Does obesity really affect renal transplantation outcomes?

INTRODUCTION

Kidney transplantation is the treatment of choice for patients with stage 5 chronic kidney disease (CKD). About 60% of CKD patients are overweight or obese at the time of kidney transplantation, and post-transplant obesity occurs in 50% of patients, with a weight gain of 10% in the first year and high risk of cardiovascular mortality. Obesity is associated with an increased risk of delayed graft function (DGF), acute rejection, surgical complications, graft loss and mortality. The aim of this study is to assess the clinical evolution of obese and overweight patients that have received a kidney transplant, based on short- and long-term complications associated with a higher BMI.

MATERIAL AND METHODS

A descriptive, observational, cross-sectional study was conducted with 104 kidney or pancreas-kidney transplant patients between March 2017 and December 2020, with a follow-up until April 2021. For comparative analysis, patients were grouped according to BMI.

RESULTS

Mean age was of 56.65 years, 60.6% male and 39.4 % female. Overweight patients experienced prolonged surgeries, more surgical wound dehiscence, delayed graft function, hernias, proteinuria and more indications for renal biopsies. Additionally, obese patients displayed more DGF, indications for renal biopsies, proteinuria, development of diabetes mellitus, atrial fibrillation and needed prolonged hospital stays.

CONCLUSIONS

Despite a high prevalence of comorbidity in the overweight and/or obese population, we found no reduction in patient and/or graft survival. However, longer follow-up is needed.

Kidney stones in renal transplant recipients: A systematic review

INTRODUCTION

Lithiasis in renal graft recipients might be a dangerous condition with a potential risk of organ function impairment.

EVIDENCE ACQUISITION

A systematic literature search was conducted through February 2023. The primary objective was to assess the incidence of lithiasis in kidney transplant (KT) recipients. The secondary objective was to assess the timing of stone formation, localization and composition of stones, possible treatment options, and the incidence of graft loss.

EVIDENCE SYNTHESIS

A total of 41 non-randomized studies comprising 699 patients met our inclusion criteria. The age at lithiasis diagnosis ranged between 29-53 years. Incidence of urolithiasis ranged from 0.1-6.3%, usually diagnosed after 12 months from KT. Most of the stones were diagnosed in the calyces or in the pelvis. Calcium oxalate composition was the most frequent. Different treatment strategies were considered, namely active surveillance, ureteroscopy, percutaneous/combined approach, or open surgery. 15.73% of patients were submitted to extracorporeal shock wave lithotripsy (ESWL), while 26.75% underwent endoscopic lithotripsy or stone extraction. 18.03% of patients underwent percutaneous nephrolithotomy whilst 3.14% to a combined approach. Surgical lithotomy was performed in 5.01% of the cases. Global stone-free rate was around 80%.

CONCLUSIONS

Lithiasis in kidney transplant is a rare condition usually diagnosed after one year after surgery and mostly located in the calyces and renal pelvis, more frequently of calcium oxalate composition. Each of the active treatments is associated with good results in terms of stone-free rate, thus the surgical technique should be chosen according to the patient's characteristics and surgeon preferences.

Radial head prosthesis disassembly: case report and medico-legal implications

BACKGROUND

The aim of the treatment of radial head comminuted fractures is the restoration of anatomical normalcy to avoid the risk of several complications such as joint instability. Among the options for the treatment of such fractures, it is worth mentioning osteosynthesis, resection of the radial head or prosthetic replacement. In the presence of comminution or severe dislocation of the fracture's fragments, as in our patient's type III Mason fracture, prosthesis implantation is the treatment of choice.

CASE REPORT

This clinical case reports a 22-year-old volleyball player, who during training suffered a comminuted fracture of the radial head, type III according to Mason's classification. A prosthesis was implanted. The post-operative course took place regularly. However, approximately three months after surgery, the patient experienced sudden pain and functional limitation following a normal elbow extension movement, so much so that he required medical attention in our emergency room. Following all the appropriate clinical-instrumental tests, a complete dissociation of the bipolar prosthesis of the radial head was found.

CONCLUSIONS

Our clinical case shows the disassembly of a bipolar radial head prosthesis, a rather rare complication. From a medicolegal perspective, the patients should be aware of the increased risk of requiring further surgery after radial head replacement. When patients are thoroughly informed, they can cooperate and comply with indications more effectively, thus taking an active role in recovery management.

Is there such a thing as an indispensable skills profile to be a good doctor? "Life skills" as essential capabilities in the medicoforensic professions

Abstract

This writing aims to convey the essential nature and features of a cultural tool based on a set of skills and capabilities generally referred to as "life skills", which allow for the proper management (in the medical and medical-forensic professional realms) of daily situations in an effective and rewarding fashion. Such a process is based on individual tools such as communication, problem solving, stress management, self-control, the ability to make timely decisions, empathy, creativity and the opportunity to work in a multidisciplinary setting. Life skills include everything the professional should rely on in order to minimize the risks of a professional error, through the acquisition of knowledge and behavioral traits which constitute the fundamental, experience-based starting point. The chief objective of this commentary is to outline the scope of a straightforward discussion by specifically defining such skills; that in turn will make it possible to identify all the technical issues to address during the medical-diagnostic assessment, also from a medico-legal perspective, in order to frame the residual life skills and evaluate the possibilities of recovery and any disabilities, based on observation and interactions with each patient aimed at weighing their psychophysical performance.

Consequences of COVID-19 restrictions on adolescent mental health and drug abuse dynamics

The COVID-19 pandemic has hit elderly people the hardest in terms of severity and mortality. However, it is also evident that children and adolescents have been significantly impacted and experienced major disruptions in their lives. The psychological, mental, and developmental repercussions have been major and have led to a reshaping of drug abuse dynamics and substance addiction. The authors have outlined a narrative review of the major issues affecting adolescents and their mental well-being by clarifying the lingering effects and pandemic aftermath, especially on drug abuse, developmental aspects, and behavioral addiction. The unique traits of adolescent risk factors have been outlined, in order to identify areas to be prioritized for future strategies. Possible repercussions on juvenile crime linked to social estrangedness and disrupted interactions have been briefly explored as well. All such aspects are highly meaningful and relevant from a medicolegal perspective as well. The looming mental health crisis involving youngsters will have to be confronted by fine-tuning and optimizing mental health care services, building on current experiences, raising awareness, and eliminating the stigma that often comes with mental issues. Healthcare systems should look at the current scenario as an opportunity to improve care delivery to eliminate access inequalities and stigmatization of mental issues and raise awareness for the benefit and well-being of all. Similarly, law enforcement, lawmakers, and the judiciary will have to account for such factors, too, as will economic policy-makers. In that regard, a set of defining criteria has been framed in order to provide a degree of objectivity when meeting the unique challenges of the pandemic for youth mental health, in a comprehensive and tailored fashion.

Beneficial effects of music in the healing process of traumatic injuries: perceptual control of suffering and possible abatement of disability conditions

Abstract

Numerous scientific studies report that listening to music can beneficially affect physical and mental health, and even expedite the healing process of traumatic conditions. One of the most noteworthy positive effects of music lies in its ability to control stress and anxiety by lowering heart rate, blood pressure and blood cortisol levels. Furthermore, music can help improve mood especially in traumatized people who are faced with a wide range of negative emotions, reducing symptoms of depression and stimulating the production of dopamine in the brain, favorably inducing sleep quality, thanks to the their relaxing action. Listening to music can stimulate brain activity and improve short-term memory and concentration, having positive effects on the healing process of traumatic pathologies. Therefore, music should be considered a complementary treatment option for people facing treatment for traumatic pathologies, also stimulating the production of endorphins in the brain and intervening on pain control, resulting in positive effects on the quality of life of the traumatized. Furthermore, music can help people express their emotions and communicate with others, providing a way to connect with the world and share similar experiences, reducing social isolation and improving emotional well-being.

The posterior interosseus artery flap (piaf) in reconstructive surgery of the hand: strategies of use and medico-legal implications

Background and aim

The fascio-cutaneous posterior interosseus artery flap (PIAF) is used in hand reconstruction, especially to repair skin or tissue defects such as burn injuries, open fractures, gunshot wounds or traumatic amputations. The aim of this study is to examine the anatomical features of this flap, to describe the surgical harvesting technique and the difficulties associated with the dissection.

Methods

From January 2016 to January 2022, we performed PIAF in 10 patients (3 women and 7 men) with a mean age of 28 years (range 22-44). This flap is taken from the back of the forearm, between the extensor carpi ulnaris (ECU) muscle and the extensor digitorum common (EDC) muscle.

Results

We analyzed retrospectively our patients indicating the failures of this reconstructive surgery, the complications that have arisen and the results using DASH score with the related clinical and medico-legal implications.

Conclusions

Due to its location and structure, PIAF is one of the most versatile fascio-cutaneous flaps in upper limb reconstructive surgery and can be used to reconstruct parts of the hand, wrist, or elbow, allowing to restore limb function and improve the quality of life of patients even if there could be some medico-legal implications.

COVID-19 and its aftermath, new drivers of infertility?

Abstract

Law 40/2004, the Italian piece of legislation governing access to assisted reproductive technologies (ART), is relatively young, compared to the number of years that have passed since the first attempts at ART in the world. Still, such a law has undergone several revisions in recent years, mostly by court rulings, and such changes are indeed necessary in light of the constant evolution in ART innovations. Then, the COVID-19 pandemic struck on a global scale, disrupting virtually all aspects of social and economic life. COVID-19's impact on fertility has to do, although it is not limited to, the distribution and function of ACE2 in the female reproductive system: such receptors are in fact expressed extensively in the ovaries, uterus, vagina and placenta. We point out that overcoming the "demographic winter" Italy has been going through, compounded by the pandemic, will require major adjustments in the way we ensure access to ART services in an equitable, sustainable and affordable fashion for all who wish to fulfill their reproductive potential and have been prevented to do so by legal, regulatory and financial factors.

Fresh vs. frozen embryo transfer in assisted reproductive techniques: a single center retrospective cohort study and ethical-legal implications

OBJECTIVE

Several studies have shown higher pregnancy rates and better perinatal outcomes with frozen embryo transfers than with fresh techniques, with better results in patients with polycystic ovary syndrome (PCOS) but with a higher rate of pregnancy complications such as preeclampsia. This retrospective cohort study aims to compare the cumulative live birth rates, maternal and neonatal complications of fresh embryo transfers (ET) and frozen-embryo transfers (FET) in infertile women who underwent assisted reproduction techniques (ART) at the Azienda Ospedaliera Ospedali Riuniti (AOOR) Villa Sofia Cervello, Palermo, Italy. In addition, the authors have focused on the legislative and ethical complexities which such a procedure entails.

PATIENTS AND METHODS

Out of 475 women undergoing in vitro fertilization programs from January 2017 to January 2021, 128 were enrolled; 70 patients underwent ET, and 58 patients FET. The main outcome measure was live birth rates. Secondary outcomes were clinical pregnancy, ongoing pregnancy, pregnancy loss, low birth weight (LBW), ectopic pregnancy, and obstetrical and perinatal complications.

RESULTS

The cumulative live birth rates were similar between the fresh transfer (95.7%) and frozen transfer (93.1%). Biochemical pregnancy rates, clinical pregnancy, ongoing pregnancy, and pregnancy loss were similar between the groups.

CONCLUSIONS

Obstetrical outcomes were not statistically different between the two groups; a higher preterm delivery rate was reported in the FET group. ET birth weights were notably lower for singletons compared to the freeze-all strategy. ET patients also had higher LBW rates, with a 2.5-fold higher rate compared to FET. No significant differences were found in cumulative live birth rates between ET and FET, which is consistent with earlier studies. FET protocols are linked to higher neonatal birth weight and lower risk of LBW than fresh ET. The ethical and legal quandaries inherent in such techniques, as technology moves on and outpaces current legislative frameworks, cannot be discounted.

Monteggia fracture associated with ipsilateral intercondylar distal humeral fracture with posterior interosseous nerve palsy: case report, medico-legal implications, and methodological assessment analysis

BACKGROUND

The Monteggia fracture, defined as a fracture of the proximal third of the ulnar shaft associated with an anterior or posterior dislocation of the proximal radial epiphysis, is a serious injury accounting for 0.7% of all elbow fractures and dislocations in adults. For adult patients, good results can only be obtained through early diagnosis and adequate surgical treatment. Monteggia fracture-dislocations associated with distal humeral fracture are extremely rare injuries in adults and there are few cases described in the literature. Medico-legal implications arising from such conditions have a host of complexities that cannot be discounted.

CASE REPORT

This case report revolves around a patient affected by a type I Monteggia fracture-dislocation, according to the Bado classification, associated with an ipsilateral intercondylar distal humeral fracture. To our knowledge, this combination of lesions has never been reported before in adult patients. A positive result was obtained due to early diagnosis, achievement of anatomical reduction, and optimal stabilization with internal fixation which made it possible to achieve early functional recovery.

CONCLUSIONS

Monteggia fracture-dislocations associated with ipsilateral intercondylar distal humeral fracture are extremely rare in adults. In the case herein reported, a favorable outcome was obtained due to early diagnosis, achievement of anatomical reduction and management with internal fixation with plate and screws, as well as early functional training. Misdiagnosis makes such lesions risky in terms of potentially delayed treatment, increasing the need for surgical interventions and the possibility of high-risk complications and disabling sequelae, with possible medico-legal implications. In the case of unrecognized injuries under urgent circumstances, the injuries may become chronic, making the treatment more complex. The ultimate outcomes of a misdiagnosed Monteggia lesion can lead to very serious functional and aesthetic damage.

Bilateral femur fracture as the first manifestation of multiple myeloma: a case report

Abstract

The authors aimed to elaborate on an interesting clinical case of a subject that came to our attention following a low-energy traumatic event, producing a bilateral femur fracture. During the instrumental investigations, findings pointing to multiple myeloma were described, in fact later confirmed by the histological and biochemical investigations. In this specific case, unlike manifestations in most patients with MM, the classic correlated pathognomonic symptoms, such as lower back pain, weight loss, recurrent infections, asthenia, were not present. Furthermore, the inflammatory indices, the values of serum calcium, renal function and hemoglobin were completely normal, although numerous bone localizations of disease already coexisted, and these were all unknown to the patient.

The core notion of euthanasia in its primordial beginnings

Abstract

This article provides a brief review of the history of euthanasia, which has always been an ethical, social, legal and medical issue. Euthanasia, meaning "good death" refers to the practice of ending a life to relieve pain and distress. The term was already known in ancient Greece, from the time of Plato, who advocated the suppression of those who were not healthy "of body and soul". Completely different was the thinking of Hippocrates, who mentioned it in his oath, laying the foundation for modern medical ethics based on absolute respect for the person and human life. Recognizing the growing interest in the topic, this writing succinctly outlines the historical evolution of the concept of euthanasia limited to its origins.

Robot-assisted vs. open radical cystectomy: systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Several randomized controlled trials (RCTs) have been launched in the last decade to examine the surgical safety and oncological efficacy of robot-assisted (RARC) vs open radical cystectomy (ORC) for patients with bladder cancer. The aim of the study was to perform a systematic review and meta-analysis of RCTs to compare the perioperative and oncological outcomes of RARC vs ORC.

METHODS

A literature search was conducted through July 2022 using PubMed/Medline, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The outcomes were intraoperative, postoperative, and oncological outcomes of RARC vs ORC.

RESULTS

A total of eight RCTs comprising 1,024 patients met our inclusion criteria. RARC was associated with longer operative time (mean 92.34 min, 95% CI 83.83-100.84, p < 0.001) and lower blood transfusion rate (Odds ratio [OR] 0.43, 95% CI 0.30-0.61, p < 0.001). No differences emerged in terms of 90-day overall (p = 0.28) and major (p = 0.57) complications, length of stay (p = 0.18), bowel recovery (p = 0.67), health-related quality of life (p = 0.86), disease recurrence (p = 0.77) and progression (p = 0.49) between the two approaches. The main limitation is represented by the low number of patients included in half of RCTs included.

CONCLUSIONS

This study supports that RARC is not inferior to ORC in terms of surgical safety and oncological outcomes. The benefit of RARC in terms of lower blood transfusion rate need to be balanced with the cost related to the procedure.

Preoperative Risk Factors for Conversion from Laparoscopic to Open Cholecystectomy: A Systematic Review and Meta-Analysis

Laparoscopic cholecystectomy is a standard treatment for patients with gallstones in the gallbladder. However, multiple risk factors affect the probability of conversion from laparoscopic cholecystectomy to open surgery. A greater understanding of the preoperative factors related to conversion is crucial to improve patient safety. In the present systematic review, we summarized the current knowledge about the main factors associated with conversion. Next, we carried out several meta-analyses to evaluate the impact of independent clinical risk factors on conversion rate. Male gender (OR = 1.907; 95%CI = 1.254−2.901), age > 60 years (OR = 4.324; 95%CI = 3.396−5.506), acute cholecystitis (OR = 5.475; 95%CI = 2.959−10.130), diabetes (OR = 2.576; 95%CI = 1.687−3.934), hypertension (OR = 1.931; 95%CI = 1.018−3.662), heart diseases (OR = 2.947; 95%CI = 1.047−8.296), obesity (OR = 2.228; 95%CI = 1.162−4.271), and previous upper abdominal surgery (OR = 3.301; 95%CI = 1.965−5.543) increased the probability of conversion. Our analysis of clinical factors suggested the presence of different preoperative conditions, which are non-modifiable but could be useful for planning the surgical scenario and improving the post-operatory phase.

Ovarian tissue cryopreservation and transplantation in menopause: new perspective of therapy in postmenopausal women and the importance of ethical and legal frameworks

Menopausal transition entails a progressive decrease in hormone production by the ovaries that lead to important physical and psychological changes that could significantly affect quality of life. Hormone replacement therapy (HRT) administered from the onset of menopausal symptoms usually improves quality of life and life expectancy. Nevertheless, it is not risk-free. Ovarian tissue cryopreservation (OTC) has been investigated as a potential new strategy for delaying menopause and/or to avoid HRT. This review analyzes the critical points of HRT to assess whether OTC and subsequent reimplantation can affect postmenopausal management. We assessed available randomized clinical trials in PubMed, Cochrane Library, ISI web of science, and Scopus from August 2021 to November 2022, including studies and trials evaluating the efficacy of OTC in both cancer and menopausal patients, the efficacy of freezing techniques and the possible clinical scenarios that OTC can open, even from the standpoint of legal and ethical issues arising as such innovative techniques become mainstream. Lower duration of the graft and efficacy on estrogen secretions at a physiological and safer concentration of estrogen than conventional HRT based on hormonal supplements. OTC can reportedly trigger estrogen secretions at a lower and safer physiological concentration than conventional HRT. OTC and subsequent reimplantation remain a valid fertility-sparing approach in patients undergoing gonadotoxic treatments. Further studies are needed to better evaluate its safety and efficacy within postmenopausal therapy management and in order to lay out widely shared and evidence-based guidelines and best practices and perform such novel and innovative techniques in a legally and ethically safe fashion, in the best interest of patients and healthcare professionals.

The autobiographical narrative as a damage assessment means: injuries to profound subjective sensitivities - personalization and objectivization of medicolegal relevance

The article aims to outline and expound upon the impairing aspects of an acoustic lesion involving deafness, analyzing the disabling effects on all aspects of the daily life of the injured person, even in the absence of permanent psychic damage that can be nosographically categorized. Such a form of additional damage, which can hardly be quantified, is certainly immaterial and perhaps cannot even be qualified as biological; although it still falls within the realm of psychic functioning, it must be adequately framed by the forensic doctor, in order to enable the Judge to issue a coherently motivated ruling, fully contextualized within the clinical reality of the patient. This task is strictly medicolegal in nature, and requires the professional to carry out in-depth work thoroughly based on listening for the purpose of providing the courts with a faithful representation.

Comparison of Quantitative Real-Time PCR and Digital PCR to Detect the Polyomavirus in Merkel Cell Carcinoma

Merkel cell polyomavirus (MCPyV) prevalence in Merkel cell carcinoma (MCC) cases is controversial. The detection and quantification of MCPyV DNA is mainly performed by PCR techniques using formalin-fixed, paraffin-embedded (FFPE) tissues. The aim of this study is to compare the performance of two different molecular techniques, specifically the quantitative Real-Time PCR (qPCR) and digital PCR (dPCR). Samples from 31 cases of MCC excisional surgical biopsies were analyzed. DNA extraction and purification from clinical samples were performed using the QIAcube Qiagen automated nucleic acid extractor. After the extraction, MCPyV was detected by qPCR and dPCR using specially designed primers and probes. Of the 31 MCC samples under study, the MCPyV genome was detected in 11 samples (35%) by qPCR compared with 20 samples (65%) detected by dPCR. Notably, 65% of primary tumors were positive for MCPyV (15/23). The viral genome was detected in 75% of tumors located at UV-exposed sites (6/8), 55% of tumors at partially UV-protected sites (5/9), and 67% of tumors at UV-protected sites (4/6). Our results showed a better sensitivity of dPCR in detecting the MCPyV genome in MCC samples compared with traditional qPCR techniques.