A study of hospitalized COVID-19 patients with AKI in a setting of multiracial developing country

BACKGROUND

The commonest indication for hospitalization in COVID-19 patients is hypoxemia or severe respiratory symptoms. However, COVID-19 disease may result in extrapulmonary complications including kidney-related pathology. The reported incidence of renal involvement related to COVID infection varies based on geographical location.

OBJECTIVE

This study aimed to assess the incidence rate of AKI in hospitalized COVID-19 patients and identify risk factors and prognostic predictors.

METHOD

In this retrospective study, we recruited hospitalized COVID-19 patients from January 2021 until June 2021 at the University Malaya Medical Center. The inclusion criteria were hospitalized for ≥ 48 h with confirmed COVID-19 infection and at least 18 years old. Patient demographic and clinical data were collected from electronic medical records. The staging of AKI was based on criteria as per KDIGO guidelines.

RESULTS

One thousand five hundred twenty-nine COVID patients fulfilled the inclusion criteria with a male-to-female ratio of 759 (49.6%) to 770 (50.3%). The median age was 55 (IQR: 36-66). 500 patients (32.7%) had diabetes, 621 (40.6%) had hypertension, and 5.6% (n = 85) had pre-existing chronic kidney disease (CKD). The incidence rate of AKI was 21.1% (n = 323). The percentage of COVID patients in different AKI stages of 1,2 and 3 were 16.3%, 2.1%, and 2.7%, respectively. Fifteen hospitalized patients (0.98%) required renal replacement therapy. 58.8% (n = 190) of AKI group had complete recovery of kidney function. Demographic factors included age (p < 0.001), diabetes (p < 0.001), hypertension (p < 0.012), CKD (p < 0.001), and vaccination status (p = 0.042) were associated with an increased risk of developing AKI. We found that the AKI cohort had statistically significant lower platelet counts and higher ferritin levels than the non-AKI cohort. AKI is a risk predictor of prolonged hospitalization (p < 0.001) and higher mortality rates (P < 0.001).

CONCLUSION

AKI is a common clinical complication among hospitalized COVID-19 patients. The etiology of AKI is multifactorial and may have an adverse impact on patient morbidity and mortality.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Surgical site infection and development of antimicrobial sutures: a review

Sutures are used to facilitate wound healing and play an important role in ensuring the success of surgical interventions in healthcare facilities. Suture-associated surgical site infection (SSI) may develop when bacterial contaminants colonize the suture surface and establish biofilms that are highly resistant to antibiotic treatment. The outcome of SSI affects postoperative care, leading to high rates of morbidity and mortality, prolonged hospitalization, and increased financial burden. Antimicrobial sutures coated with antiseptics such as triclosan and chlorhexidine have been used to minimize the occurrence of SSI. However, as the efficacy of antiseptic-based sutures may be affected due to the emergence of resistant strains, new approaches for the development of alternative antimicrobial sutures are necessary. This review provides an update and outlook of various approaches in the design and development of antimicrobial sutures. Attaining a zero SSI rate will be possible with the advancement in suturing technology and implementation of good infection control practice in clinical settings.

793 The Giant Hogweed as A Rare Cause of Chemical Burns: A Case Series

Introduction

The Giant Hogweed (Heracleum mantegazzianum) is a rare cause for chemical burns in humans and animals and is acquiring growing recognition in mainstream media as a relevant public health concern.

Injuries attributed to this plant range from innocuous superficial irritation to full-thickness chemical burns. A vast majority of cases will resolve with conservative measures and effective first aid, but these case series demonstrate the clinical course of more severe injuries.

Description

We present a case series of 2 patients requiring admission to the Royal Group Hospitals for management of mixed thickness hogweed burns. Injuries were sustained by two separate infestations of giant hogweed in the Western Trust Area. Both patients responded to observation and conservative measures, namely effective analgesia, UV light protection, topical hydrocortisone, and dressings.

Discussion

Cutaneous burns induced by giant hogweed are caused by contact with its photoactive sap containing plant furocoumarins. On exposure to sunlight, the sap initiates a damaging process known as phytophotodermatitis (PPD). This process can be managed effectively with topical steroids; however, prolonged contact and subsequent sun exposure may lead to more severe skin damage. In extremely rare instances, damage may progress to full-thickness skin burns warranting operative intervention.

ABO-Incompatible Living-Donor Kidney Transplantation in a Developing Country: A Multicenter Experience in Malaysia

Malaysia has a low deceased-donor donation rate and has not embarked on a paired kidney exchange program; therefore, ABO-incompatible and HLA-incompatible transplantation remain the main contributor to the sustainability of the national kidney transplantation (KT) program. There were 26 cases of ABO-incompatible KTs performed from 2011 to 2018 in 3 major transplant centers, namely, Hospital Kuala Lumpur, University Malaya Medical Centre, and Prince Court Medical Centre. We collected perioperative and follow-up data through June 2019. The desensitization protocol varies and is center specific: the localized Japanese protocol and Swedish protocol with a target anti-A/B isoagglutinin titer of 16 or 32 on the day of transplant. The induction and tacrolimus-based maintenance protocol was nearly identical. The median follow-up time was 62.3 months (interquartile range, 37.0-79.7). Fifteen subjects had the highest predesensitization anti-A/B titer of ≥32 (57.7%). The acute cellular rejection and antibody-mediated rejection incidence were 12.5% (3 cases) and 8.3% (2 cases), respectively. Patient, graft, and death-censored graft survival rates were 96.2%, 92.3%, and 96.0%, respectively, 1 year post-living-donor KT (LDKT) and 96.2%, 87.2%, and 90.7%, respectively, 5 years post-LDKT. Our experience shows that ABO-incompatible LDKT using a suitable desensitization technique could be a safe and feasible choice for LDKT even with varied desensitization regimens for recipients with relatively high baseline isoagglutinin titers.

Bacteria-ball in the urinary tract: a rare entity

A bacterial mass in the urinary tract is a very rare entity. We report the first case of a bacterial ball within the urinary tract of a patient with diabetic cystopathy on long term urinary indwelling catheter. She presented with fever and gross haematuria. CT scan of abdomen and pelvis revealed a gas containing hyperdense mass within the bladder suspicious of bladder stone. The lesion was resected, and histopathology revealed a matrix of acellular materials with bacteria colony.

Discovery of small molecule inhibitors against the NS3/4A serine protease of Hepatitis C virus genotype 3 via highthroughput virtual screening and in vitro evaluations

The hepatitis C virus (HCV) consists of eight genotypes and 90 subtypes, with genotype (GT) 3 being the second most common globally and is linked to higher incidences of steatosis and rapid development of fibrosis and cirrhosis. The NS3/4A serine protease, a heterodimer complex of two HCV non-structural proteins, is an effective target for pharmaceutical intervention due to its essential roles in processing HCV polyproteins and inhibiting innate immunity. This study combines structure-based virtual screening (SBVS) of predefined compound libraries, pharmacokinetic prediction (ADME/T) and in vitro evaluation to identify potential low molecular weight (<500 Dalton) inhibitors of the NS3/4A serine protease (GT3). In silico screening of ZINC and PubChem libraries yielded five selected compounds as potential candidates. Dose-dependent inhibition of the NS3/4A serine protease and HCV replication in HuH-7.5 cells revealed that compound A (PubChem ID No. 16672637) exhibited inhibition towards HCV GT3 with an IC₅₀ of 106.7µM and EC₅₀ of 25.8µM, respectively. Thus, compound A may be developed as a potent, low molecular weight drug against the HCV NS3/4A serine protease of GT3.

Ultrasound-guided percutaneous nephrolithotomy: Advantages and limitations

PURPOSE

The use of ultrasound in percutaneous nephrolithotomy (PCNL) has not been shown to translate to better clinical and stone outcomes. To compare the operative outcomes, postoperative outcomes and complication rates of ultrasound-guided access PCNL (USGA-PCNL) versus fluoroscopy-guided access PCNL (FGA-PCNL).

MATERIALS AND METHODS

A total of 184 consecutive patients who underwent PCNL from July 2008 to September 2014 were identified from our PCNL database. Seventy-two patients underwent USGA-PCNL and 112 FGA-PCNL.

RESULTS

The patients were similar in age, sex, race, American Society of Anesthesiologists physical status classification, mean largest stone diameters, side of PCNL, number of stones and the degree of hydronephrosis between both groups. There were higher rates of upper pole (5.6% vs. 3.6%), mid pole (8.3% vs. 2.7%) and multiple pole punctures (4.2% vs. 0%) in USGA-PCNL compared to FGA-PCNL (p=0.027). There was no difference in the stone free rates of both groups in univariate analysis. Those who had FGA-PCNL were 2.26 (95% confidence interval, 1.09-4.75; p=0.029) times more likely to require a second-look procedure compared to USGA-PCNL on univariate analysis but not on multivariate analysis. There were no differences in Clavien-Dindo complications. No patient in the USGA-PCNL group experienced organ injuries during puncture compared to 1 patient in the FGA-PCNL group who had pneumothorax requiring urgent chest tube insertion.

CONCLUSIONS

The use of ultrasonography to guide access puncture during PCNL eliminates the risk of inadvertent organ injuries. Similar operative and stone outcomes show that the learning curve for USGA is minimal compared to conventional FGA.

Exosomes derived from human embryonic mesenchymal stem cells promote osteochondral regeneration

OBJECTIVE

Clinical and animal studies have demonstrated the efficacy of mesenchymal stem cell (MSC) therapies in cartilage repair. As the efficacy of many MSC-based therapies has been attributed to paracrine secretion, particularly extracellular vesicles/exosomes, we determine here if weekly intra-articular injections of human embryonic MSC-derived exosomes would repair and regenerate osteochondral defects in a rat model.

METHODS

In this study, osteochondral defects were created on the trochlear grooves of both distal femurs in 12 adult rats. In each animal, one defect was treated with 100 μg exosomes and the contralateral defect treated with phosphate buffered saline (PBS). Intra-articular injections of exosomes or PBS were administered after surgery and thereafter weekly for a period of 12 weeks. Three unoperated age-matched animals served as native controls. Analyses were performed by histology, immunohistochemistry, and scoring at 6 and 12 weeks after surgery.

RESULTS

Generally, exosome-treated defects showed enhanced gross appearance and improved histological scores than the contralateral PBS-treated defects. By 12 weeks, exosome-treated defects displayed complete restoration of cartilage and subchondral bone with characteristic features including a hyaline cartilage with good surface regularity, complete bonding to adjacent cartilage, and extracellular matrix deposition that closely resemble that of age-matched unoperated control. In contrast, there were only fibrous repair tissues found in the contralateral PBS-treated defects.

CONCLUSION

This study demonstrates for the first time the efficacy of human embryonic MSC exosomes in cartilage repair, and the utility of MSC exosomes as a ready-to-use and 'cell-free' therapeutic alternative to cell-based MSC therapy.

Robotic assisted adrenalectomy: Is it ready for prime time?

Adrenal surgery is undergoing continuous evolution and minimally invasive surgery is increasingly being used for the surgical management of adrenal masses. With robotic-assisted surgery being a widely accepted surgical treatment for many urological conditions such as prostate carcinoma and renal cell carcinoma, the use of the robot has been expanded to include robotic-assisted adrenalectomy, offering an alternative minimally invasive platform for adrenal surgery. We performed a literature review on robotic-assisted adrenalectomy, reviewing the current surgical techniques and perioperative outcomes.

Robot-assisted nephroureterectomy: current perspectives

Robot-assisted surgery was just a medical curiosity until the development of the da Vinci robotic system, and since then, it has become a widely accepted surgical treatment for many urological conditions such as prostate carcinoma and renal cell carcinoma. With the increase in the number of urologists using the robot and the improvement in surgeon experience, the use of the robot has been expanded to include performing radical nephroureterectomy (NU) for the treatment of primary upper tract urothelial carcinoma. We performed a literature review on robot-assisted laparoscopic NU with the aim of providing a current perspective on robot-assisted laparoscopic NU for the management of upper tract urothelial carcinoma. Surgical technique, perioperative outcomes, and oncological outcomes are discussed.

Extended lymph node dissection in robot-assisted radical prostatectomy: lymph node yield and distribution of metastases

In this study, we reported our experience performing robotic extended lymph node dissection (eLND) in patients with prostate cancer. A total of 147 patients with intermediate and high-risk prostate cancer who underwent robotic eLND from May 2008 to December 2011 were included in this analysis. The dissection template extended to the ureter crossing the iliac vessels. We assessed lymph node yield, lymph node positivity, and perioperative outcomes. Lymph node positivity was also evaluated according to the number of lymph nodes (LNs) removed (<22 vs ≥22). The median number of LNs removed was 22 (11–51), and 97 positive LNs were found in 24 patients (16.3%). While the obturator fossa was the most common site for LN metastases (42.3%, 41/97), the internal iliac area was the most common area for a single positive LN packet (20.8%, 5/24). Eight patients (33.3%, 8/24) had positive LNs at the common iliac area. The incidence of positive LNs did not differ according to the number of LNs removed. Complications associated with eLND occurred in 21 patients (14.3%) and symptomatic lymphocele was found in five patients (3.4%). In conclusion, robotic eLND can be performed with minimal morbidity. Furthermore, LN yield and the node positive rate achieved using this robotic technique are comparable to those of open series. In addition, the extent of dissection is more important than the absolute number of LNs removed in eLND, and the robotic technique is not a prohibitive factor for performing eLND.

Associations between serum 25-hydroxyvitamin D and bone mineral density and proximal femur geometry in Koreans: the Korean National Health and Nutrition Examination Survey (KNHANES) 2008-2009

The association between 25-hydroxyvitamin D (25(OH)D) levels and bone mineral density (BMD) and proximal femur bone geometry was examined in the Korean population. A positive relationship between skeletal health and 25(OH)D levels was observed. However, there were no significant differences in skeletal health between the groups with 25(OH)D level of 50-75 nmol/L and greater than 75 nmol/L.

INTRODUCTION

Vitamin D plays an important role in calcium and phosphate homeostasis and normal mineralization of bone. However, the optimal level of vitamin D for skeletal health has not been clearly established. We analyzed the associations between serum 25(OH)D and BMD and proximal femur bone geometry and determined the optimal 25(OH)D level.

METHODS

This was a cross-sectional study of 10,062 participants (20-95 years, 4,455 men, 5,607 women) in the Fourth Korea National Health and Nutrition Examination Surveys (KNHANES IV) conducted from 2008 to 2009. Participants were divided into groups according to 25(OH)D level (<25, 25-50, 50-75, and ≥75 nmol/L). BMD and proximal femur geometric indices were measured.

RESULTS

The group with 25(OH)D levels of 50-75 nmol/L had greater bone density values, with the exception of the lumbar spine, and also had greater femur neck cortical thickness, cross-sectional area, and cross-sectional moment of inertia, as well as a lesser buckling ratio than the groups with 25(OH)D level of 25-50 nmol/L and less than 25 nmol/L. However, there were no significant differences in BMD and proximal femur geometry properties between the groups with 50-75 nmol/L and greater than 75 nmol/L of 25(OH)D.

CONCLUSION

The skeletal outcomes, including BMD and proximal femur geometric indices observed in this study, suggest that serum 25(OH)D levels of 50 to <75 nmol/L are optimal for skeletal health.

Laparoendoscopic single-site (LESS) robot-assisted nephroureterectomy: comparison with conventional multiport technique in the management of upper urinary tract urothelial carcinoma

OBJECTIVE

To compare the peri-operative, pathological and oncological outcomes of laparoendoscopic single-site (LESS) robot-assisted nephroureterectomy (LESS-RALNU) with those of multiport robot-asssisted nephroureterectomy (M-RALNU).

PATIENTS AND METHODS

A total of 38 patients with upper urinary tract urothelial carcinoma underwent LESS-RALNU (n = 17) or M-RALNU (n = 21) by a single surgeon at a tertiary institution. Data were obtained from a prospectively maintained database.

RESULTS

Patients' demographics and tumour characteristics were similar between the M-RALNU and LESS-RALNU groups. The mean follow-up was 48.4 months for M-RALNU and 30.9 months for LESS-RALNU (P = 0). The mean operating time, estimated blood loss and length of hospitalization for M-RALNU and LESS-RALNU were 251 min, 192 mL, 6.5 days and 247 min, 376 mL and 5.4 days, respectively (P > 0.05). Overall, there were no significant differences in complication rates, although three patients in the LESS-RALNU group required blood transfusion, whereas no patient in the M-RALNU group did (P = 0.081). The proportion of patients with bladder recurrence, local recurrence and distant metastases was similar between the two groups. There were no significant differences in the recurrence-free survival, cancer-specific survival and overall survival rates between the two groups.

CONCLUSIONS

Although the oncological and peri-operative outcomes of patients who underwent LESS-RALNU compared well with those who underwent M-RALNU and with series of other surgical approaches, LESS-RALNU might result in greater intra-operative blood loss. We suggest careful selection of patient for this technique.

A rare case of interparietal incisional hernia from 8 mm trocar site after robot-assisted laparoscopic prostatectomy

Trocar site hernia arising from 8 mm robotic port is very rare despite the increasing prevalence of robot-assisted surgeries. To date, there had been only a single case reported in the literature. We report a case of small bowel obstruction secondary to an interparietal trocar site incisional hernia after robot-assisted laparoscopic prostatectomy. Meticulous closure of 8 mm robotic trocar sites associated with large peritoneal defect at the end of surgery should be performed.

Robotic mechanical localization of prostate cancer correlates with magnetic resonance imaging scans

PURPOSE

To evaluate the concordance of cancer location of the tissue mapping from a mechanical pressure transducer with magnetic resonance imaging (MRI) scans.

MATERIALS AND METHODS

A total of 60 indentations were performed on 5 prostate specimens obtained after radical prostatectomy utilizing a robotic indentation system. The mechanical elastic moduli of suspected malignant lesions were calculated and mapped, and their locations were compared with suspicious areas of malignancy on MRI scans.

RESULTS

The concordance rate between the location mapping from the robotic indentation system and MRI scans results was 90.0% (54/60). The sensitivity and specificity of the robotic indentation system were 87.9% (29/33) and 92.6% (25/27), respectively. The positive predictive value and negative predictive value were 93.5% (29/31) and 93.1% (27/29), respectively.

CONCLUSION

The locations of malignant lesions derived from our robotic indentation system correlated strongly with the locations of suspected areas of malignancy on MRI scans. Our robotic system may provide a more targeted biopsy of the prostate than conventional non-targeted systemic biopsy, possibly improving the diagnostic accuracy of prostatic biopsies for cancer.

Tumor volume adds prognostic value in patients with organ-confined prostate cancer

PURPOSE

This study was designed to assess the independent prognostic value of tumor volume (TV) and whether adding TV provides additional prognostic information for predicting biochemical recurrence (BCR) after radical prostatectomy.

METHODS

We reviewed the medical records of 1,129 patients who underwent radical prostatectomy between July 2005 and July 2011. TV was categorized as minimal (≤1.0 ml), moderate (1.1-5.0 ml), or extensive (>5.0 ml). Cox regression analysis was performed to identify independent predictors of BCR. The predictive accuracies of Cox's proportional hazard regression models with and without TV were quantified and compared using time-dependent receiver operating characteristic curve analysis.

RESULTS

Increasing TV was associated with higher prostate specific antigen, pathological Gleason score, and pathologic tumor stage. TV was an independent predictor of BCR in multivariate analysis (p<0.001). When patients were stratified by organ-confined and nonorgan-confined tumor groups, TV remained an independent predictor of BCR in organ-confined tumors (p<0.001). In the nonorgan-confined tumor group, a significant difference was found only between extensive versus minimal TV (p=0.023). The predictive accuracy of the Cox regression model increased significantly by adding TV in organ-confined tumor group (0.748 vs. 0.704, p<0.05) but not in nonorgan-confined group (0.742 vs. 0.734, p>0.05).

CONCLUSIONS

TV was an independent prognostic predictor of BCR in organ-confined prostate cancers and provided additional prognostic information with increased predictive accuracy. In contrast, TV did not increase the predictive accuracy in nonorgan-confined tumor. TV should be considered as a prognosticator in organ-confined tumors.

Biochemical outcomes after robot-assisted radical prostatectomy in patients with follow-up more than 5-years

In this study, we assessed biochemical outcomes after robot-assisted radical prostatectomy (RARP). Between July 2005 and November 2007, one hundred and seventy-six consecutive patients treated by RARP without neoadjuvant treatment were included in this study. All procedures were performed by a single surgeon and the median follow-up period was 60 months (interquartile range (IQR): 59-69). The median prostate specific antigen was 7.50 ng ml(-1) (IQR: 5.14-11.45) and 39.2% of the patients were classified as intermediate risk and 15.3% were classified as high risk; on final pathological examination, 35.2% of the patients had non-organ confined disease and 37.5% and 14.2% had Gleason scores of 7 and 8-10, respectively. The biochemical recurrence (BCR)-free survival rates at 3 and 5 years were 85.6% and 81.2%, respectively. The 5-year BCR-free survival rates stratified by pathologic Gleason scores were 93.1% in Gleason scores of 6 or less, 74.5% in a Gleason score of 7, and 58.1% in Gleason scores of 8 or greater, respectively (P<0.001). When stratified by pathologic stage, the BCR-free survival rates were 89.8% in pT2 patients, 66.2% in pT3a patients, and 39.3% in pT3b patients at 5 years following RARP, respectively (P<0.001). Preoperative prostate-specific antigen (PSA), pathologic stage, postoperative Gleason score and surgical margin status were independently associated with BCR in multivariate analysis. In this study, we report biochemical outcomes after RARP with the longest follow-up periods to date in Asian men. We found that robotic surgery provided satisfactory biochemical outcomes, and that RARP is a safe and effective procedure in terms of oncologic outcomes.

Simplified zero ischemia in robot assisted partial nephrectomy: initial yonsei experience

Purpose

To evaluate the safety and feasibility of a simplified zero ischemia technique using kidney donor computed tomographic (CT) angiography and conventional laparoscopic bulldog clamps.

Materials and Methods

We conducted a review of seven robot-assisted partial nephrectomies (RAPNs) performed by a single surgeon from January 2012 to May 2012. Using a simplified protocol of 3-dimentional reconstruction, tertiary arterial branches supplying the tumor were selectively clamped prior to resection. We used conventional laparoscopic bulldog clamps instead of microsurgical vessel clamps. The patients' demographic information, perioperative outcomes, pathologic outcomes and pre- and postoperative renal functions up to 3 months follow-up were analyzed.

Results

RAPN were successfully performed for seven complex renal hilar tumors. There were no significant differences in the total operation time, estimated blood loss or postoperative outcomes compared with published literature on standard RAPN. Negative surgical margins were reported in all cases.

Conclusions

We presented a simplified-zero ischemia technique using kidney Donor CT angiography and conventional laparoscopic bulldog clamps. We have also demonstrated its safety and feasibility in patients with complex renal hilar tumors. This modified technique can be easily adopted by most surgeons who are currently performing RAPN.

Extended vs standard lymph node dissection in robot-assisted radical prostatectomy for intermediate- or high-risk prostate cancer: a propensity-score-matching analysis

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Although lymph node dissection (LND) is known as the most accurate method of nodal staging, the therapeutic role of LND remains undetermined. This is mainly because of the lack of randomized prospective studies and the fact that retrospective analyses often result in bias and misinterpretation. To overcome the limitation of retrospective analysis, we matched preoperative variables using propensity scores and compared the outcomes between patients treated with robot-assisted eLND and sLND. In the matched cohort, robot-asssited eLND achieved an increased detection rate of lymph node metastases; however, the therapeutic benefit was not statistically significant between the two groups on short-term follow-up.

OBJECTIVE

To compare the pathological and biochemical outcomes between extended lymph node dissection (eLND) and standard lymph node dissection (sLND) in patients undergoing robot-assisted radical prostatectomy for intermediate- or high-risk prostate cancer.

PATIENTS AND METHODS

A total of 905 patients underwent robot-assisted radical prostatectomy and lymph node dissection (LND) by a single surgeon between June 2006 and January 2011. Of these, 170 patients who underwent robot-assisted eLND and 294 patients who underwent robot-assisted sLND for intermediate- or high-risk prostate cancer were included in the study. Propensity-score matching was performed using the preoperative variables which included age, body mass index, prostate-specific antigen, clinical stage, biopsy Gleason score 1 and 2, total number of biopsied cores, number of positive cores and prostate volumes. Pathological and biochemical outcomes were assessed according to the extent of LND.

RESULTS

The median (range) follow-up period was 36 (12-77) months and the median number of lymph nodes removed was 21 and 12 in the eLND and sLND groups, respectively. Propensity-score matching resulted in 141 patients in each group. Although patients who underwent eLND had a higher clinical stage, biopsy Gleason score and number of positive cores than those treated with sLND in the entire cohort, there were no preoperative between-group differences in the matched cohort. In the matched cohort, lymph node metastases were detected at a significantly higher rate in the eLND than in the sLND group (12.1 vs. 5.0%, P = 0.033). In the matched cohort, the 3-year biochemical recurrence-free survival rates were 77.8 and 73.5% in the eLND and sLND groups, respectively, which was not significant (hazard ratio 0.85, P = 0.497).

CONCLUSION

Robot-assisted eLND achieved an increased lymph node yield and higher detection rate of lymph node metastases; however, robotic eLND did not alter biochemical outcomes in a short-term follow-up.

An Evidence-Based Evaluation of Health Information on Erectile Dysfunction From 10 Nationwide Daily Newspapers in Korea

Purpose

A rapid growth in the socioeconomic status of Koreans has triggered an unprecedented explosion of health information for the general population. Despite its obvious benefits, this increase in information could also result in potentially harmful effects for both consumers and professionals who do not use it appropriately. Thus, this study was conducted to evaluate the quality and accuracy of health information on erectile dysfunction from 10 nationwide daily newspapers.

Materials and Methods

This study analyzed health information from 10 nationwide daily newspapers in Korea from January 2011 through December 2011. We reviewed the health information for quality by using evidence-based medicine tools and evaluated the accuracy of the information provided. Articles that simply summarized scientific congresses or journal articles and that did not include direct quotations were excluded, as were advertisements.

Results

A total of 47 articles were gathered. Among them, 27 (57.4%) contained inaccurate or misleading statements on the basis of an evidence-based medicine evaluation. These statements included using inappropriate surrogate outcomes as clinical endpoints (three cases, 6.4%), extrapolating nonhuman results to humans (two cases, 4.3%), exaggerating the significance of results (eight cases, 17.0%), and using incorrect words (14 cases, 29.8%). The rate of error was higher in the information from Korean sources than in that from international sources (22 cases vs. 5 cases).

Conclusions

Approximately 57% of all articles on erectile dysfunction from 10 nationwide daily newspapers were found to contain inaccuracies.

Penicilliosis in lupus patients presenting with unresolved fever: a report of 2 cases and literature review

Penicilliosis is a rare occurrence among non human immunodeficiency virus (HIV) infected patients. We report here two cases of Penicillium marneffei infection in patients with systemic lupus erythematosus (SLE). Both patients had a recent flare of lupus and were on immunosuppressive drugs when they presented with prolonged fever without an obvious foci of infection, unresponsive to broad-spectrum antibiotics. They were leucopaenic upon admission, with rapid deterioration during the course of the illness. Diagnosis of penicilliosis via fungal isolation from blood culture was delayed resulting in the late initiation of antifungal agents. While both patients ultimately recovered, the delay in diagnosis led to a prolonged hospital stay with increased morbidity. Clinicians should be aware of this uncommon but emerging fungal pathogen in SLE patients and maintain a high index of suspicion in diagnosing this potentially fatal but treatable disease.

Acute Pyelonephritis and Renal Abscesses in Adults—Correlating Clinical Parameters with Radiological (Computer Tomography) Severity

Introduction: The aim of this study is to evaluate the correlations between clinical and biochemical parameters with radiological severity of CT diagnosed acute pyelonephritis (APN) and renal abscesses, thereafter defining clinical predictors to identify patients with severe APN or renal abscesses. Materials and Methods: The inpatient medical records of all patients diagnosed with APN or renal abscesses admitted over one year were reviewed. Patients with CT imaging performed were classified into 3 groups—mild APN, severe APN and renal abscesses. Clinical and biochemical parameters were correlated with radiological severity. Results: One hundred and thirty patients were included in the study. Male gender, older age, presence of diabetes mellitus and unobstructing renal stones were significantly associated with severe APN or renal abscesses. Clinical and biochemical parameters that were associated with more severe disease include a higher leucocyte count and C-reactive proteins, left neutrophil shift, thrombocytosis or thrombocytopenia, low serum albumin, acute renal impairment and bacteremia. The percentage of patients had positive urine and blood cultures were 40.8% and 30.7% respectively. Of these patients, 97.9% had severe APN or renal abscesses on CT imaging had diabetes mellitus (DM), hypotension, acute renal failure or leucocyte count of >20K. Conclusion: Our study showed a good correlation between clinical and radiological severity in adult patients with APN and renal abscesses. Patients with severe APN or renal abscesses were likely to be diabetics presenting with hypotension, acute renal impairment and a leucocyte count of greater than 20K. Key words: Computer topography (CT), Pyelonephritis, Renal abscess, Severity

Acute pyelonephritis and renal abscesses in adults--correlating clinical parameters with radiological (computer tomography) severity

INTRODUCTION

The aim of this study is to evaluate the correlations between clinical and biochemical parameters with radiological severity of CT diagnosed acute pyelonephritis (APN) and renal abscesses, thereafter defining clinical predictors to identify patients with severe APN or renal abscesses.

MATERIALS AND METHODS

The inpatient medical records of all patients diagnosed with APN or renal abscesses admitted over one year were reviewed. Patients with CT imaging performed were classified into 3 groups--mild APN, severe APN and renal abscesses. Clinical and biochemical parameters were correlated with radiological severity.

RESULTS

One hundred and thirty patients were included in the study. Male gender, older age, presence of diabetes mellitus and unobstructing renal stones were significantly associated with severe APN or renal abscesses. Clinical and biochemical parameters that were associated with more severe disease include a higher leucocyte count and C-reactive proteins, left neutrophil shift, thrombocytosis or thrombocytopenia, low serum albumin, acute renal impairment and bacteremia. The percentage of patients had positive urine and blood cultures were 40.8% and 30.7% respectively. Of these patients, 97.9% had severe APN or renal abscesses on CT imaging had diabetes mellitus (DM), hypotension, acute renal failure or leucocyte count of >20K.

CONCLUSION

Our study showed a good correlation between clinical and radiological severity in adult patients with APN and renal abscesses. Patients with severe APN or renal abscesses were likely to be diabetics presenting with hypotension, acute renal impairment and a leucocyte count of greater than 20K.

Antimicrobial resistance of enterococci isolated from mastitic bovine milk samples in Korea

The aim of this study was to determine the antimicrobial resistance of various species of enterococci isolated from mastitic bovine milk samples. A total of 105 enterococci isolates were examined: Enterococcus faecalis (n = 47), Enterococcus faecium (n = 39), Enterococcus gallinarum (n = 6), Enterococcus avium (n = 6), Enterococcus hirae (n = 5) and Enterococcus durans (n = 2). All the isolates were susceptible to ampicillin, gentamicin and vancomycin, and only a single E. hirae isolate was resistant to ampicillin. In general, the most frequently observed resistance among the enterococcal isolates was to tetracycline (69.5%), followed by penicillin (64.7%), erythromycin (57.1%) and cephalothin (44.7%). A similar antimicrobial resistance pattern was observed among individual species except E. durans, which exhibited only tetracycline resistance. Resistance observed among isolates of E. hirae and E. gallinarum was almost as high as E. faecium and E. faecalis. Of 105 isolates, only six (5.7%) strains of E. faecium were susceptible to all the antimicrobials tested and about 52% (55/105) showed resistance to more than three antimicrobials. The most common multiple resistance pattern was penicillin, tetracycline and erythromycin, which was observed in 32 of 105 (30.4%) isolates. This study demonstrates that enterococcal isolates belonging to minor species showed antimicrobial resistance rates as high as those of E. faecium and E. faecalis, and that monitoring of antimicrobial resistance should not be restricted only to those two major species.

Nano-electromechanical switch-CMOS hybrid technology and its applications

Si-based CMOS technology is facing a serious challenge in terms of power consumption and variability. The increasing costs associated with physical scaling have motivated a search for alternative approaches. Hybridization of nano-electromechanical (NEM)-switch and Si-based CMOS devices has shown a theoretical feasibility for power management, but a huge technical gap must be bridged before a nanoscale NEM switch can be realized due to insufficient material development and the limited understanding of its reliability characteristics. These authors propose the use of a multilayer graphene as a nanoscale cantilever material for a nanoscale NEM switchwith dimensions comparable to those of the state-of-the-art Si-based CMOS devices. The optimal thickness for the multilayer graphene (about five layers) is suggested based on an analytical model. Multilayer graphene can provide the highest Young's modulus among the known electrode materials and a yielding strength that allows more than 15% bending. Further research on material screening and device integration is needed, however, to realize the promises of the hybridization of NEM-switch and Si-based CMOS devices.

Cannabinoid receptor 1 mediates palmitic acid-induced apoptosis via endoplasmic reticulum stress in human renal proximal tubular cells

The endocannabinoid system (ECS) is activated at the onset of obesity and diverse metabolic diseases. Endocannabinoids mediate their physiological and behavioral effects by activating specific cannabinoid receptors, mainly cannabinoid receptor 1 (CB(1)R). Diabetic nephropathy (DN) is induced by hyperlipidemia, and renal proximal tubule cells are an important site for the onset of DN. However, the pathophysiology of CB(1)R, especially in the hyperlipidemia of DN, has not been elucidated. Therefore, we examined the effect of palmitic acid (PA) on CB(1)R expression and its related signal pathways in human renal proximal tubular cells (HK-2 cells). PA significantly increased CB(1)R mRNA and protein levels and induced CB(1)R internalization. PA-induced activation of CB(1)R is prevented by the treatment of AACOCF(3) (a cPLA(2) inhibitor), indomethacin and NS398 (a COX 2 inhibitors). Indeed, PA increased cPLA(2), and COX-2 but not COX-1. We also investigated whether the PA-induced activation of CB(1)R is linked to apoptosis. As a result, AM251 (a CB(1)R antagonist) attenuated PA-mediated apoptosis in a concentration-dependent manner. Furthermore, PA decreased GRP78 expression and induced increases in the endoplasmic reticulum (ER) stress signaling pathways p-PERK, p-eIF2α, p-ATF4, and CHOP, which were blocked by AM251 treatment. Moreover, PA increased the Bax/Bcl-2 ratio, cleaved PARP, and caspase-3 levels. The PA-induced apoptotic effects were decreased with CB(1)R-specific antagonist (AM251) treatment and CB1 si-RNA transfection. In conclusion, PA induced apoptosis through ER stress via CB(1)R expression in human proximal tubule cells. Our results provide evidence that CB(1)R blockade may be a potential anti-diabetic therapy for the treatment of DN.

Distribution of streptogramin resistance genes and genetic relatedness among quinupristin/dalfopristin-resistant Enterococcus faecium recovered from pigs and chickens in Korea

Fifty-four quinupristin/dalfopristin-resistant Enterococcus faecium (QDREF) isolated from chickens and pigs during 2002-2003 in Korea were screened by PCR for the presence of streptogramin resistance genes vatD, vatE, and vgbA, and macrolide resistance gene ermB. None of the QDREF isolates carried vgbA and vatD genes, while vatE and ermB were detected in 9.2% and 74% of the isolates, respectively. Twenty-six percent (14/54) of the QDREF isolates contained none of the resistance determinants tested. Pulsed-field gel electrophoresis (PFGE) patterns revealed high heterogeneity: 47 different patterns for 54 QDREF evaluated. Identical PFGE types were observed in two pairs of chicken isolates and a pair of pig isolates, respectively, but chicken isolates did not share PFGE pattern with pig isolates, suggesting clonal spread of QDREF strain between the same species of animals but not between different species of animals. This is the first report, to our knowledge, of vatE-positive E. faecium isolates and also the first evidence of clonal spread of QDREF strain between animals in Korea.

The effect of mosapride (5HT-4 receptor agonist) on insulin sensitivity and GLUT4 translocation

AIMS

We investigated the effect of mosapride, 5HT-4 (5-hydroxytryptamine) agonist, on blood glucose level and insulin sensitivity in subjects with impaired glucose tolerance (IGT) and conducted an in vitro study to evaluate the action mechanism.

METHODS

Thirty IGT patients were randomly assigned to receive either mosapride or placebo for 2 weeks. Biochemical profiles and insulin sensitivity index from euglycemic hyperinsulinemic clamp test were assessed before and after treatment. In cultured myotubes from human skeletal muscle cells, insulin- and mosapride-induced GLUT4 translocation and tyrosine phosphorylation of IRS-1 were determined.

RESULTS

After 2 weeks of treatment with mosapride, glucose disposal rates were significantly increased up to those of control (mosapride 5.47+/-1.72 vs 7.06+/-2.13, P=0.004, placebo 5.42+/-1.85 vs 5.23+/-1.53mgkg(-1)min(-1)). Fasting plasma glucose (FPG) and insulin levels were decreased. Mosapride increased the contents of GLUT4 in plasma membrane representing the increased recruitment of glucose transporters from intracellular pool. While insulin treatment on human skeletal muscle cell resulted in an increased tyrosine phosphorylation of IRS-1, mosapride did not have any effect.

CONCLUSIONS

Mosapride is effective in decreasing FPG without stimulating insulin secretion in IGT subjects, possibly by inducing GLUT4 translocation in skeletal muscles.