Association between histological diaphragm atrophy and ultrasound diaphragm expiratory thickness in ventilated patients

Background

Diaphragm fiber atrophy has been evidenced after short periods of mechanical ventilation (MV) and related to critical illness-associated diaphragm weakness. Atrophy is described as a decrease in diaphragm fiber cross-sectional area (CSA) in human diaphragm biopsy, but human samples are still difficult to obtain in clinics. In recent years, ultrasound has become a useful tool in intensive care to evaluate diaphragm anatomy. The present study aimed to evaluate the ability of diaphragm expiratory thickness (Tdi) measured by ultrasound to predict diaphragm atrophy, defined by a decrease in diaphragm fiber CSA obtained through diaphragm biopsy (the gold standard technique) in ventilated patients.

Methods

Diaphragm biopsies and diaphragm ultrasound were performed in ventilated donors and in control subjects. Demographic variables, comorbidities, severity on admission, treatment, laboratory test results and evolution variables were evaluated. Immunohistochemical analysis to determine CSA and ultrasound measurements of Tdi at end-expiration were performed, and median values of the control group were used as thresholds to determine agreement between them in further analysis. Sensitivity, specificity, and positive and negative predictive values of an ultrasound Tdi cutoff for detecting histologic atrophy were calculated. Agreement between two ultrasound observers was also assessed.

Results

Thirty-five ventilated organ donors and 5 ventilated controls were included, without differences in basic characteristics. CSA and Tdi were lower in donors than in controls. All donors presented lower CSA, but only 74% lower Tdi regarding control group thresholds. The cut-off value for lower diaphragm expiratory thickness (Tdi < 1.7 mm) presented a sensitivity of 73%, a specificity of 67%, a positive predictive value of 96% and a negative predictive value of 17% for determining the presence of diaphragm atrophy (CSA < 2851 μm²).

Conclusions

Diaphragm atrophy and thickness reduction is associated to MV. While a lower Tdi in diaphragm ultrasound is a good tool for diagnosing atrophy, normal or increased Tdi cannot rule atrophy out showing that both parameters should not be considered as synonymous.

Prediction of coronary disease incidence by biomarkers of inflammation, oxidation, and metabolism

The effect of circulating biomarkers in predicting coronary artery disease (CAD) is not fully elucidated. This study aimed to determine the relationship with CAD and the predictive capacity of nine biomarkers of inflammation (TNF-α, IL-10, IL-6, MCP-1, CRP), oxidation (GHS-Px), and metabolism (adiponectin, leptin, and insulin). This was a case-cohort study, within the REGICOR population-cohorts (North-Eastern Spain), of 105 CAD cases and 638 individuals randomly selected from a cohort of 5,404 participants aged 35–74 years (mean follow-up = 6.1 years). Biomarkers’ hazard ratio (HR)/standard deviation was estimated with Cox models adjusted for age, sex, and classical risk factors. Discrimination improvement and reclassification were analyzed with the c-index and the Net reclassification index (NRI). GHS-Px (adjusted HRs = 0.77; 95%CI:0.60–0.99), insulin (1.46; 1.08–1.98), leptin (1.40; 1.03–1.90), IL-6 (1.34; 1.03–1.74), and TNF-α (1.80; 1.26–2.57) were significantly associated with CAD incidence. In the model adjusted for all biomarkers, TNF-α (1.87;1.31–2.66) and insulin (1.59;1.16–2.19) were independently associated with CAD. This final model, compared to a model without biomarkers, showed a c-index difference of 1.3% (−0.7, 3.2) and a continuous NRI of 33.7% (2.6, 61.9). TNF-α and insulin are independently associated with CAD incidence and they improve reclassification when added to a model including classical risk factors.

MDRD or CKD-EPI for glomerular filtration rate estimation in living kidney donors

INTRODUCTION

The evaluation of the measured Glomerular Filtration Rate (mGFR) or estimated Glomerular Filtration Rate (eGFR) is key in the proper assessment of the renal function of potential kidney donors. We aim to study the correlation between glomerular filtration rate estimation equations and the measured methods for determining renal function.

MATERIAL AND METHODS

We analysed the relationship between baseline GFR values measured by Tc-⁹⁹m-DTPA (diethylene-triamine-pentaacetate) and those estimated by the four-variable Modification of Diet in Renal Disease (MDRD4) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations in a series of living donors at our institution.

RESULTS

We included 64 donors (70.6% females; mean age 48.3±11 years). Baseline creatinine was 0.8±0.1 mg/dl and it was 1.1±0.2 mg/dl one year after donation. The equations underestimated GFR when measured by Tc⁹⁹m-DTPA (MDRD4-9.4 ± 25ml/min, P<.05, and CKD-EPI-4.4 ± 21ml/min). The correlation between estimation equations and the measured method was superior for CKD-EPI (r=.41; P<.004) than for MDRD4 (r=.27; P<.05). eGFR decreased to 59.6±11 (MDRD4) and 66.2±14ml/min (CKD-EPI) one year after donation. This means a mean eGFR reduction of 28.2±16.7 ml/min (MDRD4) and 27.31±14.4 ml/min (CKD-EPI) at one year.

CONCLUSIONS

In our experience, CKD-EPI is the equation that better correlates with mGFR-Tc⁹⁹m-DTPA when assessing renal function for donor screening purposes.

Quality of life in patients with non-muscle-invasive bladder cancer: one-year results of a multicentre prospective cohort study

OBJECTIVE

Few studies describe the effect of non-muscle-invasive bladder cancer (NMIBC) on health-related quality of life (HRQL), although patients are mostly diagnosed at this stage of the disease. Taking into account this current evidence gap and the high incidence rates in Spain, we aimed to describe the evolution over time of HRQL in Spanish patients with NMIBC and to examine the clinical and treatment-related factors associated with HRQL change during the first year of management.

METHODS AND MATERIALS

Observational multicenter prospective inception cohort study conducted in urology departments of 7 Spanish hospitals. A consecutive sample of 244 patients with anatomopathologically confirmed NMIBC, recruited from October 2010 to September 2011, was followed during the diagnostic process, and 6 and 12 months later. HRQL was assessed by generic and disease-specific instruments: the Short Form-36 (covering physical and mental health) and the Bladder Cancer Index, measuring urinary, bowel, and sexual domains (summary scores: 0-100). Bivariate analysis was performed and generalized estimating equation models were constructed to assess HRQL score change.

RESULTS

Almost 52% of the patients were diagnosed at stage I, and 84% were men. The number of patients treated only with transurethral resection (TUR) was 144, and 82 also received intravesical therapy with bacillus Calmette-Guérin (BCG) or mitomycin C. Mental health was significantly worse than Short Form-36 reference norms at diagnosis (mean of 49.7 vs. 53.3, 95% CI: 52.5-54.2). Urinary domain improved significantly from diagnosis (85.2, 95% CI: 82.9-87.4) to 12-month evaluation (90.2, 95% CI: 87.7-92.8), whereas sexual domain showed deterioration from 56.4 (95% CI: 52.8-59.9) to 53.7 (95% CI: 50.0-57.4). Adjusted HRQL score changes from baseline to 12-month follow-up estimated with generalized estimating equation models showed improvement on the following parameters: urinary domain after TUR with or without intravesical therapy (+3.9, 95% CI: 0.1-7.7), bowel domain among patients treated with TUR and BCG (+7.0, 95% CI: 2.4-11.5), and sexual domain among those treated with TUR and mitomycin C (+13.1, 95% CI: 5.9-20.2).

CONCLUSIONS

For the first time, a distinctive HRQL pattern of bladder cancer treatment benefits emerges for TUR alone, and in combination with BCG or mitomycin C, which deserves further research. Treatment differences cannot be interpreted in terms of efficacy but can be useful to generate hypotheses to test in future studies.

[Elongation of the right renal vein in 120 consecutive transplant patients. A comparative analysis]

OBJECTIVES

Shorter length of the right renal vein (RRV) may represent an additional difficulty for transplant. This paper has aimed to present our experience with RRV elongation in the kidney from a cadaveric donor and to compare the results with the rest of kidneys transplanted in the same period of time.

MATERIAL AND METHODS

We performed 377 kidneys transplants within the last 11 years. Of these, in 120, the RRV was elongated with the vena cava. The surgical technique is described and the results compared with the remaining transplants of the series. Renal function, graft survival and complications were assessed at 1, 3 and 12 months. Data were obtained retrospectively from the database of the Urology Department and Hospital medical records.

RESULTS

In the 377 transplants, there were 4 (1%) venous thrombosis, 2 (1.6%) of which concerned kidneys with elongation of the RRV and 2 (0.7%) in the rest of transplanted kidneys. There was no difference in postoperative bleeding, 11 (9.1%) occurred in kidneys with elongated RRV and 22 (8.5%) in the remaining kidney. In no case was the bleeding related to the elongated segment. Graft survival and renal function were similar for both groups.

CONCLUSIONS

Elongation of the RRV with the vena cava is a feasible, fast, and effective procedure that does not increase morbidity or affect renal function or graft viability. It facilitates vascular anastomosis and places the kidney in a less forced position, shortens the warm ischemia time and avoids the risk of kinking of the renal artery because it is equal to the length of the vein artery.

Experience in the treatment of rectourethral fistulae after radical prostatectomy

OBJECTIVES

To report the clinical characteristics of rectourethral fistula (RUF) after radical prostatectomy (RP) as well as our experience managing them.

METHODS

We present our experience in the treatment of RUF based on their clinical characteristics and the presence of associated complexity factors. After medical history and physical examination, the diagnostic work up was completed in all cases with urethrograms, cystoscopy and barium enema. From January 2000 to July 2010 we treated 12 patients with RUF. Mean age was 64 years(range 56-74 years). The etiology was open surgery in two cases and laparoscopic surgery in ten. Clinical presentation varied from 4 to 60 days after surgery.

RESULTS

In our experience, endoscopic and radiological findings were well correlated. Two fistulae were small-less than 5 mm- on the urethral side of the anastomosis allowing spontaneous closure after conservative treatment. Ten patients had larger fistulas on the bladder side of the anastomosis and/or were associated with complexity factors that required a posterior transsphincteric York-Mason approach for resolution, with good recovery of urinary and fecal continence.

CONCLUSION

The RUF is a significant complication after RP and it is difficult to solve. We propose early reconstructive surgery in large or complex RUF. The posterior transsphincteric York-Mason approach has allowed the repair in all cases.

Clinical-pathological differences and smoking habit depending on gender in a cohort of patients with transitional cell carcinoma of the bladder: retrospective study

OBJECTIVES

The increased incidence of transitional cell carcinoma (TCC) of the bladder in men is known, generally attributed to greater exposure to the effect carcinogenic products. Although it has been reported that cancer-specific outcome can be particularly adverse in women due to socioeconomic or biological factors, clinical-pathological differences of TCC at the time of diagnosis have not been sufficiently studied. The aim of this study is to analyze whether there are gender-related differences in grade and tumor stage in primary bladder TCC.

METHODS

All consecutive primary bladder TCC diagnoses made in our institution between 1990 and 2009 have been included. We retrospectively analyzed age, smoking, symptoms at presentation, tumor grade (WHO 1973), tumor size and number, and TNM stage, comparing men and women. Statistical analysis was conducted using the Mann-Whitney U test as non-parametric test and Chi-squared test to compare frequencies.

RESULTS

We analyzed 1196 patients (992 males and 204 females) with a 5:1 ratio. We found significant differences in age (69 years vs. 73 years), smoking (46.5% vs. 11.2%)and muscle-invasive stage (12.1% vs. 18.1%). Correcting by tobacco consumption, never-smoker women have larger and more aggressive tumors with a frequency of muscle-invasive disease three times higher than male never-smokers and equaling to male current-smokers.

CONCLUSION

TCC of the bladder is more frequent in males than females. In this series, women are older at the time of diagnosis and most often affected by muscle-invasive disease particularly in never-smokers. We need studies to analyze the potential impact of passive smoking to justify these results.

[Indications, results and techniques of permanent prostate brachytherapy for localized prostate cancer]

INTRODUCTION AND OBJECTIVE

Prostate brachytherapy is a first-line therapeutic approach for localized prostate cancer in selected patients. We present our experience in brachytherapy and a thorough review of the literature.

MATERIALS AND METHODS

A review of the literature and evaluation of patient's selection was done. Furthermore the implantation technique, oncological results according to the different risk groups and acute and chronic complications were also analyzed.

RESULTS

The biochemical relapse-free 10 year survival rate was 87-96% in low risk tumours and 63-86% in intermediate risk tumours. A total of 3-24% underwent urinary retention that required TURP in 0-8,7%. Other complications were urinary incontinence in 0-6,7%, proctitis in 0-15,5%, erectile dysfunction in 6,3-30%, rectal ulcer/fistula in 0-5,4%.

CONCLUSIONS

Prostate brachytherapy is a safe and effective treatment in low and intermediate risk patients with prostate cancer.

Ventriculoperitoneal shunt infection by Candida glabrata in an adult

We describe the first case of infection of a neurosurgical shunt by Candida glabrata in an adult. The risk factors, clinical picture and response to therapy have been similar to similar cases caused by other Candida sp. We must emphasize the unequivocal features of infection and the rapid and probably complete response to removal of the device.

[Injectable phenytoin: problems of stability in solution]

Because of its efficient antiseizure activity, intravenous phenytoin remains a major agent in acute therapy, although it is associated with many pharmacokinetical and toxicological problems. This contribution focuses on the difficulties in finding the appropriate mode of intravenous administration, a matter which is of considerable clinical importance. The fact that precipitations of phenytoin occur when the product is incorrectly diluted is common knowledge--yet the pharmacy department is frequently contacted because of an improper handling of the products available. A review of the factors contributing to precipitation problems, the i.v. products in use in the Grand-Duchy of Luxembourg and the possible i.v. dilutions for these products are discussed.

Cytokines-adhesion molecules-invasive proteinases. The missing paracrine/autocrine link in embryonic implantation?

How implantation is regulated and brought about remains an enigma. The objective of the present review is to propose a hypothetical model based on our actual knowledge of the role of cytokines, adhesion molecules and invasive proteinases in the adhesion and invasion phases of embryonic implantation. For the purpose of clarity we will describe first what is known about the presence of these molecules in the endometrium and embryo in animal models and their relevance in embryonic implantation. Secondly, since human implantation is unique the presence of these factors in the human endometrium and embryo and their possible clinical relevance is considered separately. Finally, the link between cytokines, adhesion molecules and invasive proteinases as well as their endocrine/paracrine/autocrine regulation is put forward as a possible model that could lead us to a better understanding of the implantation process in humans.

Role of endometrial factors in regulating secretion of components of the immunoreactive human embryonic interleukin-1 system during embryonic development

In the study reported here, we localized at the protein level the major components of the interleukin (IL)-1 system in the human embryo, and we investigated the endometrial factors influencing their secretion during embryonic development. To localize these components, we performed immunohistochemical experiments in 44 oocytes and 78 embryos. The following primary antibodies were used: monoclonal mouse anti-human IL-1 receptor type I (IL-1R tl), monoclonal mouse anti-human IL-1 beta, and polyclonal rabbit anti-human IL-1 receptor antagonist (IL-1ra). For embryo culture, human embryos at different developmental stages were cultured in 100-microliters drops of Ham's F-10 medium + 4 mg/ml BSA (n = 33), in 100-microliters drops of Menezo B2 culture medium (n = 18), or in wells with 1 ml of Menezo B2 culture medium (n = 8). For embryo coculture, endometrial stromal cells (ESC) and endometrial epithelial cells (EEC) were isolated from human secretory endometrium and cultured until confluence in 75% Dulbecco's Modified Eagle's Medium and 25% MCDB-105 containing antibiotics and supplemented with 10% charcoal-Dextran-treated fetal bovine serum. Individual human embryos were cocultured with experimental EEC and ESC (n = 23 and n = 4, respectively) for 5 days in 600-microliters drops of Menezo B2 medium, and conditioned medium was removed every 24 h. Human embryos were also cultured with EEC-conditioned medium (n = 9). IL-1 alpha, IL-1 beta, and IL-1ra levels were determined by ELISA in the 24-h culture- or coculture-conditioned media. Immunostaining confirmed the presence of IL-1 beta, IL-1ra, and IL-1R tl in oocytes and embryos in all stages analyzed, with no statistical differences. IL-1 alpha, IL-1 beta, and IL-1ra were absent in conditioned media of cultured embryos and embryos cocultured with ESC. However, when human embryos were cocultured with EEC or with EEC-conditioned medium alone, two different populations of embryos were observed: IL-1 producers (57% and 56%) and IL-1 nonproducers (43% and 44%, respectively). Finally, the IL-1 profile of a single human embryo cocultured with maternal EEC which successfully implanted and developed is presented, this pattern being similar to that described in the IL-1 producer population. These results demonstrate the presence of the IL-1 system in the human embryo. However, the selective release of IL-1 only when embryos were cocultured with EEC or EEC-conditioned medium indicates an obligatory role of the endometrium in the regulation of the embryonic IL-1 system. Furthermore, the differential embryonic production of IL-1 may be related to the implantation capability of the embryos.

[Serum hepatitis B markers: atypical patterns detected at the Hospital Insular de Gran Canaria]

Two atypical serological markers of hepatitis B virus (HBV) infection were detected in 19 patients during a 18-month period study. Pattern 1 (10 patients) was consistent with HBV-2 infection. Reactivity of HbsAG was confirmed by neutralization tests; the absence of other markers was also verified, included anti-HBcIgM. Three of the patients were classified in high risk groups and seven in the low risk groups for hepatitis B; in none of them was co-infection with hepatitis A virus (HAV) detected. Pattern 2 (9 patients) was characterized by the detection of HBsAg and HBeAg and the absence of other hepatitis B markers. Six of these patients were HIV-positive patients and had increased and persistent levels (for longer than 12 weeks) of these markers. In the three remaining patients (with no underlying immunological disorders) there was a loss of these markers within a variable time (2 days to 16 weeks). Nevertheless, DNA-VHB was detected in one of these serum samples once all markers of virus B had disappeared.

[The interleukin-1 system during human implantation]

Although the immune and reproductive systems have been considered independent of each other, the cooperation of both systems are now known to be crucial for the initiation and maintenance of mammalian pregnancy. Nowadays cytokines and growth factors have became increasingly implicated in embryonic implantation. Endometrial functions, embryonic secretions and embryo-endometrial interactions require a continuous dialogue and synchronism between both partners (endometrium and embryo). The present review focuses on the Interleukin-1 system as an example of local regulator in embryonic implantation. Evidence demonstrating its presence and relevance on human endometrium physiology and human preimplantation embryonic development are presented. Furthermore, we described data suggesting the possible role of this cytokine in human implantation.