (GFR), which in severe cases results in primary nonfunction. Viability testing can identify a group of kidneys that, although unsuitable for solitary transplantation, may be considered for dual transplant. This retrospective study examined a series of 11 dual renal transplants, comparing 3- and 12-month GFR outcome data with 81 single NHBD transplants. The mean GFR at 3 months in the dual group was 47.6 and at 12 months was 48.6. In the single group the GFR at 3 months was 40.6 and at 12 months was 41.9. Thus using viability testing to identify NHBD kidneys suitable for dual transplant appears reliable and predictable.

Agonal period in potential non-heart-beating donors

The shortage of donor kidneys for renal transplantation is becoming more severe as the gap between the number of patients waiting for renal transplantation and the number of cadaveric organs available continues to widen. Therefore, many centres have started using non-heart-beating (NHB) donors. There was no clear plan for maximal duration of agonal period in Maastricht category NHB donors after withdrawal of treatment in Newcastle. This withdrawal has been audited in retrospect. Our current wait time is now a maximum of 5 hours; however, previously there have been some considerably longer periods. Concern has always been expressed about poor quality with protracted periods. Nonuse in this review of 58 kidneys can be expressed against time: 0 to 2 hours 13%, 2 to 5 hours 33%, and >5 hours 45%. Therefore, though the nonuse rate was significantly different between 0 to 2 hours and >5 hours (P < .05, chi-square), there were 16 transplants performed with kidneys >2 hours and 12 transplanted >5 hours. In conclusion, although good usable kidneys can still be used with protracted withdrawal, there are considerable logistical difficulties with our 5-hour cut-off, which means that one third of potential kidneys will not be utilized.